COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00064041 


Columbia  ©mbersJitp     \ 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 

'X^><-s.  ^::i>rv>L^M,o  Vvs>-°^- 


^^ 


\J%^^^<,~^  9?-) . 


^  ^^/f^ 

y 


8i^ 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/cyclopaediaofdis01keat 


CYCLOPEDIA 


OP   THE 


Diseases  of  Children 


MEDICAL  AND    SURGICAL. 


THE  ARTICLES  WRITTEN   ESPECIALLY  FOR  THE  WORK  BY 
AMERICAN,  BRITISH,  AND  CANADIAN  AUTHORS. 


EDITED    BY 

JOHN  M.  KEATING,  M.D. 


VOL.  I. 


ILL  US TR A  TED. 


PHILADELPHIA: 

J.  B.  LIPPINCOTT   COMPANY. 

1890. 


Copyright,  18S9,  by  J.  B.  Lippixcott  Company. 


PREFACE. 


Although  it  might  almost  seem  presumptuous  to  have  engaged 
in  an  undertaking  of  so  vast  a  scope  as  that  of  the  present  work, 
the  Editor  feels  that  the  excellence  of  the  articles  that  have  been 
contributed  by  the  various  collaborators  justifies  the  course  he  has 
pursued,  both  in  the  selection  of  the  writers  and  in  the  general 
plan. 

His  object  has  been  to  include  not  only  the  Medicine  and  Surgery 
of  Pediatrics,  but  also  all  the  specialties  tributary  to  it,  as  well  as  all 
collateral  subjects  of  interest  and  importance,  many  of  which  cannot 
be  found  treated  in  any  other  work  of  this  character.  He  has  also 
included  articles  upon  certain  prominent  symptoms,  such  as  cough, 
convulsions,  etc.,  the  proper  significance  of  which  could  be  estimated 
only  after  laborious  research,  unless  the  matter  were  considered  in 
special  chapters. 

The  work,  in  fact,  consists  of  a  collection  of  monographs — not 
mere  dictionary  articles — arranged  in  the  form  of  a  systematic  treatise, 
and  devoted  to  the  consideration  of  the  anatomy,  physiology,  medi- 
cine, surgery,  and  hygiene  of  infancy,  childhood,  puberty.,  and  adoles- 
cence. 

Each  writer  is  alone  responsible  for  his  statements.  Many  of  the 
collaborators  have  deemed  it  expedient  to  consider  their  subjects  from 
the  stand-point  of  the  adult,  viewing  in  detail  the  various  deviations 
as  afiecting  childhood.  Some,  on  the  other  hand,  taking  for  granted 
a  perfect  familiarity  with  adult  diseases,  have  dwelt  entirely  upon  the 
aftections  of  childhood. 

It  is  a  matter  of  regret  to  us  in  this  country  that  many  of  our 
practitioners  enter  upon  their  careers  with  but  a  meagre  acquaintance 
with  all  that  pertains  to  Pediatrics.  Fortunately,  however,  nature 
has  endowed  the  American  mind  with  energy,  enthusiasm,  penetra- 
tion, and  natural  aptitude,  and  as  a  consequence  we  are  enabled  to 


iv  PREFACE. 

point  to  a  brilliant  array  of  honored  names,  of  those  who  have  fought 
the  battle  single-handed  in  the  conflict  and  struggle  of  an  active  and 
extended  practice.  In  this  country  the  study  of  the  diseases  of  chil- 
dren was  fostered  altogether  at  the  bedside  of  private  practice  by 
the  unremitting  conscientious  labor  of  a  few, — unambitious  as  to  the 
laurels  they  might  win,  ever  bent  upon  arming  others  vdth  their 
experience  and  inspiring  them  with  their  enthusiasm. 

This  Cyclopsedia  is  the  outgrowth  of  the  work  of  these  men,  and 
is  a  tribute  to  the  untiring  efforts  of  such  teachers  and  writers  as 
Dewees,  Eberle,  Condie,  Charles  D.  Meigs,  W.  V.  Keating,  John 
Forsyth  Meigs  and  William  Pepper,  J.  Lewis  Smith,  and  A.  Jacobi, 
— names  which  rank  to-day  on  an  equal  footing  with  those  of  the 
ablest  European  teachers  of  Pediatrics. 

As  each  contributor  has  been  selected  with  special  reference  to  his 
familiarity  with  the  subject,  it  must  follow  that  the  articles  will  not 
only  be  of  immediate  practical  utility,  but  will  also  serve  as  standards 
for  future  reference.  The  introduction  of  the  surgical  essays  and 
certain  special  articles  has  necessitated  a  more  minute  subdivision 
of  the  subject  than  is  usual  in  works  of  this  kind,  which  naturally 
causes  a  certain  amount  of  overlapping,  and  possibly  an  occasional 
conflict  of  opinion,  but  we  believe  this  is  rather  an  advantage  than 
otherwise. 

A  few  words  should  be  said  in  regard  to  the  illustrations.  We 
have  endeavored  to  reproduce  as  accurately  as  possible  and  by  the 
best  processes  all  the  illustrations  which  the  authors  have  deemed 
necessary  for  the  elucidation  of  their  subjects.  A  large  number  of 
plates  reproduced  directly  from  the  photographic  negatives  form  a 
special  feature.  In  the  article  on  Anatomy,  the  author  has  pre- 
ferred the  introduction  of  photographs  of  a  few  special  dissections 
and  preparations,  instead  of  depending  entirely  upon  diagrams,  thus 
sacrificing  clearness  in  detail  to  accuracy.  The  great  difiiculty  of 
arranging  the  camera  which  has  to  be  suspended,  and  the  imperfect 
lighting  of  the  subject,  will  be  readily  understood  by  all  who  have 
attempted  the  photographic  reproduction  of  anatomical  specimens. 

Although  the  work  is  intended  chiefly  for  the  American  physi- 
cian, the  Editor  has  sought  the  co-operation  of  a  few  of  the  most 
distinguished  teachers  of  Great  Britain,  the  outcome  of  whose  ripe 
experience  and  profound  research  cannot  but  prove  a  valuable  addi- 
tion to  our  literature. 


PREFACE.  V 

The  aim  of  the  Editor  has  Ik-cii,  as  far  as  possible,  to  impress 
upon  each  writer  the  importance  of  giving-  his  article  an  individuality 
of  its  own,  avoiding  too  liberal  quotation,  which  tends  to  fatigue  and 
confuse  rather  than  to  entertain  and  instruct  the  reader.  He  believes 
that  he  has  succeeded  in  uniting  in  a  single  work  a  collection  of 
monographs  expressive  of  the  vicAvs  of  most  of  the  distinguished 
teachers  of  this  country  and  Great  Britain,  and  that  these  volumes, 
owing  to  their  scientific  excellence  and  practical  value,  will  be  of 
equal  importance  to  the  busy  practitioner  and  to  the  student  and 
teacher. 

The  Editor  feels  himself  under  a  special  obligation  to  the  w^riters 
who  have  so  heartily  joined  with  him  in  this  work,  often  at  great 
personal  inconvenience  to  themselves,  many  of  them  indeed  laboring 
under  the  serious  disadvantage  of  extreme  professional  pressure.  He 
wishes  to  take  this  opportunity  of  expressing  his  thanks  to  Drs. 
William  Osier,  Thomas  Barlow,  T.  M.  Rotch,  T.  Lauder  Brunton, 
J.  Mitchell  Bruce,  B.  Sachs,  and  W.  A.  Edwards,  through  whose 
able  co-operation  the  jilan  of  this  Avork  has  been  elaborated  and 
its  accomplishment  realized.  He  also  desires  to  acknowledge  his 
indebtedness  to  Mr.  Joseph  McCreery,  who  has  so  carefully  and 
critically  examined  the  proofs. 

Philadelphia.  Mav  1.  1889. 


CONTENTS  OF  VOLUME  I. 


PACiH 

INTRODUCTORY.  By  A.  Jacobi,  M.D.,  New  ^ork,  Clinical  Professor  of  Dis- 
eases of  Childi-en  in  the  College  of  Physicians  and  Surgeons,  New  York,  late 
President  of  the  New  York  Academy  of  Medicine 1 


RART    I. 
GENERAL   SUBJECTS. 

ON  THE  ANATOMY  OF  CHILDREN.  By  George  McCleli.ax,  M.D., 
Philadelphia,  Pa.,  Lecturer  on  Anatomy,  Pennsylvania  School  of  Anatomy  ; 
Surgeon  to  and  Lecturer  on  Anatomy,  Philadelphia  Hospital,  etc 11 

THE  PHYSIOLOGY  OF  INFANCY.      By  Angel  Money,  M.D.,  M.K.C.P., 

London,  England,  Assistant  Physician  to  the  Hospital  for  Children,  Great  Or- 
mond  Street,  and  to  the  L'niversity  College  Hospital 51 

DIAGNOSIS.  By  James  Finlaysou,  M.D.,  Glasgow,  Scotland,  Physician  to 
Glasgow  Hospital  for  Sick  Children  ;  Physician  and  Lecturer  on  Clinical  Medi- 
cine, Glasgow  Western  Infirmary ;  formerly  President  of  the  Glasgow  Pathologi- 
cal and  Clinical  Society ;  Honorary  Librarian  to  the  Faculty  of  Physicians  and 
Surgeons,  Glasgow 73 

THE  INFLUENCE  OF  RACE  AND  NATIONALITY  UPON  DISEASE. 

By  J.  Wellington  Byers,  M.D.,  Charlotte,  North  Carolina 132 

OUTLINES  OF  PRACTICAL  BACTERIOLOGY.  By  E.  O.  Shakespeark, 
M.D.,  Ph.D.,  etc.,  Philadelphia,  Pa.,  Patliologist  and  Ophthalmologist  to  the 
Philadelphia  Hospital;  United  States  Commissioner  to  India  for  the  Investiga- 
tion of  Cholera  ;   Ex-President  of  the  Philadelphia  Pathological  Society    ....    147 

MATERNAL  IMPRESSIONS.     By  William  C.  Dabney,  M.D.,  University  of 

Virginia,  Professor  of  Obstetrics  and  Practice  of  Medicine  in  the  University  of 
Virginia !!♦! 

DISEASES  OF  THE  FCETUS.  By  Barton  Cooke  Hirst,  M.D.,  Philadelphia, 
Pa.,  Associate  Professor  of  Obstetrics  in  the  University  of  Pennsylvania;  Ol)- 
stetrician  to  the  Philadelphia  and  Maternity  Hospitals 217 

THE  CARE  OF  THE  CHILD  AT  AND  IMMEDIATELY  AFTER  BIRTH, 
IN    HEALTH    AND    DISEASE.      By   11.  A.   F.    Penrose,   M.D.,  LL.D., 

Philadelphia,  Pa.,  Kiiieritus  Professor  of  Obstetrics  and  Di.seases  of  Women  and 

Children  in  the  Uni\ersity  of  Pennsj'lvania,  etc '2'Mi 

vii 


VI II  CONTENTS    OF    VOLUME    I. 

PAGE 

THE  CLOSURE  OF  THE  DUCTUS  ARTERIOSUS  AND  OF  THE  UM- 
BILICAL AND  HYPOGASTRIC  ARTERIES.  By  J.  Collins  Warren, 
M.D.,  Boston,  Mass.,  Associate  Professor  of  Surgery,  Harvard  University;  Sur- 
geon to  the  Massachusetts  General  Hospital 2-52 

INJURIES   OF  THE   NEW-BORN.     By  Theophilus  Parvin,  M.D.,  LL.D., 

Philadelphia,  Pa.,  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children 
in  the  Jeflerson  Medical  College ;  Visiting  Obstetrician  to  the  Philadelphia  Hos- 
pital     .    258 

INFANT-FEEDING— WEANING.  By  T.  M.  Eotch,  M.D.,  Boston,  Mass., 
Assistant  Professor  of  Diseases  of  Children  in  Harvard  University ;  Physician 
to  Boston  City  Hospital,  Children's  Hospital,  Infants'  Hospital,  and  West  End 
Xursery 270 

WET-NURSES.  By  Wm.  H.  Parish,  M.D.,  Philadelphia,  Pa.,  Obstetrician  to 
the  Philadelphia  Hospital ;  Professor  of  Obstetrics,  Dartmouth  Medical  College ; 
Professor  of  Anatomy,  Woman's  Medical  College  of  Pennsylvania  ;  Member  of 
the  American  Gynaecological  Society 330 

DIET  AFTER  WEANING.  By  Samuel  S.  Adams,  A.M.,  M.D.,  Washington, 
D.C.,  Professor  of  the  Theory  and  Practice  of  Medicine,  Medical  Department 
of  National  University  ;  Attending  Physician  to  the  Children's  Hospital,  etc. .    .    337 

NURSING  OF  SICK  CHILDREN.  By  Miss  Catherine  Wood,  London,  Eng- 
land, Great  Ormond  Street  Hospital  for  Children  .    .    .    .  ' 347 

NURSERY  HYGIENE.     By  L.  M.  Yale,  M.D.,  New  York,  Lecturer  Adjunct 

on  Diseases  of  Children  at  Bellevue  Hospital  Medical  College 360 

DENTITION.     By  .John  Dorning,  M.D.,  New  York,  Instructor  in  Diseases  of 

Children,  New  York  Polyclinic  ;  Attending  Physician  to  St.  Joseph's  Hospital   .    373 

PUBERTY:  ITS  PATHOLOGY  AND  HYGIENE.  By  Thos.  More  Mad- 
den, M.D.,  F.Pv.C.S.,  Dublin,  Ireland,  President  of  the  Obstetric  Section  of  the 
British  Medical  Association  ;  Physician  to  Hospital  for  Sick  Children  (St.  Jo- 
seph's), Dublin  ;  Obstetric  Physician  to  Mater  Misericordiie  Hospital ;  Ex-Presi- 
dent of  the  Obstetric  Section  of  the  Academy  of  Medicine  in  Ireland ;  formerly 
Examiner  in  Obstetrics  and  Diseases  of  Women  and  Children,  Queen's  Univei-sity    389 


PART    II. 
FEVERS   AND    MIASMATIC    DISEASES. 

FEVER— GENERAL  CONSIDERATIONS  AND  TREATMENT.— SIM- 
PLE CONTINUED  FEVER.— THERMIC  FEVER.  By  William  Pas- 
teur, M.D.,  F.K.C.P.,  London,  England,  Physician  to  North-Eastern  Hospital 
for  Children  ;  Medical  Kegistrar  to  Middlesex  Hospital 417 

ENTERIC  OR  TYPHOID  FEVER.  By  James  C.  Wilson,  M.D.,  Philadel- 
phia, Pa.,  Physician  to  the  Philadelphia  Hospital,  the  Jefferson  College  Hospital, 
and  St.  Agnes's  Hospital 441 

TYPHUS  FEVER.  By  Alexander  Collie,  M.D.,  M.Pv.C.P.,  London,  Eng- 
land, Medical  Superintendent  of  the  Eastern  (Fever)  Hospitals,  etc 497 

RELAPSING  FEVER.  By  PvOLAND  G.  Curtin,  M.D.,  Philadelphia,  Pa.,  Lec- 
turer on  Physical  Diagnosis  in  the  University  of  Pennsylvania  ;  Visiting  Physi- 
cian to  the  Philadelphia  and  Presbyterian  Hospitals,  etc 504 


CONTENTS    OF    VOLUME    I.  IX 

PAGE 

CEREBRO-SPLNAL  FEVER.  By  J..  Lewis  Smith,  M.D.,  New  York,  Clinical 
Professor  of  Diseases  of  Children,  Bellevue  Hospital  Medical  College ;  Physician 
to  the  New  York  Foundling  Asylum ;  Consulting  Physician  to  the  New  York 
Infants'  Asylum 514 

SCARLET  FEVER.      By  Samuel  C.  Busey,  M.D.,  LL.D.,  Washington,  D.C., 

Fellow  of  the  American  Gynaecological  Society,  etc 555 

DIPHTHERIA.  By  J.  Lewis  Smith,  M.D.,  New  York,  Clinical  Professor  of 
Diseases  of  Children  in  Bellevue  Hospital  Medical  College ;  Physician  to  the 
New  York  Foundling  Asylum;  Consulting  Physician  to  New  York  Infants' 
Asylum,  etc 580 

MEASLES.  By  F.  E.  Waxham,  M.D.,  Chicago,  111.,  late  Professor  of  Diseases 
of  Children,  College  of  Physicians  and  Surgeons  of  Chicago;  Professor  of  Otol- 
ogy, Rhinology,  and  Laryngologj"^,  College  of  Physicians  and  Surgeons  of  Chi- 
cago, etc 675 

RUBELLA  (Rotheln).  By  Wm.  A.  Edwards,  M.D.,  San  Diego,  California,  for- 
merly Instructor  in  Clinical  Medicine,  and  Physician  to  Medical  Dispensary,  in 
the  University  of  Pennsylvania 684 

PERTUSSIS.     By  T.  M.  Dolan,  M.D.,  F.R.C.P.,  Halifax,  England,  Fellow  of  the 

Medical  Society  and  of  the  Obstetrical  and  Gynsecological  Societies  of  London     .    703 

VARIOLA.  By  A.  D.  Blackader,  M.D.,  Montreal,  Canada,  Instructor  in  Diseases 
of  Children,  McGill  University;  Physician  to  the  Out-Door  Department  for  Dis- 
eases of  Children,  Montreal  General  Hospital ;  Physician  to  St.  Margaret's  Nur- 
sery and  Protestant  Infants'  Home , 722 

VACCINATION.  By  W.  T.  Plant,  M.D.,  Syracuse,  N.Y.,  formerly  Passed  As- 
sistant Surgeon,  United  States  Navy;  Professor  of  Pediatrics  in  the  Medical 
Department  of  Syracuse  University 743 

VARICELLA.  By  Charles  G.  Jennings,  M.D.,  Detroit,  Mich.,  Professor  of  Dis- 
eases of  Children  and  Chemistry,  Detroit  College  of  Medicine ;  and  Physician 
for  Diseases  of  Children,  Out-Patient  Department,  St.  Mary's  Hospital 754 

PAROTITIS.  By  O.  P.  Eex,  M.D.,  Philadelphia,  Pa.,  Physician  to  Presbyterian 
and  Jefferson  College  Hospitals ;  Clinical  Lecturer  on  Diseases  of  Children, 
Jefferson  Medical  College 767 

ERYSIPELAS.  By  Jos.  O.  Hirschfelder,  M.D.,  San  Francisco,  Cal.,  Professor 
of  Clinical  Medicine  in  Cooper  Medical  College ;  Visiting  Physician  to  the  City 
and  County  Hospital 771 

RHEUMATISM.  By  W.  B.  Cheadle,  M.D.,  F.E.C.P.,  London,  England,  Physi- 
cian to  St.  Mary's  Hospital  and  Lecturer  on  Medicine  at  St.  Mary's  Medical 
School;  Senior  Physician  to  the  Hospital  for  Children,  Great  Ormond  Street, 
London,  etc 785 

MALARIA.  By  F.  Forchheimer,  M.D.,  Cincinnati,  Ohio,  Professor  of  Phj'siology 
and  Clinical  Diseases  of  Children,  Medical  College  of  Ohio ;  Physician  to  Home 
for  Sick  Children;  Physician  to  Children's  Ward,  Good  Samaritan  Hospital; 
Physician  to  Cincinnati  Hospital;  Member  of  Association  of  American  Physi- 
cians, etc 825 

YELLOW  FEVER.  By  John  Guiteras,  M.D.,  Charleston,  S.C,  Passed  Assist- 
ant Surgeon,  United  States  Marine  Hospital  Service;  Professor  of  Pathology  in 
the  University  of  Pennsylvania;  formerly  Professor  of  the  Theory  and  Practice 
of  Medicine,  Medical  College  of  South  Carolina,  etc 853 

DENGUE.     By  PvUDOLPH  Matas,  M.D.,  New  Orleans,  La 878 


X  CONTENTS   OF   VOLUME   I. 

PAGE 

CHOLERA  INFECTIOSA.  By  E.  O.  Shakespeare,  M.D.,  Philadelphia,  Pa., 
Pathologist  and  Ophthalmologist  to  the  Philadelphia  Hospital ;  United  States 
Commissioner  to  India  for  the  Investigation  of  Cholera,  etc .    900 

JOINED  TWINS.  By  William  Wright  Jaggard,  M.D.,  Chicago,  111.,  Pro- 
fessor of  Obstetrics,  Chicago  Medical  College,  Medical  Department  of  North- 
western University  ;  Obstetrician  to  Mercy  Hospital,  Bellevue 922 

EMBRYOLOGY.  By  Horace  Jayne,  M.D.,  Philadelphia,  Pa.,  Professor  of  Ver- 
tebrate Morphology  in  the  Universitj'^  of  Pennsylvania 939 

THE  GENERAL  THERAPEUTICS  OF  CHILDREN'S   DISEASES.     By 

Egberts  Bartholow,  M.D.,  LL.D.,  Philadelphia,  Pa.,  Professor  of  Materia 
Medica,  General  Therapeutics,  and  Hygiene  in  the  Jeiferson  Medical  College, 
Philadelphia,  etc 956 


LIST  OF  ILLUSTRATIONS  TO  VOLUME  L 


PLATES. 

PAGE 

Photograph  of  Skull  of  Infant  Seven  Months  Old,  front  view facing  12 

The  same,  side  view       "  12 

Photograph  from  Dissection  of  Brain  of  Infant,  showing  Convolutions  and 

Fissures "  12 

Vertical  Section  (frozen)  from  a  Child  Six  Years  Old,  by  Symington    .    .    ,    .      "  14 

Another  Section  of  the  same "  14 

Vertical  Section  (frozen)  from  Child's  Head,  Six  Years  Old "  16 

Horizontal  Section  (frozen)  from  Child's  Head,  Six  Years  Old,  by  Symington  "  16 
Skull  of  Child  Seven  Years  Old,  showing  Permanent  and  Temporary  Sets  of 

Teeth "  18 

Jaws  of  Child  Seven  Years  Old,  showing  Permanent  and  Temporary  Sets  of 

Teeth "  18 

Photograph  from  Dissection  showing  Eelations  of  Bladder  and  Uterus  in 

Infant "  18 

Longitudinal  Section  (frozen)  from  Child  Six  Years  of  Age,  by  Symington  .  '•  20 
Photograph  from  Preparation  showing  Lymphatic  Vessels  of  Head,  Face,  and 

Neck,  from  Mutter  Museum "  22 

Photograph  from  Dissection  of  Child  Ten  Months  Old "  24 

Photograph  of  Child  Seven  Months  Old,  showing  Topographical  Eelations  of 

Organs  and  Landmarks  in  front "  26 

Photograph  of  Child  Four  Years  of  Age,  showing  Topographical  Position  of 

Organs  and  Landmarks  in  front "  28 

Photograph  of  Child  Four  Years  of  Age,  showing  Topographical  Position  of 

Organs  and  Landmarks  behind       "  28 

Photograph  of  Boy  Ten  Years  of  Age,  showing  Topographical  Position  of 

Organs  and  Landmarks  in  front "  30 

Photograph  of  Recent  Dissection  of  New-Born  Child between  32  and  33 

Diagram  of  the  same "       32  and  33 

Photograph  of  Recent  Dissection  of  New-Born  Infant,  showing  Position  and 

Shape  of  Stomach facing  34 

Photograph  from  Recent  Dissection  of  New-Born  Infant,  showing  Usual  Size 

of  Liver between  34  and  35 

Diagram  of  the  same "        34  and  35 

Photograph  of  Child  Seven  Months  Old,  showing  Topographical  Position  of 

Organs  and  Landmarks  behind facing  36 

Photograph  of  Skeleton  of  Child  Five  Months  Old "  38 

Photograph    from    Preparation    in    Mutter    Museum,   showing    Lymphatic 

Vessels  of  Skull,  Head,  Face,  and  Neck  of  Child  Six  Y^ears  Old    ...    .      "  40 

Photograph  of  Micro-  and  Streptococci "  182 

Tubercle-Bacilli  in  Sputum "  182 

Typhoid  Bacilli "  182 

Bacteria  of  Intestinal  Contents,  with  Two  Comma  Bacilli "  182 

xi 


xu 


LIST   OF   ILLUSTRATIONS   TO   VOLUME   I. 


Photograph  of  Colony  of  Cholera  Nostras,  Tinkler 

Photograph  of  Colony  of  an  Air  Micrococcus 

Photograph  of  Colony  of  Comma  Bacillus  of  Koch      

Photograph  of  Colonies  of  Curved  Bacillus  resembling  that  of  Koch  .... 
Photograph  of  Culture  in  Gelatin-Tube  of  Comma  Bacillus  of  Koch  .... 
Comparison  of  Tube-Cultures,  Comma  Bacillus  of  Koch  and  Curved  Bacillus 

of  Pinkler 

Photograph  of  Pure  Culture  of  Deneke  .    .    .    , 

Photograph  of  Pure  Culture  of  Tinkler 

Photograph  of  Pure  Culture  of  Comma  Bacillus  of  Koch       

Charts,  Enteric  Pever 

Chart,  Enteric  Fever  with  Kelapse 

Chart,  Enteric  Fever,  Kemittent  Type      

Chart,  Enteric  Fever  complicated  by  Measles      

Chart  of  Cases  of  Typhus  Fever 

Rheumatic  Nodules,  and  Microscopic  Section  of  the  same 

Charts  of  Cases  and  Death-Rate  of  Yellow  Fever      

Charts  of  Cases  and  Death-Rate  of  Yellow  Fever      

Charts  of  Temperature  of  Yellow  Fever 

Photo-micrograph  of  McLaughlin's  Dengue  Micrococcus  Culture     .    .    .    .    . 

Map  of  Geographical  Distribution  of  Dengue 

Iniodymus  (Depaul),  Opodymus  (Soemmering),  Dicephalus  Dibrachius  .  .  . 
Rita-Christina  (Serres),  Dicephalus  Tetrabrachius  (Serres),  Rose-Marie  Drouin, 

"  the  Saint  Benoit  Twins" 

Ischiopagus  (Prochaska),  Pelvis  of  an  Ischiopagus  (after  Du  Verney),  Helen 

and  Judith,  The  Two-Headed  Nightingale,  Dipygus  Tetrapus 

Dipygus  Dibrachius  Tetrapus,  Dipygus  Parasiticus,  Janiceps  (Bordenave), 

Prosopo-Thoracopagus 

Janiceps  Asymmetros  (Sterley) 

Craniopagus  Parietalis  (De  Baer),  The  Siamese  Twins,  Sternopagus  (Maternite) 
Sternopagus  (Herrgott),  Sternopagus  Parasiticus 


facing 


PAGE 

182 
182 
184 
184 
184 

184 
186 
186 
186 
458 
460 
462 
476 
498 
800 
854 
856 
864 
884 
880 
926 

928 

930 

932 
934 

936 

938 


FIGURES. 

Hydrocephalic  Skull  of  Infant   ...*.. 12 

Diagram  of  Fissures 13 

Section  of  Temporal  Bone 15 

Transverse  Section  of  Neck  of  Child  Six  Years  of  Age 21 

Anterior  Region  of  Neck  of  Child  Nine  Years  of  Age 23 

The  Fcetal  Circulation 27 

Human  Embrj'o  of  the  Ninth  Week 30 

Diagram  of  Nerve-Circuit 57 

Diagrams  of  Cocci,  Bacilli,  Bacteria,  and  Spirilli,  afcer  Hiippe    150,  151,  153,  154,  155,  157 

Instruments  for  Bacteriological  Investigation 171,  172 

Dry-Heat  Sterilizer 173 

Steam  Sterilizer 174 

Culture-Oven 176 

Porcelain  Filter  of  Chamberland 189 

Tibia  showing  Syphilitic  Osteochondritis,  Wegner 223 

Microscopic  Appearance  of  Syphilitic  Osteochondritis,  Wegner 223 

Head  of  Femur  showing  Syphilitic  Osteochondritis 224 

Caput  Succedaneum,  from  Depaul 259 


lAST   OF   ILLUSTRATIONS   TO   VOLUME   I.  Xlll 

PAGE 

Caput  Succedaneum  of  Face  and  Vertex,  from  Depaul 260 

Funnel-Shaped  Depression  of  Left  Parietal  Bone,  from  V^inckel 264 

Fissure  of  Eight  Parietal  Bone,  from  Winckel 264 

Position  after  Pelvic  Presentation 269 

Chart  showing  Gain  in  Weight  of  Healthy  Child  for  First  Twenty-nine  Weeks   .    .  272 

Diagram  of  Actual  Size  of  Stomach  of  Infant  Five  Days  Old 294 

Diagram  showing  Actual  Size  of  Tube  for  each  Feeding  of  Child  during  First  Week  295 

Diagram  showing  Actual  Size  of  Stomach  of  Female  Infant  Twelve  Months  Old      .  269 

Diagram  showing  Actual  Size  of  Stomach  of  Eachitic  Infant  Seven  Months  Old  .    .  297 

Diagram  of  Tubes  used  in  Infant  Feeding 298 

Sterilizer  for  Infant  Feeding 299 

Four-Ounce  Erlmeyer  Flask 328 

Nursery  Window-Sash 363 

Diagram  of  Bacilli  of  Enteric  Fever,  Fliigge 446 

Chart  of  Eelapsing  Fever,  from  Murchison 508 

Clonic  Convulsion  in  Cerebro-Spinal  Fever 530 

Pigmented  Body  in  Eed  Blood-Corpuscle 829 

Small  Vein  of  the  Pia  Mater,  with  Pigmented  Hyaline  Bodies,  Councilman  ....  829 

Section  of  Kidney,  showing  the  same  . 829 

Chart  of  Thermic  Fever 871 

Micrococci  in  Blood  of  Dengue  Fever 885 

Section  of  Ovary 939 

Section  of  Ovary 940 

Ovum  of  the  Cat 940 

Formation  of  Polar  Cells  in  a  Star-Fish 941 

Fertilization  of  Ovum  of  a  Star-Fish ........' 944 

First  Stages  of  Segmentation  of  a  Babbit's  Ovum 945 

Optical  Sections  of  a  Babbit's  Ovum 945 

Babbit's  Ovum  after  Impregnation 946 

Blastodermic  Vesicle  of  a  Babbit 946 

Embryonic  Area  of  a  Seven  Days'  Embryo  Babbit 947 

Sections  through  the  Blastoderm  of  a  Mole 947 

Embryo  Babbit  of  Eight  Days  and  Nine  Hours .  948 

Embryo  Babbit  of  Eight  Days  and  Nine  Hours  with  Five  Protovertebrae 949 

Transverse  Section  of  an  Embryo  Fowl  of  Three  Days'  Incubation 949 

Diagrammatic  Longitudinal  Section  through  the  Axis  of  an  Embryo 950 

Five  Diagrammatic  Figures  illustrating  the  Formation  of  the  Fcetal  Membranes  of 

a  Mammal 9,51 

Diagram  of  the  Foetal  Membranes  of  a  Mammal 952 

Diagram  of  the  Circulation  of  the  Yolk-Sac  of  a  Chick  at  the  End  of  the  Third  Day 

of  Incubation 953 

Structure  of  the  Human  Placenta 955 


CYCLOPEDIA 


OF    THE 


DISEASES  OF  CHILDREN 


INTRODUCTORY. 

By   a.   JACOBI,   M.D. 


Upon  me  has  been  conferred  the  honor  of  introdncing  to  the  medical 
public  the  essays  of  all  the  distinguished  men  contributing  to  this  great 
work.  Though  with  some  hesitation,  it  is  with  still  more  satisfaction  that 
I  comply  with  this  demand.  For  the  very  enterprise  marks  an  immense 
progress  in  the  history  of  both  general  medical  and  pediatric  literature.  In- 
deed, when  I  began  my  professional  life,  such  a  collection  of  monographs  as 
will  here  be  offered  could  not  have  been  written.  Now,  that  during  a  single; 
generation  there  should  have  been  such  a  thorough  change  in  the  methods 
of  both  medical  thought  and  work,  is  a  source  of  the  most  intense  gratifi- 
cation as  well  to  me  as  to  every  other  man  who  has  absolute  faith  in  the 
persistent  evolution  of  science  and  the  improvement  of  the  race. 

That  there  should  be  any  doubt  as  to  the  propriety  of  a  large  special 
work  on  the  diseases  of  children,  I  can  hardly  believe  in  the  present  stage 
of  development  of  American  medical  literature.  As  far  as  I  am  concerned, 
I  never  objected  to  being  found  among  the  adversaries  of  the  wildfire  of 
specialism  which  has  been  spreading  among  the  groups  of  medical  men. 
On  the  contrary,  I  am  still  of  the  opinion  I  expressed  eight  years  ago  when 
I  opened  the  first  session  of  the  Section  on  Diseases  of  Children,  of  the 
American  Medical  Association,  in  its  meeting  at  New  York. 

With  more  pertinacity  than  logic,  pediatrics  (comprehending  the  anat- 
omy, physiology,  pathology,  and  therapeutics  of  infancy  and  chiklhood)  lias 
also  been  claimed  as  a  specialty.  This  is  a  mistake,  however,  which  has 
been  made  more  frequently  on  the  continent  of  Europe  than  with  us.  It 
is  there  tliat  practitioners  and  authors  advertise  themselves,  for  reasons  of 
their  own  whicli  would  not  be  approved  of  here,  as  "  children's  physicians"' 
7      Vol.  I.— 1  1 


Z  INTEODUCTORY. 

and  "specialists/'  Pediatrics,  however,  is  no  specialty  in  the  common 
acceptation  of  the  term.  It  does  not  deal  with  an  organ,  but  with  the 
entire  organism  at  the  very  period  which  presents  the  most  interesting 
features  to  the  student  of  biology  and  medicine.  Infancy  and  childhood 
are  the  links  between  conception  and  death,  between  the  foetus  and  the 
adult.  The  latter  has  attained  a  certain  degree  of  invariability.  His 
physiological  labor  is  reproduction,  that  of  the  young  is  both  reproduction 
and  growth.  As  the  history  of  a  people  is  not  complete  with  the  narra- 
tion of  its  condition  when  established  on  a  solid  constitutional  and  material 
basis,  so  is  that  of  man,  either  healthy  or  diseased,  not  limited  to  one  period. 
Indeed,  the  most  interesting  time  and  that  most  difficult  to  understand  is 
that  in  which  a  persistent  development,  increase,  and  improvement  are 
taking  place. 

This  appears  to  have  been  felt,  instinctively,  from  the  very  beginning. 
The  history  of  pediatrics,  therefore,  is  as  old  as  that  of  medicine.  Their 
literatures  have  developed  uniformly,  from  superstitious  beliefs  to  empiri- 
cal statements  and  the  methodical  researches  of  the  present  time.  The 
last  centuries,  particularly  the  last  decades,  are  replete  with  text-books  on 
the  diseases  of  children,  monographs  on  their  pathology,  physiology,  and 
hygiene,  and  journals,  quite  a  number  of  which  are  now  published  in  the 
four  principal  languages  of  the  civilized  world. 

These  monographs  and  journals  have  contributed  a  great  deal  to  the 
amount  of  medical  knowledge.  Special  researches  of  the  normal  condition 
of  embryonic,  foetal,  and  infant  growth,  the  study  of  the  functions  of  the 
organs  in  their  constant  development  and  changes,  and  anatomical  and 
clinical  investigations,  have  contributed  to  prove  that  pediatrics  does  not 
deal  with  miniature  men  and  women,  with  reduced  doses  and  the  same 
class  of  diseases  in  smaller  bodies,  but  that  it  has  its  own  independent 
range  and  horizon,  and  gives  as  much  to  general  medicine  as  it  has  received 
from  it. 

There  is  scarcely  a  tissue,  or  an  organ,  which  behaves  exactly  alike  in 
the  diiferent  periods  of  life.  The  bones  contain  less  phosphates  in  the 
young  and  exhibit  other  chemical  differences,  their  anatomical  structure  is 
different,  their  increase  less  periosteal,  than  in  advanced  years.  The  carti- 
laginous condition  of  the  epiphyses  gives  rise  to  a  number  of  disorders  ;  the 
cartilages  between  the  epiphyses  and  diaphyses  are  subject  to  all  forms  of 
disease,  from  a  simple  irritation  resulting  in  abnormal  growth  (for  instance, 
after  eruptive  fevers)  to  a  separation,  by  suppuration,  of  the  epiphyses. 
There  is  hardly  a  chapter  more  interesting  than  that  of  the  relation  of  the 
bones  of  the  cranium  to  its  contents.  A  solid  skull  serves  as  a  support  to 
the  brain  and  its  blood-vessels,  or  it  may  prove  an  obstacle  to  their  develop- 
ment ;  an  insufficient  degree  of  ossification,  and  an  undue  amount  of  sutural 
substance,  will  enhance  the  possibility  of  enlargement  of  the  blood-vessels 
and  the  liability  to  effusion.  Premature  ossification,  however,  either  partial 
or  general,  is  a  cause  of  asymmetry,  epilepsy,  or  idiotism,  and  influences  the 


INTRODUCTORY.  3 

course  of  intercurrent  diseases.  The  large  size  of  the  head,  which  is  equalled 
by  that  of  the  thorax  about  the  middle  or  the  end  of  the  third  year  only,  is 
in  close  relation  to  the  physiological  growth  of  the  brain  and  its  pathological 
changes. 

The  vertebral  column  is  quite  flexible,  but  straight,  and  mainly  so  in  its 
upper  portion.  Its  very  flexibility  is  a  ready  cause  of  the  frequent  occur- 
rence of  scoliosis.  Its  distance  from  the  manubrium  sterni  is  so  small  that 
occasionally  a  thymus,  and  frequently  enlarged  lymph-bodies,  are  a  cause  of 
irritation  or  compression.  The  base  of  the  thorax  is,  however,  relatively 
wide,  while  its  height  is  less.  This  becomes  particularly  striking  by  the 
almost  rectangular  insertion  of  the  ribs  at  the  transverse  processes  of  the 
vertebrae  and  the  sternum,  and  by  their  almost  horizontal  and  circular 
position,  by  which  the  respiration  becomes  less  costal,  and  the  viscera  of  the 
abdominal  cavity,  mainly  the  liver,  appear  more  prominent.  Changes  of  a 
})athological  character  are  quite  frequent  about  this  time,  and  a  frequent 
cause  of  disease  in  later  life.  Hueter's  researches  on  the  congenital  contrac- 
tion of  the  chest,  and  Freund's  investigations  on  the  premature  ossification 
of  the  costo-cartilaginous  junctures,  are  exceedingly  important,  inasmuch  as 
they  explain  many  of  the  isolated  cases  of  thoracic  insufficiency,  phthisical 
habitus,  and  pulmonary  incompetency. 

The  nervous  system  of  the  young  is  but  in  a  preparatory  condition. 
The  brain  is  large,  but  contains  a  large  percentage  of  water,  is  soft,  and  its 
gray  and  white  substances  differ  but  little  in  color  and  composition.  The 
spinal  cord  has  not  yet  the  consistency  of  a  later  period  ;  the  anterior  horns  are 
predominant,  and  therefore  more  frequently  the  seat  of  pathological  changes. 
The  peripheral  nerves  are  relatively  large,  but  little  excitable,  in  the  first 
days.  Their  excitability  grows  very  fast,  however,  towards  the  end  of  the 
first  year,  and  quite  out  of  proportion  with  the  slow  development  of  the 
inhibitory  centres.  Thus  it  is  that  about  that  time  convulsive  symptoms 
are  so  very  frequent.  For  a  short  time  after  birth  the  conducting  fibres  be- 
tween the  undeveloped  brain  (it  takes  the  psycho-motor  centres  of  Ferrier 
and  Hitzig  a  month  to  exhibit  the  first  signs  of  existence)  and  the  pyramidal 
fibres  of  the  cord  perform  no  functions :  thus  the  first  movements  of  the 
newly-born  are  not  controlled  by  will-power  at  all,  but  subject  to  reflex 
exclusively.  After  that  time  the  brain  develops  very  fast  indeed,  but  far 
from  uniformly  in  all  its  parts.  It  is  a  most  interesting  study  thus  to 
follow  the  evolution  of  the  cerebral  functions  in  their  dependency  upon 
the  anatomical  development. 

The  digestive  organs  of  the  infimt  exhibit  a  great  many  peculiarities  in 
their  anatomy,  physiology,  and  pathology.  The  epithelial  "  pearls"  along 
the  median  line  of  the  palate,  and  the  thinness  of  the  mucous  membranes 
over  the  roof  of  the  oral  cavity  and  along  the  gums,  give  rise  to  early 
trouble,  the  small  size  and  vertical  position  of  the  stomach  to  a  number  of 
abnormal  symptoms,  the  congenital  malformations  of  the  intestine  to  serious 
dangers,  the  abnormal  length  of  the  lower  part  of  the  colon  to  an  unusual 


4  INTEODUCTORY. 

form  of  protracted  constipation,  the  prevalence  of  polypi  in  the  rectum  to 
hemorrhages  of  a  kind  seldom  found  in  advanced  age.  The  glands  required 
for  the  digestive  processes  are  but  gradually  prepared  for  their  functions. 
The  salivary  glands  are  but  partially  active  at  birth,  the  pancreas  requires 
time  for  its  full  development,  the  secretion  of  lactic  predominates  over  that 
of  muriatic  acid  in  the  stomach,  the  intestinal  lymph-bodies  are  in  part, 
particularly  the  patches  of  Peyer,  so  behind  their  future  size  and  formation 
as  to  change  their  functions  considerably.  The  time  of  dentition  adds  to 
the  interest  of  the  period,  more,  it  is  true,  from  a  physiological  and  ana- 
tomical stand-point  than  on  account  of  pathological  reasons ;  for  its  alleged 
causal  connection  with  the  large  number  of  diseases  attributed  to  its  mere 
occurrence  has  been  greatly  exaggerated. 

In  connection  with  these  brief  remarks  on  some  of  the  peculiarities  of 
the  alimentary  tract  of  infancy,  I  may  be  permitted  to  merely  allude  to  the 
question  of  nutrition  and  feeding.  Several  meetings  of  the  Children's 
Section  of  the  German  Association  of  Physicians  and  Naturalists,  the  last 
one  of  that  in  the  American  Medical  Association,  and  the  deliberations  of 
every  medical  society  in  every  land,  prove  its  importance.  These  questions 
belong,  as  special  studies,  eminently  to  pediatrics ;  physiology  and  chem- 
istry can  teach  the  general  principles  only,  and  to  clinical  observation  is  left 
the  final  settlement  of  the  hygiene  of  infancy.  The  relation  of  nurse's 
to  mother's  milk,  the  utilization  of  cow's  milk  in  all  its  different  forms 
as  one  of  the  constituents  of  artificial  foods,  the  value  of  farinaceous  ad- 
mixtures, the  addition  of  animal  foods,  the  proportions  of  salts  and  water, 
the  quantity  to  be  administered,  the  length  of  intervals  between  meals,  the 
alterations  required  in  sickness,  are  just  so  many  questions  which  demand 
persistent  study  and  special  industry. 

The  blood  and  the  organs  of  circulation  exhibit  the  most  interesting 
differences  in  the  young  as  compared  with  the  adult. 

The  young  infant  (and  child)  has  less  blood  in  proportion  to  its  entire 
weight ;  this  blood  has  less  fibrin,  fewer  salts,  less  haemoglobulin  (except  in 
the  newly-born),  less  soluble  albumin,  less  specific  gravity,  and  more  white 
blood-corpuscles  than  the  blood  of  advanced  age. 

There  are  some  other  differences,  depending  on  age,  in  the  composition 
of  the  blood,  more  or  less  essential.  The  foetal  blood  and  that  of  the 
newly-born  contain  but  little  fibrin,  but  vigorous  respiration  Avorks  great 
changes  in  that  respect.  Nasse  found  the  blood  of  young  animals  to  co- 
agulate but  slowly.  In  accordance  with  that  observation,  it  strikes  us,  in 
regard  to  cerebral  apoplexy  of  the  newly-born,  that  the  time  for  coagulation 
of  the  blood  must  be  longer  than  in  the  adult ;  for  hemorrhages  are  apt  to 
be  most  extensive  in  the  infant.  In  the  sanguineous  tumor  (kephalhsema- 
toma)  of  the  newly-born,  the  blood  remains  liquid  in  the  sac  for  many  days. 
In  apoplexy  it  is  apt  to  sjDread  all  over  the  hemispheres,  and  has  plenty  of 
time  to  perforate  and  penetrate  the  pia  in  all  directions,  destroy  much  of  the 
cerebral  tissue^  and  flow  down  the  spinal  cavity.     These  occurrences  are  so 


INTRODUCTORY.  H 

frequent  in  the  infant,  and  so  rare  in  the  apoplectic  adult,  that  they  can 
hardly  be  explained  except  through  the  insufficient  coagulability  of  foetal 
and  infant  blood. 

The  size  and  vigor  of  the  newly-born  heart  offer  a  ready  explanation 
of  the  rapid  growth  of  the  infant  body,  and  mainly  those  organs  which  are 
in  the  most  direct  communication  with  the  heart  by  straight  and  fairly 
laro-e  blood-vessels.  In  this  condition  are  the  head  and  brain.  Thus  the 
latter  has  an  opportunity  to  grow^  from  400  grammes  to  800  in  one  year ; 
after  that  period  its  growth  becomes  less  marked.  At  seven,  boys  have 
brains  of  1100  grammes  ;  girls,  of  1000.  In  more  advanced  life  its  weight 
is  relatively  less, — 1424  in  the  male  and  1272  in  the  female.  At  the  same 
early  period  the  Avhole  body  grows  in  both  length  and  weight.  The  original 
length  of  50  centimetres  of  the  newly-born  increases  to  110  with  the  seventh 
year ;  the  greatest  increase  after  that  time  amounts  to  60  (in  the  female  50) 
centimetres  only.  In  the  same  time  the  weight  increases  from  3.2  kilo- 
grammes to  20.16  in  the  boy,  from  2.9  to  18.45  in  the  girl.  This  gives 
a  proportion  of  1  to  6  or  7,  while  after  that  time  the  increase  is  but  three- 
or  fourfold. 

The  normal  relation  of  the  weight  of  the  heart  to  that  of  the  lungs, 
between  the  second  and  twentieth  year,  is  1  :  5—7  ;  in  scrofula  it  is  1  :  8—10. 
That  means,  the  heart  is  smaller  than  normal,  in  the  latter  condition. 
Other  parts  of  the  system  of  circulation  exhibit  traits  of  their  own.  It 
is  particularly  in  the  "torpid"  form  of  scrofula  that,  by  virtue  of  insuf- 
ficient circulation,  the  lymphatic  system  participates  pre-eminently.  This 
fact  is  the  more  important,  as  the  size,  patency,  and  number  of  lymphatics 
are  quite  unusual  in  infancy.  Sappey  found  that  they  could  be  more  easily 
injected  in  the  child  than  in  the  adult,  and  the  intercommunication  between 
them  and  the  general  system  is  more  marked  at  that  than  at  any  other 
period  of  life.  These  facts  have  been  confirmed  by  S.  L.  Schenk,  who, 
moreover,  found  the  net-work  of  the  lymphatics  even  in  the  skin  of  the 
newly-born  endowed  with  open  stomata,  through  which  the  lymph-ducts 
can  communicate  with  the  neighboring  tissue  and  cells. 

In  rhachitis,  the  heart  is  of  average  size,  but  the  arteries  are  abnormally 
large.  Great  width  of  the  arteries  lowers  blood-pressure.  This  allows  of 
the  best  explanation  of  the  murmur  first  discovered  by  Fisher,  of  Boston, 
over  the  open  fontanelles  of  rhachitical  babies,  a  very  much  better  one  than 
that  proposed  by  Jurasz,  who  looks  for  their  cause  in  irregularities  of  the 
canalis  caroticus.  Still,  it  is  a  mistake  to  believe  that  these  murmurs,  au- 
dible over  the  brain,  belong  to  rhachitis  only.  They  are  found  in  every 
condition  in  which  the  blood-pressure  in  the  large  arteries  of  the  cranial 
cavity  is  lessened. 

E.  Hoffmann  discovered  the  peculiar  fact  that  the  arterial  pressure  is 
very  small  in  the  newly-born  animal.  Even  as  large  arteries  as  the  carotid, 
when  cut,  do  not  spurt  as  in  the  adult.  This  low  arterial  pressure  is  one  of 
the  reasons  why  cords  not  ligatcd  will  often  not  bleed,  with  the  exception 


6  INTEODUCTORY. 

of  those  cases  in  which  the  arterial  pressure  is  increased  by  a  moderate 
degree  of  asphyxia,  or  when  the  lungs  are  not  inflated  in  consequence  of 
incomplete  development  of  the  muscular  strength  in  the  prematurely-born 
foetus. 

According  to  a  number  of  actual  observations  made  by  R.  Thoma,  the 
post-foetal  growth  is  relatively  smallest  in  the  common  carotid,  and  largest 
in  the  renal  and  femoral  arteries.  Between  these  two  extremes  there  are 
found  the  subclavian,  aorta,  and  pulmonary  arteries.  These  are  differences 
which  correspond  with  the  differences  in  the  growth  of  the  several  parts  of 
the  body  supplied  by  those  blood-vessels.  In  regard  to  the  renal  artery 
and  the  kidney,  it  has  been  found  that  the  size  of  the  former  increases  more 
rapidly  than  the  volume  and  weight  of  the  latter.  Thus  it  ought  to  be  ex- 
pected that  the  frequency  of  congestive  and  inflammatory  processes  in  the 
renal  tissue  will  be  almost  predestined  by  this  disproportion  between  the 
size  of  the  artery  and  the  condition  of  the  tissue.  Moreover,  the  resistance 
of  the  arterial  current  ofifered  by  the  kidney-substance  depends  also  upon 
the  readiness  with  which  the  current  is  permitted  to  pass  the  capillaries. 
N^ow,  it  has  been  found  experimentally  that  their  permeability  is  greater, 
and  that  within  a  given  time  more  water  proportionately  can  be  squeezed 
through  them,  in  the  adult,  than  in  the  child.  This  anatomical  difference 
may  therefore  be  the  reason  why  renal  diseases  are  so  much  more  frequent 
in  infancy  and  childhood  from  all  causes,  with  the  exception  of  that  one 
which  is  reserved  for  the  last  decades  of  natural  life,  viz.,  atheromatous 
degeneration. 

In  the  arteries  of  medium  and  small  calibre  the  elastic  membrane  is  a 
thin  and  simple  membrane ;  it  is  only  in  larger  arteries  that  elastic  fibres 
will  also  extend  into,  and  mix  Avith,  the  adjoining  layers.  The  elastic  mem- 
brane is  particularly  thin,  may  even  be  entirely  absent,  where  the  branches 
are  given  off  from  the  arteries.  It  is  here  that  spontaneous  hemorrhages  are 
most  apt  to  take  place.  It  is  here  also  that,  in  later  life,  aneurisms  are 
met  with,  such  as  find  no  ready  explanation  by  an  injury. 

The  anatomical  structure  of  the  three  umbilical  vessels  differs  from  that 
of  all  the  rest  of  either  arteries  or  veins  in  many  points,  principally  in  this, 
that  there  is  no  elastic  membrane  and  no  intima  in  the  arteries.  Some  elastic 
tissue  is  found  near  the  umbilicus,  and  it  gradually  increases  in  the  ab- 
dominal cavity ;  but  the  intima  is  not  developed  in  the  arteries  until  they 
are  in  close  proximity  to  the  iliac.  Thus  by  the  massive  and  powerful 
development  of  the  muscular  layer  it  is  explained  why  there  are  so  few 
hemorrhages  though  no  ligature  have  been  applied  to  the  cord. 

The  umbilical  vein  differs  from  the  arteries  very  much  less  than  is  usual 
with  veins  and  arteries  in  any  other  parts  of  the  body.  The  muscular  layer 
is  very,  large  and  strong  in  the  vein.  There  is  no  intima.  None  of  the 
three  vessels  emits  branches ;  there  are  no  vasa  vasorum  and  no  nerves  in 
their  walls. 

Altogether,  the  growth  of  the  internal  organs  and  the  whole  body  does 


INTRODUCTORY.  7 

not  proceed  uniformly.  In  this  respect  the  blood-vessels  do  not  stand 
alone.  What  Beneke  called  the  morbid  disjDOsition  of  the  several  ages,  is 
best  explained  by  these  variations  in  gro\vth  and  power.  That  author 
spent  much  time  and  labor  on  the  measuring  of  blood-vessels  in  particular. 
It  was  he  that  found  the  arteries  proportionately  wide  until  the  period  of 
puberty.  From  that  time  the  heart  increases  rapidly,  and  the  arteries  less. 
In  infancy  the  relation  of  the  volume  of  the  heart  to  the  width  of  tha 
ascending  aorta  is  25  :  20,  before  puberty  140  :  56,  and  after  puberty  290  :  61. 
Thus  it  is  that  the  general  arterial  blood-pressure  of  infants  is  less  and  the 
heart-beats  are  more  frequent. 

After  birth  the  pulmonary  artery  is  much  larger  than  the  aorta ;  after 
the  first  year  the  width  of  the  former  compared  with  that  of  the  latter  is 
46  :  40,  in  the  adult  35.9  :  36.2,  in  advanced  age  38.2  :  40.4.  It  is  easily 
understood  to  what  extent  both  the  normal  development  and  the  diseases  of 
the  lungs  may  be  influenced  by  these  relative  sizes  of  the  vessels.  That 
the  size  and  strength  of  the  right  heart  should  have  a  favorable  influence 
on  the  course  of  a  pneumonia  is  an  inference  deserving  of  credit. 

The  reverse  of  the  normal  oversize  of  blood-vessels  in  the  infant  and 
child  is  found  in  abnormal  smallness,  particularly  of  the  arteries.  The 
worst,  and  mostly  incurable,  forms  of  chlorosis  are  the  results  of  this 
anomaly.  They  have  been  studied  by  Trousseau,  Virchow,  See,  and  others, 
in  connection  with  a  small,  or  normal,  or  fatty  heart,  and  in  their  compli- 
cations with  occasional  hemorrhagic  diathesis.  All  forms  of  persistent 
anaemia  may  depend  on  this  insufficient  development  of  the  arteries :  the 
specimens  taken  from  a  woman  of  thirty-two  years,  who  died  with  all  the 
symptoms  of  "  essential"  ansemia,  are  in  my  possession. 

To  the  consideration  of  the  organs  of  circulation  I  have  given  so  much 
prominence  because  of  their  pre-eminent  influence  in  etiology.  The  changes 
of  periods  of  life  and  advancing  age  are  mainly  occasioned  by  the  alterations 
in  the  structure  of  the  walls  of  the  blood-vessels.  Their  original  thinness 
and  fragility  occasion  hemorrhages  in  the  newly-born,  as  does  their  anoma- 
lous condition  in  senility.  Nor  is  there  any  organ  which  is  not  constantly 
under  the  control  of  the  blood-current.  This  chapter  would,  however, 
grow  to  undue  length,  and  encroach  too  much  upon  the  legitimate  province 
of  the  special  essays  devoted  to  the  consideration  of  the  subjects  to  which  I 
could  only  allude,  were  I  to  continue  to  enlarge  upon  them.  A  few  more 
remarks,  therefore,  may  suffice. 

There  are  anomalies  and  diseases  which  are  met  with  in  the  infant  and 
child  only.  Among  this  class  we  meet  congenital  diseases  and  malforma- 
tions, the  aflections  of  the  umbilical  cord,  of  the  ductus  arteriosus,  and  of 
the  tunica  vaginalis  of  the  spermatic  cord,  atelectasis  and  cyanosis,  the  dis- 
eases of  the  thymus,  the  anomalies  of  the  intestinal  tract,  congenital  consti- 
pation, as  I  have  called  it,  resulting  from  the  exaggeration  of  the  normal 
length  of  the  long  sigmoid  flexure,  and,  finally,  rhachitis. 

Other  diseases  are  mostly  found  in  children,  or  with  a  characteristic 


8  IXTEODUCTOEY. 

symptomatology  and  course.  Both  acute  and  chronic  hydrocephahis,  acute 
eruptive  diseases,  whooping-cough,  and  diphtheria  are  mostly  found  at  an 
early  age.  Diphtheria  is  veiy  liable  to  assume  different  characters  in  dif- 
ferent ages ;  even  the  simple  inflammations  of  the  tonsils  vary  in  severitv 
and  nature  according  to  the  amount  of  tissue  destroyed  or  new  hyperplastic 
connective  tissue  formed  in  the  course  of  repeated  attacks.  Almost  all  the 
diseases  of  the  intestinal  tract  in  children  have  their  peculiarities,  and  re- 
quire the  special  study  of  foods  and  hygiene.  The  majority  of  cases  of 
intussusception  take  place  in  infants,  in  localities  and  with  symptoms  of 
their  own. 

There  are  diseases  which  affect  both  the  young  and  the  old  :  in  them 
the  size  or  nature  of  the  organ,  or  the  difference  in  the  degree  of  irrita- 
bility, affect  the  symptomatology  of  the  case  considerably.  In  the  narrow 
larynx  of  the  child,  diphtheria  gives  rise  to  the  complex  symptoms  of 
pseudo-membranous  croup.  Tracheotomy  and  intubation  are  subjects  emi- 
nently belonging  to  pediatrics.  In  the  vulnerable  infant  only,  intestinal 
worms  will  give  rise  to  convulsions ;  and  the  large  majority  of  cases  of 
poliomyelitis  and  polioencephalitis  also  are  resei'ved  for  infancy ;  indeed,  so 
great  is  the  difference  between  the  ages,  that  the  infant  is  the  proprietor  of 
the  medio-canellata,  while  the  adult  glories  in  the  taenia  solium  as  a  tenant. 
Let  me  add  that  there  are  differences  of  many  degrees  in  many  other  dis- 
eases, accordingly  as  they  occur  in  the  young  or  in  the  old.  The  pneu- 
monia, tuberculosis,  typhoid  fever,  rheumatism,  epilepsy,  and  diabetes  of 
the  young  differ  considerably  from  the  same  affections  of  the  adult,  in  their 
clinical  and,  sometimes,  anatomical  aspects. 

Therapeutics  of  infancy  and  childhood  are  by  no  means  so  similar  to 
those  of  the  adult  that  the  rules  of  the  latter  can  simply  be  adapted  to 
the  former  by  reducing  doses.  The  differences  are  many.  Among  the 
antifebriles  cold  is  tolerated  less,  quinia  more,  in  proportion,  than  in  the 
adult.  So  are  antipyrin  and  antifebrin,  also  phenacetin.  Heart-stimulants 
are  also  borne  in  relatively  large  doses :  thus,  digitalis,  strophanthus,  and 
sparteine.  Caffeine  is  less  advisable  except  where  there  is  positively  no 
cerebral  complication  of  a  congestive  or  inflammatory  nature.  Of  the 
narcotics,  opium  must  be  watched ;  its  doses  must  be  relatively  small. 
Belladonna  is  borne  in  rather  large  doses,  and  hyoscyamus  can  be  given  in 
much  larger  doses  proportionately  in  spasmodic  conditions  of  the  bladder 
than  in  advanced  age.  Some  of  the  powerful  medicines  are  required  in 
smaller,  some  in  larger  doses.  Chlorate  of  potassium  demands  great  care ; 
carbolic  acid  becomes  poisonous  in  small  doses  given  to  the  veiy  young, 
even  externally ;  preparations  of  arsenic  are  borne  in  rather  larger  doses 
for  many  weeks  and  months ;  corrosive  sublimate — mercurials  generally — 
in  rather  large  doses,  because  of  the  extraordinary  immunity  in  regard  to 
stomatitis  and  to  the  gastric  and  intestinal  irritation  so  often  observed  in 
the  adult. 

Now,  what  has  been  done  to  facilitate  the  acquisition  of  knowledge  on 


INTRODUCTORY.  9 

all  tbese  points  by  the  student  and  practitioner  of  medicine  ?  Very  little 
indeed.  There  never  was  any  systematic  instruction  in  the  diseases  of 
children,  by  a  teacher  appointed  for  that  branch  of  medicine  exclusively, 
until  (in  1860)  I  established  a  weekly  children's  clinic  in  the  New  York 
Medical  College,  at  that  time  in  East  Thirteenth  Street,  That  was  the 
first  of  its  kind  in  the  United  States.  When  the  college  ceased  to  exist  (in 
1865)  I  established  a  children's  clinic  in  the  University  Medical  College, 
and  in  1870  in  the  College  of  Physicians  and  Surgeons.  In  both  these 
institutions,  as  also  in  the  Bellevue  Hospital  Medical  College,  such  clinics 
have  existed  since,  and  a  number  of  the  medical  schools  of  the  country 
have  imitated  the  example. 

In  them,  a  single  hour  weekly,  during  the  regular  courses  of  the  winter, 
is  given  to  the  student  of  medicine  for  the  special  study  of  the  diseases  of 
children,  who  will,  in  his  future  practice,  form  the  majority  of  his  patients. 
In  the  course  of  two  so-called  years,  which  the  legislatures  of  our  States 
pronounce  sufficient  for  the  attainment  of  all  medical  knowledge  required 
for  the  welfare  of  the  country,  the  student  is  pressed  very  hard  for  time. 
There  are  a  number  of  branches  which  he  is  taug-ht  to  deem  worth  his 
while  and  attention,  by  being  told  that  he  will  be  examined  in  them  before 
obtaining  his  diploma ;  but  the  diseases  of  children  are  not  among  these. 
To  my  knowledge,  there  is  no  school  in  the  country  which  lays  the  least 
stress  on  that  branch  of  instruction ;  for  I  hope  there  is  nobody  nowadays, 
even  among  the  teachers  of  medicine,  who  believes  that  a  few  didactic 
lectures  of  the  professor  of  "  theory  and  practice"  are  a  sufficient  prepara- 
tion for  the  preservation  of  the  children  of  the  people.  Xo  examination 
being  required  by  those  to  whom  the  student  looks  for  direction  and 
enlightenment,  he  neglects  the  study,  to  find  out  too  late  the  mistake  he  has 
made  in  so  doino-. 

It  is  no  consolation  that  in  Great  Britain  the  same  complaints  are  made. 
But  a  few  months  ago  the  chairman  of  the  Section  of  Diseases  of  Children, 
Dr.  Cheadle,  spoke  in  feeling  terms  of  the  neglect  in  the  schools  and  clin- 
ical institutions  of  Great  Britain  of  this  most  important  part  of  practical 
medicine,  before  the  British  Medical  Association.  The  continent  of  Europe 
has  made  more  rapid  progress.  Most  of  both  the  large  and  the  small  uni- 
versities have  their  chair  of  the  Diseases  of  Children,  not  a  "  clinical"  one, 
which  means  the  authority  given  an  enthusiastic  worker  to  teach  as  much 
or  as  little  as  he  can  in  an  hour  weekly,  without  recognition,  thanks,  or 
reward,  of  a  doctrine  not  officially  recognized  ;  they  have  hospitals  in  which 
to  teach  practically  every  day  what  has  been  taught  in  didactic  lectures  and 
learned  from  books,  and  their  students  know  beforehand  that  they  will  have 
to  prove,  before  being  permitted  to  practise,  their  acquaintance  with  what 
they  are  compelled  to  learn  of  the  diseases  of  children.  Thus  it  is  in  France 
and  Italy,  in  Germany,  Austria,  and  Sweden ;  thus  it  is  now  in  Russia,  but 
not  so  in  England  and  in  our  country. 

What  can  be  done  to  improve  this  state  of  things  ? 


10  INTRODUCTORY. 

Every  future  improvement  in  general  medical  education  will  favor  the 
study  of  pediatrics.  There  will  be  a  time  in  the  near  future  when  the 
student  in  medicine  will  be  aware  that  he  will  have  to  pass  an  examination 
in  the  subjects  connected  with  the  physiology  and  pathology  of  the  young. 
There  will  be  another  time  when  the  medical  courses  will  be  both  long:  and 
numerous  enough  to  permit  of  clinical  instruction  in  the  diseases  of  children 
being  given  three  or  six  times  a  week,  and  another  in  which  there  will  be 
bedside  teaching.  For  that  purpose  it  is  that  either  special  hospitals  or 
large  wards  in  general  hospitals  are  an  absolute  necessity.  It  is  in  them 
only  that  the  student,  and  the  professional  man  also,  may  learn  under  super- 
vision, and  without  the  danger  of  each  having  to  fill  with  victims  a  burying- 
ground  of  his  own,  both  how  to  diagnosticate  a  disease  in  a  child  and  how 
to  nurse  and  treat  a  sick  one.  In  hospitals  alone  can  good  observations  be 
made  in  reference  to  the  course  of  diseases,  and  the  effects  of  remedies  and 
methods  of  treatment. 

Moreover,  special  societies  must  be  founded  for  the  purpose  of  studying 
questions  connected  with  pediatrics,  or  special  sections  formed  in  larger  and 
established  associations.  The  new  Children's  Section  in  the  New  York 
Academy  of  Medicine,  that  of  the  American  Medical  Association,  and  the 
successful  organization  of  the  American  Pediatric  Society  prove  the  inten- 
sity of  the  interest  the  American  profession  has  commenced  to  take  in  the 
subjects  legitimately  belonging  to  that  part  of  medical  science  and  practice. 

Finally,  all  of  the  latter,  as  well  those  to  which  I  could  but  incom- 
pletely allude,  as  all  others  suggesting  themselves  to  the  careful  observer 
and  thorough  student,  must  be  the  themes  of  persistent  individual  study. 
Besides,  as  there  must  be  time  to  learn  other  men's  observations,  so  time 
must  be  found  to  contribute  what  is  new  and  valuable  in  every  professional 
man's  life.  The  basis  on  which  to  proceed  is  to  be  furnished  by  this  Cyclo- 
psedia,  the  introductory  remarks  to  which  I  am  kindly  permitted  to  oJGFer. 
This  book  bids  fair  to  contain  all  that  is  knowm  at  present  on  the  anatomy, 
physiology,  pathology,  and  therapeutics  of  infancy  and  childhood.  INIay  the 
American  profession  see  to  it  that  this  same  book,  while  being  a  digest  both 
of  the  labors  of  the  past  and  the  attainments  of  the  present,  shall  become 
the  solid  foundation  of  successful  scientific  work  in  the  near  and  distant 
future. 


PART    I. 
GENERAL    SUBJECTS. 


ON  THE  ANATOMY  OF  CHILDREN. 

By  GEOEGE  McCLELLAN,  M.D. 


Of  the  differences  between  the  anatomy  of  children  and  that  of  adults 
it  may  be  said,  in  a  general  way,  that  the  bones  are  more  elastic  and  less 
firm ;  the  muscles  softer,  and  less  capable  of  great  effort ;  the  arteries,  veins, 
lymphatic  vessels,  and  nerves  larger  in  proportion  to  the  parts  which  they 
furnish,  drain,  or  supply  than  they  afterwards  appear,  and  the  thoracic  and 
abdominal  organs  developed  to  a  greater  degree  of  perfection  in  comparison 
to  the  brain  and  the  organs  of  generation. 

In  approaching  this  subject,  however,  it  should  be  borne  in  mind  that 
the  modifications  which  occur  before  and  after  birth,  at  the  separate  periods 
of  growth  towards  puberty,  are  so  subtle  that  it  is  difficult  to  assert  more 
than  a  limited  number  of  general  truths,  and  impossible  to  draw  any  reliable 
deduction,  except  by  the  special  study  of  each  period. 

In  addition,  therefore,  to  describing  the  important  anatomical  variations 
which  may  from  time  to  time  be  noted  in  each  part  of  the  body  separately 
considered,  in  the  long  gamut  of  changes  which  slowly  progress  through 
infancy  to  manhood,  the  subject  will  be  considered  regionally,  as  it  is  believed 
that  the  comparative  study  of  the  relations  which  these  parts  bear  to  one 
another  at  different  ages  will  give  the  most  practical  and  useful  knowledge 
to  the  reader. 

THE  HEAD. 

The  skin  of  the  scalp  in  children  is  thicker  than  it  is  in  any  other  part 
of  the  body ;  it  is  closely  adherent  to  the  aponeurosis  of  the  subjacent 
muscle  (the  occipito-frontalis),  and  whenever  that  muscle  moves,  it  moves 
with  it.     This  mobility  of  the  scalp  is  even  more  noticeable  in  infancy. 

The  pericranium  is  very  slightly  attached  to  the  skull-bones,  but  at  the 
sutures  it  is  intimately  blended  with  the  membrane  between  the  sofl  and 
growing  bones  of  the  young  child's  head ;  it  is  somewhat  lax,  and  admits 

11 


12 


ON    THE    ANATOMY    OF    CHILDEEN. 


Fig 


of  limited  extravasations  of  blood  beneath  it,  which  are  usually  congenital, 
and  are  due  to  pressure  on  the  head  at  birth,  when  the  bones  are  very  vascu- 
lar as  well  as  soft.  In  the  temporal  region  the  pericranium  is  more  adherent 
to  the  bone  than  anywhere  else.  Embryology  shows  that  the  vault  of  the 
skull  is  formed  in  membrane,  and  the  base  in  cartilage;  and  pathology 
often  makes  the  distinction  more  manifest.  The  bones  of  the  vertex  appear 
before  those  of  the  base,  but  at  birth  ossification  is  more  advanced  in  the 
base.  The  occipital  and  sphenoid  bones  are  united  at  their  basilar  portions 
about  the  twentieth  year.  The  sutures  usually  become  obliterated  some 
time  after  the  complete  formation  of  the  skull,  but  the  time  of  their  dis- 
appearance is  extremely  variable.  The  fontanelles,  or  the  intermembranous 
spaces  at  the  angles  of  the  parietal  bones,  normally  disappear  before  the  age 
of  four  years.     The  anterior  fontanelle,  at  the  junction  of  the  coronal  and 

sagittal  sutures,  is  the  largest, 
and  is  usually  closed  at  the  end 
of  the  second  year.  Sometimes 
it  persists  throughout  life ;  but 
these  cases  are  generally  due 
to  hydrocephalus  (see  Fig.  1). 
The  yielding  nature  of  the 
young  child's  skull  is  such  that 
it  may  be  indented  by  a  blow, 
or  compressed  by  a  bandage,  or 
its  shape  may  even  be  altered 
by  the  weight  of  the  contained 
brain  if  the  infant  is  habitually 
allowed  to  lie  on  one  side.  Su- 
pernumerary bones  (ossa  Wor- 
miana),  varying  in  size  and 
number,  are  frequently  found 
in  the  course  of  the  sutures.  Congenital  fissures  occasionally  occur  from 
the  arrest  of  the  ossifying  process,  and  are  liable  to  be  mistaken  for  frac- 
tures. The  frontal  suture  between  the  two  foetal  portions  of  the  frontal 
bone  usually  becomes  obliterated  shortly  after  birth,  but  may  remain  (see 
Fig.  2).  All  the  hollows  or  sinuses  are  rudimentary  at  birth,  and  remain 
of  small  size  up  to  about  the  ninth  year,  after  which  they  gradually  increase 
until  puberty,  when  they  undergo  great  enlargement, — notably  the  frontal, 
which  is  indicated  in  the  adult  skull  by  the  prominence  of  the  superciliary 
ridges.  The  thickest  parts  of  the  skull-cap  are  in  those  portions  which 
originally  were  developed  in  cartilage. 


Hydrocephalic  Skull  of  an  Infant,  showing  the 
sutures,  1,  and  fontanelles  in  exaggei'ation,  2 ;  Wormian 
bones,  3. 


THE   BEAIN   AND  ITS   MEMBRANES. 

The  dura  mater  in  the  young  is  adherent,  and  does  not  allow  extrava- 
sations to  collect  between  it  and  the  bone.  There  is  a  greater  amount  of 
fluid  in  the  subdural  space  in  childhood  than  is  usually  found  later  in  life, 


Fig.  2. 


Fig.  10 


Photograph  OF  feKLLL  uf  Infant  Seven  Months 
OLD. — 1,  anterior  fontanelle ;  2,  frontal  suture. 


Photograph  of  Skull  of  Infant  Seven 
Months  old,  showing  Proportionate  Size  of 
the  Face  to  the  Head. 


Fig.  3. 


Photograph  from  a  Dissection,  showing  the  Convuli  tions  .vnd  Fl-^si'rls  uf  the 
Brain  of  the  Infant.—],  lissure  of  Sylvius;  2,  fissure  of  Rolando;  3,  occipitoparietal 
fissure. 


ox    THE    ANATOMY    OF    CHILDEEX. 


13 


and  the  subaraohnoicleau  space  is  always  well  filled.  The  foramen  of 
Mao-endie,  which  is  an  opening  in  the  pia  mater  at  the  inferior  boundary 
of  the  fonrth  ventricle,  may  become  impervious  and  give  rise  to  hydro- 
cephalus by  an  excessive  accumulation  of  fluid  within  the  ventricles 
(Hikon). 

During  intra-utcrine  life  the  development  of  the  brain  is  very  active, 
and  at  birth  the  organ  is  relatively  of  large  size,  presenting  an  approxima- 
tion in  form  and  relations  to  the  adult  brain  (see  Fig.  3).  Up  to  the 
seventh  year  the  brain  grows  rapidly,  and  increases  slowly  in  weight  after 
that  period  throughout  life.  The  primary  fissures  of  the  cerebral  hemi- 
spheres— viz.,  the  Sylvian,  hippocampal,  parieto-occipital,  and  calcarine — 
appear  during  the  third  month  of  foetal  life.  The  secondary  fissures,  the 
most  important  being  the  fissure  of  Rolando,  appear  between  the  fifth  and 
sixth  months.  The  further  development  of  the  fissures,  and  consequently 
the  convolutions,  occupy  the  last  two  months  of  foetal  life,  and  the  first  five 
or  six  weeks  after  birth,  at  which  time  the  cerebral  surface  can  be  clearly 
mapped  out.  Much  attention  has  been  given  to  the  relation  which  the 
cerebral  fissures  and  convolutions  in  the  adult  bear  to  the  skull  and  scalp, 
on  account  of  its  practical  importance  in  surgery.  These  investigations 
have  recently  been  attended  with  remarkably  accurate  results ;  but  veiy  few 
have  studied  the  relations 

between  the  fissures  and  Ftg.  n. 

the  skull-sutures  in  chil- 
dren. The  main  pecu- 
liarities found  in  the  latter 
are  doubtless  due  to  the 
contemporaneous  devel- 
opment and  growth  of  the 
surrounding  parts.  Sy- 
mington, whose  recent 
work  in  this  department 
of  topographical  anatomy 
is  most  thorough  and  reli- 
able, shows  that  the  most 
important  difference  is  the 
higher  position  in  chil- 
dren of  the  fissure  of  Syl- 
vius, in  its  relation  to  the 
spheno-parietal  and  squa- 
mous sutures  (see  Fig.  4). 
He  found  it,  in  numerous 
frozen  sections  of  children 

of  different  ages  under  seven,  always  above  the  squamous  suture  and  covered 
by  the  parietal  bone.  Tlie  author  has  verified  this  by  dissections  of  children 
under  three  years  of  age,  as  in  Fig.  3.     Also  see  Fig.  5,  a  diagram  from 


Diagram  of  Relations  ok  Fissuke  of  Sylvius  (S)  to  Squamous 
Suture  (Sq)  in  a  Young  Child's  Head.— Fissure  of  Rolando,  R; 
coronal  suture,  C;  frontal  bone,  F;  parietal  bone.  P;  temporal 
bone,  T;  occipito-parietal  fissure,  OP;  cerebrum,  X;  cerebellum, 
Y;  medulla,  Z. 


14  ON   THE    ANATOMY    OF    CHILDEEN. 

dissections,  as  suggested  by  Symington.  From  careful  study  of  his  obser- 
vations it  is  probable  that  the  adult  relations,  where  the  squamous  suture 
is  said  to  correspond  with  the  horizontal  branch  of  the  Sylvian  fissure,  are 
attained  by  the  changes  which  occur  in  the  growth  of  the  skull,  which  tend 
to  raise  the  squamous  suture,  and  as  the  base  of  the  skull  increases  in  its 
breadth  it  is  more  likely  to  modifs'  the  form  of  the  brain  resting  upon  it, 
occasioning  a  descent  of  the  Sylvian  fissure. 

The  position  of  the  fissure  of  Rolando  in  an  infant  six  months  old  has 
been  found  to  correspond  with  that  of  the  adult  (as  in  Fig.  3).  Huschke 
has  shown  that  the  cerebellum  is  much  smaller  at  birth  as  compared  with 
the  cerebrum,  and  that  the  latter  overlaps  the  former  as  it  does  in  the 
adult. 

The  convolutions  of  the  brain  in  the  child  have  a  less  complex  arrange- 
ment than  in  the  adult,  and  the  sulci  between  them  are  less  deep.  The 
number  and  extent  of  the  convolutions  appear  to  bear  close  relation  to  the 
intellectual  power  of  the  individual  at  all  ages. 

THE   EYE   AND   ORBIT. 

The  first  stage  of  the  development  of  the  eyes  in  the  fcetus  begins  at  a 
very  early  period,  about  the  first  week,  and  proceeds  steadily  towards  per- 
fection at  the  time  of  birth.  There  is  a  vascular  tunic  surrounding  the  lens, 
the  front  of  which  closes  in  the  pupil,  and  is  called  the  pupillary  membrane. 
This  becomes  absorbed  and  atrophied  in  the  human  subject  before  birth. 
There  is  very  little  comparative  variation  in  the  structure  of  the  child's 
eye  and  its  relations  to  the  muscles  and  nerves  in  the  orbit  (see  Fig.  6). 
In  fact,  the  eye,  considered  as  the  organ  of  vision,  is  probably  as  perfect 
in  the  young  child  as  it  ever  is,  only  the  power  of  perceiving  requires 
further  development  of  the  brain-centre  which  presides  over  intelligent 
observation. 

The  orbital  plate  of  the  frontal  bone  is  often  incomplete  at  puberty,  and 
may  be  deficient  in  bony  matter  throughout  life.  Fatal  injuries  have  been 
frequently  reported  in  consequence  of  children  falling  upon  sharp  objects 
which  have  penetrated  the  orbital  plate  at  this  weak  point  and  entered  the 
brain.  The  capsule  of  Tenon  in  the  young  is  markedly  attached  to  the 
recti  muscles,  and  connects  them  with  the  globe  of  the  eyeball  and  the 
margins  of  the  orbit. 

In  operating  for  strabismus  the  capsule  requires  to  be  divided  after 
the  conjunctiva  has  been  cut  through,  else  the  section  of  the  muscle  cannot 
be  properly  made.  A  quantity  of  fat  occupies  the  orbit  behind  Tenon's 
capsule,  and  will  accommodate  foreign  bodies  of  considerable  size  (see 
Fig.  7). 

In  children  the  sclerotic  coat  is  somewhat  transparent,  and  appears 
bluish,  owing  to  the  deeper  hue  of  the  subjacent  choroid  coat.  The  con- 
vexity of  the  cornea  appears  to  vary  with  age. 


S  T.  <2  S  .S 

°  -  §  o  iT 
S  ^.  6  5 


r  a  2-  s 


s 

(-1 

3 

Cft 

3 
S 

■d 

K 

0 

=3 

"2 

3 

0 

C 

to* 

'p. 
3 

3 
0 

2 
li 

0) 

3 

0 

1) 

"3 

0 

p. 

3 

2 

3 

« 

cc 

"3 

_o 

p^ 

Cb 

Cl" 

^ 

'E 

•■"I 

s 

3 

0 

0. 

J2 

3 

IS] 

,2 

c 

lO" 

0 

M 

c 

00" 

{Z^" 

b 

■-3 

lO" 

.- 

„ 

QJ 

w  « 


iH  N   CO     >^i  lO   to    1>   CO 


oj  a  . 

.Sg3 

3  cS  — 

S  (H  o 
P  o3  .2 


OO  .S  A^   ^ 


iCCDt^  C0050t-(C^  CC  Tt<lOtDt^  OCOS 


"3    ^ 


a, 

03     >-     O 

a    o    ti 


rl     O    rt    .3, 


0 
0 

3 
erf 
0 

"3 

0) 

p. 

Fh 

0 

co" 

OJ 

p< 

0 

a> 

>< 

'S 

"3 
3 
3 

01 

a' 

2 

"a 
3 

a 

(-1 

to" 

-IT 

3 

0 

■c 

d 

'S 

'rt 

2 

3 
be 

a 

« 

3 

C 

03 

3 

3 

0 

"3 

0) 

a 

ON    THE    ANxiTOMY    OF    CHILDREN. 


15 


THE    EAR. 

The  development  of  the  ear  in  its  several  parts  is  very  unequal,  the 
structure  of  the  internal  ear  and  the  tympanic  cavity  and  auditory  ossicles 
bcinc  fully  formed  at  birth,  while  the  external  auditory  meatus,  Eustachian 
tube,  and  mastoid  portion  of  the  temporal  bone  undergo  many  modifications 
before  their  completion  at  puberty.  The  meatus  in  the  new-born  child  con- 
sists of  an  external  part,  which  is  cartilaginous,  and  an  internal  part,  which 
is  osseo-fibrous,  instead  of  completely  osseous  as  in  the  adult.  In  the  child 
the  osseous  portion  is  relatively  shorter  than  it  subsequently  becomes.  The 
entire  meatus  is  as  long  proportionately  in  the  child  as  in  the  adult  (see 
Fig.  4).  At  birth  the  meatus  passes  inward  and  inclines  downward.  The 
upper  walls  of  the  meatus  are  comparatively  thin,  and  are  apt  to  give  way 
in  abscess  or  bone-disease  and  occasion  meningitis.  The  pain  felt  by  chil- 
dren in  eating  when  suffering  with  inflammation  of  the  meatus  is  owing  to 
the  distribution  of  the  auriculo-temporal  nerve. 

At  birth  the  membrana  tympani  is  nearly  horizontal,  but  becomes  more 
oblique  as  age  increases. 

The  notch  of  Rivinus  is  the  deficiency  in  the  upper  part  of  the  bony 
ring  in  wdiich  the  membrane  is  attached,  and  rupture  may  occur  at  this 
point  from  concussion.  Suppurative  disease  of  the  middle  ear  may  damage 
the  chorda  tympani  nerve. 

There  is  a  petro-squamous  suture  in  the  roof  of  the  tympanum  in  infancy 
by  which  inflammatory  action  may  be  transmitted  from  the  lining  membrane 
to  the  dura  mater  (Symington). 

During  childhood  the  mastoid  processes  are  hardly  noticeable,  and  the 
mastoid  cells,  although  existing,  are  not  developed  until  after  puberty.  The 
mastoid  antrum  is  a  large  cavity 

in  the  mastoid  part  of  the  petro-  ^^°-  ^• 

mastoid  bone,  having,  like  the 
tympanic  cavity,  a  thin  roof 
separating  it  from  the  cranial 
cavity.  From  infancy  to  pu- 
berty there  is  a  continuous  for- 
mation of  new  bone  from  the 
periosteum  on  the  surface,  ren- 
dering the  outer  walls  of  the 
antrum  thicker  with  age.  It 
consists  of  cancellous  tissue,  and 
can  be  readily  penetrated  by  a 
knife  in  mastoid  disease  (see 
Fig.  8).  At  puberty  this  can- 
cellous tissue  becomes  hollowed  by  absorption  into  air-cells  which  com- 
municate with  the  antrum  and  one  another.  They  vary  in  size  in  differ- 
ent bodies  and  on  the  two  sides  of  the  same  head.     The  proximity  of  the 


■MC 


Section  of  Temporal  Bone  to  show  the  Mastoid 
Cells  (MC)  and  Antri'm  (MA)  in  the  Child  about 
Ten  Years  of  Age,— M,  Meatus  auditorius,  laid  open  at 
its  centre. 


16  ON    THE   ANATOMY   OF    CHILDEEN. 

lateral  sinus  renders  it  liable  to  become  involved  by  extension  of  inflam- 
mation in  suppurative  disease  of  the  mastoid  cells,  and  especially  so  in  the 
adult,  owing  to  the  thin  bony  septa  which  separate  the  cells  from  the  sinus. 
The  Eustachian  tube  is  at  first  horizontal,  but  becomes  gradually  di- 
rected downward. "  The  tympanic  orifice  to  the  tube  is  as  large  in  the  child 
as  in  later  life,  but  the  opening  from  it  into  the  pharynx  is  smaller.  There 
is  scarcely  any  osseous  tissue  in  the  composition  of  the  Eustachian  tube  at 
birth,  and  even  in  old  age  it  is  still  principally  cartilaginous  (see  Fig.  9). 
■I  Arnold's  nerve  supplies  the  back  of  the  concha  near  the  mastoid  process, 
and  its  connection  with  the  pneumogastric  has  been  shown  by  the  produc- 
tion of  coughing  and  vomiting  in  consequence  of  irritation  by  foreign  bodies 
having  been  introduced  by  children  into  the  ears  in  play. 

THE   NOSE. 

The  first  depression  which  indicates  the  nose  in  the  early  embryo  occurs 
about  the  fourth  week.  Its  formation  continues  with  the  growth  of  the 
face,  and  it  is  of  relatively  small  size  in  the  young  child.  The  centre  of  the 
nasal  fossae  is  the  widest  part,  and  foreign  bodies  are  often  retained  there  for 
long  periods  of  time.  At  all  ages  the  fossse  are  very  narrow  above  the  lower 
border  of  the  middle  turbinated  bones.  The  septum  of  the  nose  is  usually 
straight  up  to  the  seventh  year  ;  after  that  it  very  commonly  inclines  to  one 
side.  The  infundibulum  connects  the  antrum  of  Highmore  with  the  frontal 
sinus  (see  Fig.  6).  When  there  is  a  direct  joassage  into  the  middle  meatus 
it  is  not  so  common  as  supposed.  The  suture  between  the  nasal  and  frontal 
bones  sometimes  gives  place  to  a  protrusion, — i.e.,  meningocele  or  encepha- 
locele, — which  may  be  mistaken  for  nsevoid  growths  such  as  frequently  occur 
at  this  locality.  Severe  catarrh  of  the  nasal  mucous  membrane  in  infancy 
may  occasion  depression  of  the  bridge  of  the  nose.  A  coryza  may  be  ex- 
tended by  continuity  of  structure  to  the  Eustachian  tube,  lachrymal  sac,  and 
conjunctiva,  and  even  the  frontal  sinus  and  antrum.  In  children  there  is 
almost  always  a  communication  between  the  nasal  veins  and  the  superior 
longitudinal  sinus  through  the  foramen  caecum.  This  is  usually  closed 
about  puberty.  There  is  a  venous  plexus  about  the  inferior  turbinated  bone, 
and  the  paroxysms  of  whooping-cough  often  bring  on  epistaxis  through 
interference  with  the  venous  circulation  of  the  nose.  The  anterior  part  of 
the  nose  is  supplied  by  the  nasal  nerve,  which  is  a  branch  of  the  ophthalmic, 
and  hence  the  lachrymation  which  follows  the  introduction  of  irritants  into 
the  nostrils. 

THE    FACE. 

The  skin  of  the  face  is  everywhere  very  thin,  having  loose  cellular  tissue 
excepting  over  the  alse  of  the  nose  and  the  chin,  where  it  is  closely  adherent 
to  the  parts  beneath. 

A  careful  study  of  the  face  in  young  children  will  prove  of  great  value 
to  the  physician  in  forming  a  diagnosis  in  many  diseases  peculiar  to  them. 


ox    THE    ANATOMY    OF    CHILDREN.  17 

Au  infant  is  unable  to  communicate  ideas  by  speech,  and  the  only  way  of 
obtaining  information  is  by  carefully  noticing  the  expression  and  gestures. 
The  particular  locality  of  pain  is  often  ascertained  by  this  means.  Con- 
traction of  the  brows  indicates  pain  in  the  head  ;  sharpening  of  the  nostrils, 
pain  in  the  chest ;  and  draNving  of  the  upper  lip,  pain  in  the  abdominal 
region. 

M.  Jadelot  long  ago  pointed  out  certain  furrows  or  lines  which  become 
marked  in  the  face  of  a  child  suffering  from  serious  diseases.  According 
to  his  view,  the  oculo-zygomatic  line,  which  begins  at  the  inner  corner  of 
the  eye  and  passes  outward  towards  the  cheek-bone  beneath  the  lower  lid, 
shows  disorder  of  the  cerebro-nervous  system.  The  nasal  line,  passing 
from  the  ala  of  the  nose  round  the  corner  of  the  mouth,  points  to  disorder 
of  the  digestive  tract,  and  especially  if  associated  with  marked  dimpling  of 
the  cheek.  The  labial  line,  extending  from  the  angle  of  the  mouth  to  the 
lower  part  of  the  face,  is  a  sign  of  diseases  of  the  respiratory  organs. 

There  is  much  fat  in  the  subcutaneous  tissue,  especially  in  the  cheeks,  in 
oliildren.  Over  the  buccinator  muscles,  in  addition  to  the  ordinary  subcu- 
taneous layer  of  fat,  there  is  an  arrangement  of  fatty  lobules  surrounded  by 
a  capsule  on  either  side.  These  have  been  called  "  sucking  cushions,"  be- 
cause they  are  thought  to  be  instrumental  in  distributing  the  atmospheric 
pressure,  and  prevent  the  buccinator  muscles  being  pressed  inwai'd  between 
tlie  alveolar  arches  when  a  vacuum  is  created  in  the  mouth.  These  sucking 
pads  are  best  developed  in  infants,  but  may  be  found  at  all  periods  of  life 
(see  Fig.  7).  They  are  even  present  when  the  other  fat  in  this  region  is 
absorbed  during  the  wasting  diseases  of  childhood.  The  bony  walls  of  the 
cheeks  in  the  young  are  thicker  than  in  the  adult,  because  the  maxillary 
sinuses,  or  antra  of  Highmore,  are  hollowed  out,  chiefly  by  absorption. 

The  face  is  frequently  the  seat  of  nsevi,  owing  to  the  great  vascularity  of 
its  tissues.  Injections  of  nsevi  in  infancy  may  occasion  thrombosis,  which 
has  in  some  instances  proved  fatal,  owing  to  the  direct  communication  be- 
tween the  facial  vein  and  the  internal  jugular.  Mumps  may  give  rise  to 
cerebral  hypersemia  through  pressure  upon  the  internal  jugular  vein. 

The  lips  are  very  vascular,  and  are  often  the  seat  of  vascular  tumors. 
The  branches  of  the  coronary  arteries  run  close  to  the  mucous  lining  of  the 
mouth  beneath  the  outer-lying  muscles,  and  can  be  readily  felt  pulsating  by 
pressing  the  lip  from  within.  There  are  many  submucous  glands  about  the 
li))s,  which  are  supposed  to  cause  enlarged  lip  by  becoming  hypertrophied. 

THE   .JAWS   AND   TEETH. 

The  small  size  of  the  facial  portion  of  the  skull  at  birth  and  during 
early  childhood  is  due  to  the  rudimentary  condition  of  the  jaws  and  teeth 
(see  Fig.  10).  Tlie  u])]ier  and  lower  maxillary  bones  commence  to  ossify  at 
a  very  early  period,  the  lower  one  first.  They  are  developed  very  slowly, 
and  undergo  various  modifications,  de])ending  mainly  u])on  the  eruption  of 
the  teeth,  until  their  comj)lete  form  is  attained  at  })uberty.  The  gums  are 
Vol.  I.— 2 


18  ON    THE    ANATOMY    OF    CHILDREN. 

composed  of  a  dense  fibrous  tissue^  covered  by  a  vascular  mucous  membrane 
of  very  slight  sensibility.  Tliey  form  a  tough  protecting  covering  to  the  de- 
veloping teeth  until  the  eruption  of  the  latter.  They  are  closely  connected  to 
the  periosteum  of  the  alveolar  processes  and  surround  the  necks  of  the  teeth. 
The  gums  in  new-born  children  do  not  meet,  and  until  the  further  develop- 
ment of  the  alveolar  arches  and  teeth  there  is  always  a  separation  between 
them.  There  are  two  sets  of  teeth,  both  of  which  appear  at  different  periods 
during  childhood, — the  first,  called  the  temporary,  giving  way  to  the  second, 
called  the  permanent.  The  development  of  the  temporary  teeth  in  the  fcetus 
begins  with  the  first  formation  of  the  jaws,  about  the  seventh  week.  The 
teeth  are  ultimately  simply  calcified  mucous  membrane.  The  stages  of  their 
development  have  been  more  carefully  studied  than  perhaps  any  other  por- 
tion of  the  body  in  this  important  period  of  life.  Briefly  stated,  the  process 
may  be  summed  up  as  follows : 

The  primitive  dental  groove  is  caused  by  a  turning  inward  or  depression 
of  the  oral  epithelium,  forming  a  furrow  in  the  edges  of  the  jaws,  from  the 
bottom  of  which  a  vascular  ridge  of  papillse  springs  up  contemporaneously.. 
Each  of  these  papillse  gradually  assumes  the  shape  of  a  future  tooth  and  is 
covered  with  a  cap  of  epithelial  cells,  which  undergo  a  differentiation  so  as 
to  form  the  dentine,  the  enamel,  and  the  cement.  The  changes  which  take 
place  in  the  bones  of  the  jaws  relate  only  to  the  formation  of  the  sockets  of 
the  teeth.  At  first  there  is  no  appearance  of  alveoli,  but  as  the  changes 
occur  in  the  mucous  membrane  by  which  the  teeth  are  developed,  there  is 
also  a  groove  formed  in  the  jaw  itself,  which  by  degrees  becomes  wider  and  is 
divided  across  by  thin  bony  partitions.  The  edges  of  the  alveoli  are  turned 
towards  one  another  shortly  after  birth,  so  as  to  protect  the  developing  tem- 
porary teeth  from  injury. 

The  germs  of  the  temporary  teeth  make  their  appearance  from  the  seventh 
to  the  twelfth  week  of  embryonic  life.  They  are  not  set  vertically  opposite 
one  another  in  the  two  dental  arches,  the  upper  jaw  teeth  being  in  front  of 
the  lower.  They  are  very  imperfectly  developed  at  birth,  and  are  only  fully 
formed  about  the  age  of  four  and  a  half  years.  They  number  twenty, — four 
incisors,  two  canine,  and  four  molars  in  each  jaw.  Their  periods  of  eruption 
after  birth  are,  approximatively,  the  central  incisors  about  the  seventh  month, 
the  lateral  incisors  from  the  eighth  to  the  tenth  month,  the  anterior  molars 
from  the  twelfth  to  the  eighteenth  month,  the  canine  from  the  fourteenth  to 
the  twentieth  month,  the  posterior  molars  from  the  eighteenth  to  the  thirty- 
sixth  month.     The  lower  teeth  generally  precede  the  upper  ones. 

The  permanent  teeth  consist  of  two  groups, — ^those  which  have,  and  those 
which  have  not,  predecessors.  To  the  former  group  belong  the  incisors, 
canines,  and  bicuspids;  to  the  latter,  the  molars.  The  incisors,  canines,, 
and  bicuspids  directly  succeed  to  the  positions  occupied  by  the  temporary 
teeth,  and  correspond  in  number  to  them.  The  molars,  three  in  number,  on 
either  side  of  either  jaw,  are  the  additional  permanent  teeth.  The  develop- 
ment of  the  first  group  of  the  permanent  teeth  is  effected  in  a  manner 


Fig.  11. 


Fig.  12. 


Skull  of  Child  Seven  Years  old,  showing 
Permanent  and  Tempokaky  Sets  of  Teeth. 


Jaws  of  Child  about  Seven  Years  old,  show- 
ing Temporary  and  Permanent  Sets  of  Teeth, 
except  the  Wisdom. 


Fig.  29. 


I  .'iM&i^^ ..^.,^.  

Photograph  from  a  Dissection,  showing  Kelation.s  and  Position  and  Shape  of  the 
Bladder  and  Uterus  in  the  Infant.— 1,  umbilicus;  2,  bladder;  3,  uterus;  4,  hypogastric 
arteries;  5,  intestines;  6,  pubic  sympliysis. 


ox    THE    ANATOMY    OF    CHILDREN.  19 

analogous  to  that  of  the  temporaiy  teeth,  having  a  second  dental  furrow 
formed  out  of  the  epithelial  lining  of  the  gums  and  vascular  papillse.  In 
the  process,  the  sac  which  encloses  each  tooth-germ  becomes  attached  to  the 
back  of  the  sac  of  a  temporary  tooth.  The  three  additional  permanent 
teeth,  the  molars,  are  developed  by  successive  prolongations  of  the  epithelial 
tissue  towards  the  angles  of  the  ja>vs.  The  calcification  of  the  permanent 
teeth  extends  from  before  birth  to  about  the  twelfth  vear  of  life.  The  fano-s, 
or  roots,  of  the  temporary  teeth  disappear  by  absorption  as  the  permanent  teeth 
become  developed,  and  the  loose  crowns  gradually  become  detached,  giving 
place  to  the  new-comers.  The  eruption  of  the  permanent  teeth  takes  place 
usually  as  follows :  the  first  molars  at  six  and  a  half  years,  the  middle 
incisors  in  the  seventh  year,  the  lateral  incisors  in  the  eighth  year,  the  first 
bicuspid  in  the  ninth  year,  the  second  bicuspid  in  the  tenth  year,  the  canine 
about  the  twelfth  year,  the  second  molars  from  the  twelfth  to  the  thirteenth 
year,  the  third  molars  (wisdom-teeth)  from  the  eighteenth  to  the  twenty-first 
year,  or  later.  The  lower  jaw  teeth  precede  the  upper  jaw  teeth,  as  in  the 
temporary  set. 

About  the  sixth  year  of  age,  before  the  temporary  incisors  are  shed,  the 
jaws  contain  all  the  temporary  and  permanent  teeth,  except  the  wisdom- 
teeth  (see  Figs.  11  and  12). 

During  the  growth  of  the  teeth,  the  lower  jaw  increases  in  depth  and 
length,  and  changes  its  form.  At  birth  this  bone  consists  of  two  lateral 
halves  united  by  fibro-cartilage.  The  body  is  a  mere  shell  of  bone,  and  the 
angle  of  the  jaw  is  obtuse.  About  the  first  year  the  two  halves  become 
jointed  at  the  symphysis.  The  jaw  becomes  gradually  elongated  behind 
the  mental  foramen,  so  as  to  accommodate  the  three  extra  permanent  molars. 
The  angle  also  steadily  becomes  less  obtuse  until  adult  age  is  reached,  when 
it  is  nearly  a  right  angle.  In  old  age  it  becomes  again  obtuse.  The  differ- 
ence in  width  between  the  incisors  of  the  temporary  and  permanent  sets  is 
compensated  for  by  the  smallness  of  the  bicuspids  in  comparison  with  the 
temporary  molars  to  which  they  succeed. 

THE   TONGUE. 

The  tongue  is  rarely  the  seat  of  congenital  defects,  and  ''  tied  tongue,"  or 
contraction  of  the  frsenum  linguse,  is  not  so  often  met  with  among  children 
as  commonly  supposed.  The  ranine  vessels  occupy  the  position  of  the 
elevated  folds  of  mucous  membrane  on  the  under  surface  of  the  tongue 
converging  at  its  tip.  The  artery  is  more  deep  than  the  vein  on  either 
side  (see  Figs.  6  and  7).  If  the  frsenum  and  subjacent  muscular  fibres 
be  too  freely  divided  in  operating  for  tongue-tic,  there  is  danger  of  the 
child,  in  its  efforts  'at  sucking,  tearing  these  lax  fibres  farther  open,  so 
that  the  tongue  may  be  forced  down  upon  the  epiglottis  by  the  muscles 
of  deglutition  and  occasion  suffocation. 


20  ON   THE    ANATOMY    OF    CHILDREN. 


THE    PALATE. 


The  arch  of  the  hard  palate  varies  in  height  and  shape  in  different 
individuals,  and,  according  to  Treves,  it  is  particularly  narrow  and  high  in 
congenital  idiots.  Cleft  palate  is  a  congenital  defect  in  the  middle  line,  and 
may  involve  the  soft  palate  or  uvula,  extending  sometimes  forward  to  the 
alveolus.  In  front  of  this  the  cleft  occurs  at  the  suture  between  the  upper 
maxillary  and  intermaxillary  bones. 

Hare-lip  is  a  fissure  in  the  upper  lip  opposite  this  suture.  It  may  be 
double,  occurring  on  both  sides  of  the  os  incisivum, — this  bone  appearing 
to  be  attached  to  the  septum  of  the  nose.  The  suture  referred  to  is  only 
noticeable  in  very  early  life,  and  the  so-called  inter-  or  pre-maxillary  bone 
does  not  exist  in  the  human  subject,  except  upon  the  occurrence  of  congenital 
defects  at  these  sutures.  Most  commonly  hare-lip  is  uncomplicated  with 
cleft  palate.  Hare-lip  and  cleft  palate  are  due  to  the  imperfect  closure  of 
the  foetal  gaps  in  these  situations.  The  mucous  membrane  covering  the 
hard  palate  cannot  be  separated  from  the  periosteum ;  it  is  thickened  at  the 
alveoli.  The  descending  palatine  branch  of  the  internal  maxillary  artery 
supplies  the  tissues  of  the  hard  palate.  It  comes  through  the  posterior 
palatine  canal  at  the  side  of  the  last  molar  tooth  and  runs  forsvard  to  the 
anterior  palatine  canal  lying  close  to  the  bone.  A  cleft  in  the  soft  palate  is 
widened  by  the  action  of  the  levator  and  tensor  palati  muscles. 

THE   PHAKYNX. 

The  pharynx  is  always  widest  near  the  hyoid  bone  and  narrowest  oppo- 
site the  cricoid  cartilage.  A  finger  can  easily  reach  the  latter  part  in  the 
child,  where  foreign  bodies  are  apt  to  lodge.  The  connective  tissue  between 
the  pharynx  and  the  spine  is  very  lax.  The  internal  carotid  artery  and  the 
pneumogastric,  glosso-pharyngeal,  and  hypoglossal  nerves  are  in  relation  to 
the  walls  of  the  pharynx  on  either  side  (see  Fig.  9).  The  artery  can  be 
felt  by  the  finger  introduced  through  the  mouth. 

THE   TONSILS. 

The  tonsils  are  situated  between  the  palatine  arches  opposite  the  angles 
of  the  lower  jaw,  and  when  enlarged  project  into  the  cavity  of  the  pharynx, 
and  cannot  so  readily  be  felt  externally  as  commonly  supposed.  The  ton- 
sils are  moved  inward  by  the  superior  constrictor  and  outward  by  the  stylo- 
pharyngei  muscles.  A  child  with  prominent  anterior  arches  of  the  palate 
and  vigorous  muscles  of  deglutition  offers  great  difficulty  to  the  operator  in 
removal  of  the  tonsils.  The  orifice  of  the  Eustachian  tube  may  be  blocked 
by  interference  with  the  function  of  the  tensor  palati  muscles,  but  not  by 
pressure  of  an  hypertrophied  tonsil.  The  tonsils  derive  their  blood  from 
the  branches  from  the  facial  artery,  mainly.  The  internal  carotid  is  not 
in  immediate  relation  with  this  gland,  as  usually  described.  In  the  child 
it  is  comparatively  out  of  the  way,  and  is  always  behind  it.     The  ascending 


Yu:.  r?,. 


Longitudinal  Section  (frozen) 
FROM  A  Child  about  Six  Years  of 
Age,  by  Symington.— 1,  superior 
longitudinal  sinus ;  2,  inferior  longi- 
tudinal sinus ;  3,  veins  of  Galen  ;  4, 
falx  major ;  5,  straight  sinus ;  6, 
falx  minor ;  7,  medulla ;  8,  odontoid 
process ;  9,  body  of  atlas  vertebra ; 
10,  cricoid  cartilage ;  11,  seventh 
cervical  vertebra;  12,  trachea;  13, 
lymphatic  glands;  14,  right  pulmo- 
nary artery  ;  15,  oesophagus  ;  16,  left 
auricle ;  17,  diaphragm ;  18,  lobulus 
Spigelii ;  19,  twelfth  dorsal  verte- 
bra; 20,  aorta;  21,  superior  mesen- 
teric vein  ;  22,  third  part  of  duode- 
num ;  23,  left  iliac  vein  ;  24,  sigmoid 
flexure;  25,  rectum;  26,  recto-vesi- 
eal  pouch  of  peritoneum  ;  27,  peri- 
neum; 28,  corpus  callosum;  29, 
septum  lucidum ;  30,  anterior  cere- 
bral artery;  31,  sphenoidal  sinus; 
32,  pons  Varolii ;  33,  basilar  artery  ; 
34,  Eustachian  tube ;  35,  genio-hyo- 
glossus;  36,  genio-hyoid  :  ;37,  mylo- 
hyoid ;  38,  hyoid  bone ;  39,  thyroid 
cartilage ;  40,  cricoid  cartilage ;  41, 
isthmus  of  thyroid  gland  ;  42,  ante- 
rior jugular  vein  ;  43,  left  innomi- 
nate vein ;  44,  thymus  gland ;  45, 
pericardial  cavity;  .O,  aorta;  47, 
conus  arteriosus ;  48,  right  ventri- 
cle ;  49,  ensiform  cartilage ;  50,  left 
lobe  of  liver;  51,  pylorus;  52,  pan- 
creas; 53,  transverse  colon;  54, 
small  intestine;  55,  bladder;  56, 
symphysis  pubis. 


ON    THE    ANATOMY    OF    CHILDREN, 


21 


pharyngeal  artery  is  in  close  relation  Avith  the  tonsil,  and  severe  hemorrhao-e 
caused  by  wounds  of  this  vessel  has  often  been  attributed  to  injury  of  the 
internal  carotid  artery. 


THE    NECK. 

The  anatomy  of  this  region  in  childhood  varies  somewhat  from  that  of 
the  adult,  and  there  is  generally  more  subcutaneous  fat  and  greater  laxity  of 
connective  tissue.  The  assertion  that  the  neck  is  very  short  in  new-born 
children  is  probably  due  to  the  slight  development  of  the  face.  The  size  of 
the  various  parts  is  commensurate  with  the  stature  of  the  individual,  and  in 
considering  this  region  it  should  be  remembered  that  the  larynx  is  connected 
with  the  tongue  and  hyoid  bone,  and  that  their  position  is  associated  with 
that  of  the  jaws.  The  larynx  increases  in  size  and  grows  downward,  as  does 
the  face,  from  birth  to  puberty.  Careful  observations,  made  by  Symington 
and  others,  show  that  there  is  very  little  difference  in  size  in  the  two  sexes 
during  childhood.  As  boys  approach  puberty,  it  is  well  kno\vn  that  there 
is  a  very  marked  increase  in  the  size  of  the  larynx.  The  neck  is  limited  in 
front  by  the  symphysis  of  the  lower  jaw  and  the  top  of  the  manubrium 
sterni ;  and  it  is  important  to  note  that  the  latter  is  higher  in  relation  to  the 
vertebral  colimm  in  the  child 
than  in  the  adult.  In  survey- 
ing the  relations  and  taking 
measurements  for  surgical  pur- 
poses by  the  finger-breadth,  it 
is  well  to  employ  the  finger 
of  the  patient  in  question 
rather  than  that  of  the  ob- 
server. 

The  cricoid  cartilage  is 
always  prominent  in  infancy 
and  old  age,  in  fat  as  well  as 
lean  subjects,  and  is,  when  the 
head  is  upright,  about  opposite 
the  fifth  cervical  vertebra  (see 
Figs.  13  and  14).  When  the 
head  is  stretched  so  as  fully  to 
extend  the  neck,  it  is  raised 
opposite  the  fourth  vertebra; 
when  the  neck  is  flexed  acutely, 
it  corresponds  to  the  sixth  vertebra,  being  depressed.  The  cricoid  carti- 
lage is  the  most  reliable  landmark  in  the  neck.  A  line  drawn  across 
from  the  cricoid  cartilage  to  the  fifth  cervical  vertebra  will  indicate  the 
position  of  the  top  of  the  gullet,  and  also  the  point  where  the  common 
carotid  artery  is  crossed  by  the  omo-hyoid  muscle.  The  cartilages  of  the 
larynx  are  small  and  insignificant  in  the  child  and  easily  compressible,  but 


Transverse  Section  of  the  Neck  of  a  Child  about 
Six  Years  of  Age,  showing  Relations  of  the  Parts  to 
THE  Cricoid  Cartilage  in  Front  and  to  the  Sixth  Cer- 
vical Vertebra  Behind— 1,  middle  line ;  2,  sixth  cervical 
vertebra;  3,  cricoid  cartilage ;  4,  pharynx;  5,  internal  jugu- 
lar vein:  6,  pneumogastric  nerve;  7,  carotid  artery;  8, 
thyroid  body ;  9,  sternohyoid  muscle ;  10,  sterno-thyroid 
muscle;  11,  platysma;  12,  sterno-mastoid  :  13,  trapezius ;  14, 
vertebral  artery.    (By  the  author.) 


22  ON    THE    ANATOMY    OF    CHILDREN. 

towards  puberty  they  are  well  developed,  and  notably  so  in  the  male,  the 
notch  in  the  top  of  the  thyroid  cartilage  becoming  prominent  (the  pomum 
Adami).  The  thyro-hyoid  and  crico-thyroid  membranes  are  respectively 
about  as  wide  as  the  breadth  of  the  child's  finger.  The  ujDper  rings  of  the 
trachea  can  be  detected  only  in  very  thin  subjects,  and  then  by  stretching 
the  head  backward  over  a  pillow  or  block  so  as  to  distend  and  force  upward 
the  neck.  By  the  latter  procedure,  however,  the  innominate  artery  and 
veins  are  pulled  upward  into  the  supra-sternal  notch.  The  middle  line 
here,  as  elsewhere  in  the  body,  is  regarded  surgically  as  the  line  of  safety, 
owing  to  the  feeble  arterial  anastomosis  from  side  to  side.  About  the 
breadth  of  a  finger  from  the  cricoid  cartilage  is  the  isthmus  of  the  thyroid 
body,  and  below  it  are  the  inferior  thyroid  veins.  Occasionally  short  trans- 
verse connecting  links  between  the  two  anterior  jugular  veins  exist  also  in 
the  middle  line.  The  only  artery  is  the  crico-thyroid,  which  passes  along 
the  lower  border  of  the  thyroid  cartilage  over  the  crico-thyroid  membrane. 
There  is  little  danger  from  interfering  with  either  the  latter  or  the  isthmus 
in  tracheotomy,  but  much  trouble  may  arise  from  the  venous  links  or  in- 
ferior thyroid  veins  above  mentioned  (see  Fig.  15).  It  is  difficult  to  make 
an  injection  travel  across  the  isthmus  of  the  thyroid  gland.  In  little  chil- 
dren the  neck  is  usually  very  fat,  and  the  great  difficulty  in  tracheotomy 
is  in  fixing  the  trachea  in  the  middle  line,  owing  to  its  dej)th  and  mobility. 
The  calibre  of  the  trachea  may  be  said,  in  a  general  way,  to  correspond  to 
the  size  of  the  patient's  forefinger.  The  trachea  naturally  descends  with  the 
downward  growth  of  the  larynx,  and  we  find  in  the  new-born  child  that  its 
bifurcation  is  about  opposite  the  third  dorsal  vertebra,  while  in  the  adult  it 
is  opposite  the  fourth.  The  isthmus  of  the  thyroid  gland  is  usually  very 
small  in  children,  and  it  is  connected  by  strong  fibrous  tissue  to  the  sub- 
jacent cartilage. 

The  condition  known  as  wry-neck,  common  in  childhood,  is  produced 
by  some  congenital  defect  or  spasmodic  contraction  of  the  sterno-mastoid 
muscle  on  one  side  or  paralysis  of  the  corresponding  muscle  on  the  opposite 
side.  Holden  has  pointed  out  that  the  affection  may  also  be  due  to  the 
permanent  contraction  of  the  splenius  on  one  side.  The  sealeni  and 
trapezius  muscles  may  be  involved  as  well.  The  contraction  is  due  to 
reflex  irritation  through  the  cervical  plexus  and  its  connection  with  the 
spinal  accessory  nerve.  In  tenotomy  upon  the  sterno-mastoid  muscle  just 
above  the  clavicle  it  should  be  remembered  that  the  anterior  jugular  and 
external  jugular  veins  are  respectively  situated  at  the  anterior  and  poste- 
rior borders  of  the  muscle.  Sometimes  at  birth  a  tumor  is  noticed  in  the 
sterno-mastoid  muscle  which  has  been  attributed  to  tearing  of  its  fibres  in 
delivery.  The  deep  layers  of  fascia  in  this  region  are  more  lax  in  infancy, 
and,  although  they  form  distinct  sheaths  for  the  various  parts,  they  do  not 
offer  the  same  resistance  to  growths  and  abscesses  as  in  later  life,  and  not 
alw^ays  then  as  definitely  as  has  been  supposed. 

The  lymphatic  glands  in  the  neck  are  very  often  enlarged  and  inflamed 


Fig.  17. 


Right  side. 


J-eft  side. 


Photogra'Hed  from  Preparations  in  Mutter  Musetim,  College 
OF  Physicians  of  Philadelphia,  showing  Lymphatic  Vessels  of  Head, 
Face,  AND  Upper  Part  of  the  Neck  in  the  Infant. 


ON   THE    ANATOMY    OF    CHILDREN. 


23 


in   scrofulous   affectious  of  children   (see   Figs.   16    and    17).      They  are 
numerous,  and  have  been  tabulated  as  follows : 


Fig.  15. 


The  Antepjor  Region  of  the  Neck  in  the  Child  about  Nine  Years  of  Age,  drawn  by  Dr. 
McClellan.  The  sterno-thyroid  and  hyoid  muscles  are  removed,  to  show  the  deeper  relations  of  the  ves- 
sels and  thyroid  body.— 1,  hyoid  bone  ;  2,  left  carotid  artery,  near  its  bifurcation  ;  3,  left  pneumogastric 
nerve;  4,  left  internal  jugular  vein  ;  5,  upper  portion  of  sterno-thyroid  muscle;  6,  omo-hyoid  muscle ;  7, 
crico-thyroid  artery ;  8,  cricoid  cartilage ;  9,  isthmus  of  thyroid  body ;  10,  left  external  jugular  vein  ;  11. 
sterno-mastoid  muscle ;  12,  inferior  thyroid  veins ;  13,  lower  end  of  sterno-thyroid  muscle ;  U,  top  of  thy- 
roid cartilage  ;  15.  right  superior  thyroid  artery ;  16,  superior  laryngeal  nerve ;  1",  right  internal  jugular 
vein ;  18,  right  lobe  of  thyroid  body ;  19,  cervical  plexus  of  nerves;  20,  right  common  carotid  artery ;  21. 
right  pneumogastric  nerve;  22,  scalenus  anticus  muscle;  23,  right  inferior  thyroid  artery:  24,  supra- 
.scapular  vessels;  25,  right  recurrent  laryngeal  nerve;  26,  right  i)hrenic  nerve;  27,  innominate  vessels; 
2S,  remains  of  thymus  gland  in  the  supra-sternal  notch. 

"  Submaxillaiy  ten  to  fifteen,  situated  along  the  base  of  the  jaw  ;  supra- 
hyoid one  or  two,  between  the  chin  and  hyoid  bone;  superficial  cervical 
four  to  six,  along  the  external  jugular  beneath  the  platysma  muscle;  deep 
cervical  ten  to  twenty,  about  the  bifurcation  of  the  carotid  artery  and  upper 


24  ON   THE    ANATOMY    OF    CHILDEEN. 

part  of  the  internal  jugular;  lower  deep  cervical  ten  to  sixteen,  about  the 
lower  part  of  the  internal  jugular,  extending  to  the  supraclavicular  fossa 
and  continuous  with  the  axillary  and  mediastinal  glands." 

There  are  congenital  fistulse  occurring  occasionally  which  are  due  to 
persistence  of  the  so-called  branchial  clefts  of  foetal  life. 

There  is  a  tendency  for  foreign  bodies  which  descend  through  the 
trachea  to  pass  into  the  right  bronchus,  owing  to  the  bronchus  of  that  side 
being  larger  than  that  of  the  left,  and  to  there  being  a  septum  at  the  bottom 
of  the  trachea  occupying  the  left  of  the  median  line, 

THE    (ESOPHAGUS. 

The  oesophagus  presents  an  antero-posterior  curve  corresponding  to  the 
spinal  column,  and  deviates  at  its  commencement  to  the  left  side,  returning 
at  the  root  of  the  neck  to  the  middle  line  behind  the  trachea,  and  finally 
just  before  it  pierces  the  diaphragm  it  turns  again  to  the  left.  There  are 
three  slight  constrictions  in  the  tube,  corresponding  to  the  above  points  of 
deviation,  but  the  lowest  one  at  the  cardiac  opening  in  the  stomach  is  most 
contracted  and  offers  the  greatest  obstacle  to  the  further  passage  of  a  foreign 
body  (see  Fig.  13),  Its  diameter  in  the  adult  is  about  three-quarters  of  an 
inch,  and  diminishes  proportionately  with  the  youth  of  the  patient.  In  manv 
cases  within  the  writer's  observation  the  diameter  of  the  tube  has  not  ex- 
ceeded half  an  inch  in  children  about  ten  years  of  age,  although  capable  of 
distention  to  nearly  twice  that  extent. 

THE   THOEAX. 

There  is  much  variability  in  the  form  of  the  thorax  in  children  as  well 
as  in  adults,  even  when  in  health ;  and  very  commonly  a  want  of  symmetry 
is  noticed  in  the  two  sides  of  the  chest,  the  circumference  of  the  right  being 
greater  than  that  of  the  left.  In  early  infancy  the  top  of  the  sternum  is 
about  on  a  level  with  the  first  dorsal  vertebra,  Avhile  in  the  adult  it  is  oppo- 
site the  second.  This  change  is  due  to  the  causes  which  produce  the  normal 
curvatures  of  the  spinal  column.  The  ribs  are  very  yielding  throughout 
childhood,  and  any  undue  continued  pressure  or  direct  violence  may  cause 
lateral  flattening  or  depression.  In  rickets,  changes  occur  leading  to  the 
formation  of  bony  beads  at  the  juncture  of  the  ribs  and  their  cartilages. 
Pigeon-breast  is  a  peculiar  protuberance  of  the  sternum  caused,  it  is  thought, 
by  interference  with  inspiration.  In  strumous  children,  affected  with  chron- 
ically enlarged  tonsils,  there  is  sometimes  such  an  impediment  to  the  en- 
trance of  air  in  inspiration  that  the  thoracic  walls  yield  to  the  unbalanced 
atmospheric  pressure  brought  to  bear  upon  them  externally  (Shaw). 

The  most  elastic  part  of  the  thorax  is  where  the  ribs  join  their  carti- 
lages. In  early  childhood  the  ribs  are  flatter  and  less  hooped,  and  up  to 
the  end  of  the  third  year  breathing  is  more  abdominal  than  thoracic,  while 
after  that  age  in  boys,  and  in  men  too,  it  is  effected  by  the  action  of  the 
muscles  attached  to  the  lower  seven  ribs  as  well  as  the  diaphragm.    In  adult 


Fig.  18. 


Photograph  from  a  Dissection  in  which  the  Viscera  were  held  in  Position  by 
Transfixion  with  Pins:  from  a  child  about  ten  months  old. — 1,  clavicle;  2,  right  lung, 
covered  with  pleura;  3,  round  ligament  of  liver;  4,  right  lobe  of  liver;  5,  small  intestine 
pulled  aside  to  show  arrangement  of  .sigmoid  flexure  ;  6,  thymus  gland  ;  7.  first  rib  ;  8.  second 
rib;  9,  third  rib;  10,  fourth  rib;  11,  apex  of  heart,  covered  with  pericardium;  12,  fifth  rib; 
13,  diaphragm;  14,  left  lobe  of  liver;  15,  stomach  ;  Ifi,  sigmoid  flexure;  17,  bladder;  18,  left 
lung,  covered  with  pleura,  approaching  the  right  in  the  middle  line. 


ON    THE    ANATOMY    OF    CHILDREN,  25 

females  the  upper  ribs  are  brought  more  into  play,  whieh  is  a  natural  adap- 
tation of  the  chest  to  the  condition  of  the  abdomen  during  pregnancy. 

The  intercostal  muscles  have  very  little  power  over  the  ribs  until 
towards  puberty,  and  chiefly  aid  the  diaphragm  in  the  motions  of  tranquil 
breathing ;  but  in  forced  inspiration  the  shoulders  are  steadied  by  the  great 
staying  muscles  attached  to  them  and  to  the  collar-bones  and  upper  part  of 
the  chest,  so  as  to  allow  greater  expansion  of  the  thoracic  cavity.  Expira- 
tion is  performed  mainly  by  the  simple  elastic  properties  of  the  chest-walls 
relaxing  after  the  effort  of  inspiration.  Respiration  is  in  a  measure  under 
the  control  of  the  will,  but  the  phenomena  attendant  upon  it  are  mainly  due 
to  the  influence  of  the  pneumogastric  and  phrenic  nerves.  Drs.  Carpen- 
ter and  INIarshall  Hall  have  shown  that  there  are  other  sources  of  respira- 
tory excitation.  The  fact  that  a  new-born  infant  first  begins  to  draw  breath 
vigorously  when  the  air  comes  in  contact  with  its  face  leads  to  the  inference 
that  the  surface-nerves  play  an  important  part  in  inciting  the  first  inspira- 
tory eflbrt  and  no  doubt  assist  the  effort  of  respiration  at  all  times. 

THE   THYMUS   GLAND. 

This  glandular  body  is  situated  just  behind  the  top  of  the  sternum, 
extending  when  fully  developed  at  the  end  of  the  second  year  into  the  root 
of  the  neck  over  the  trachea,  and  separated  from  the  great  vessels  by  the 
thoracic  fascia.  It  rests  below  upon  the  pericardium  just  above  the  point 
where  the  pleurae  approach  each  other  (see  Fig.  18).  After  the  second  year 
it  diminishes  until  it  entirely  disappears  or  is  substituted  by  a  mass  of  fat. 
It  is  of  a  pinkish-gray  color  and  lobulated,  and  at  birth  weighs  half  an 
ounce.  It  is  very  vascular,  and  is  now  supposed  to  be  concerned  in  the 
production  of  the  colored  blood-corpuscles. 

THE    PLEURA. 

The  pleurae  in  a  young  child  are  quite  thick  in  their  costal  relations. 
The  pleurae  generally  reach  as  low  as  the  articulation  of  the  twelfth  ribs 
with  their  vertebrae,  and  sometimes  to  the  transverse  process  of  the  first 
lumbar  vertebra.    This  should  be  remembered  in  operating  upon  the  kidney. 

THE   LUNGS. 

The  lungs  are  of  a  pinkish-gray  color  at  birth,  and  become  more  gray, 
and  finally  mottled  gray  and  black,  owing  to  the  chemical  changes  in  their 
tissue  derived  from  the  air  and  blood  in  the  processes  of  respiration.  The 
vesicles  increase  in  size  from  birth  to  old  ajje.  "  In  the  foetus  at  the  full 
period  or  a  still-born  child,  the  lungs,  comparatively  small,  lie  jiackcd  at 
the  back  of  the  thorax,  and  do  not  entirely  cover  the  side  of  tlie  jiericar- 
dium  ;  after  respiration  has  been  established  they  expand  and  completely 
cover  the  pleural  portions  of  the  sac,  and  are  also  in  contact  with  almost 
the  whole  extent  of  the  thoracic  wall,  where  it  is  covered  with  the  pleural 


26  ON    THE    ANATOMY    OF    CHILDREN. 

membrane.  At  the  same  time  their  previously  thin  sharp  margins  become 
more  obtuse,  and  their  whole  form  is  less  compressed."     (Quaiu.) 

In  children  the  respiratory  eiforts  are  very  rapid,  being  forty-four  in 
a  minute  at  birth,  twenty-six  in  a  minute  at  fiye  years  of  age,  twenty  in  a 
minute  from  fifteen  to  twenty  years,  and  after  that  age  about  sixteen  in  a 
minute. 

The  apices  of  the  lungs  in  children  very  closely  correspond  in  their 
relations  to  those  of  the  adult,  mounting  as  high  in  the  neck  above  the 
clavicle  as  two  finger-breadths  behind  the  subclavian  arteries.  The  vesicu- 
lar sounds  can  best  be  heard  below  the  clavicle,  and  the  bronchial  sounds 
at  the  ujDper  part  of  the  sternum  (see  Figs.  19,  20,  and  21).  In  the  latter 
situation  there  is  no  lung-tissue  overlying  the  bronchial  tube,  the  lungs  con- 
verging from  the  sternal  ends  of  the  clavicles  towards  the  middle  line,  where 
their  borders  nearly  meet  opposite  the  junction  of  the  second  ribs  and  the 
sternum.  Below  this  latter  point  to  the  level  of  the  fourth  costal  cartilage 
the  inner  margins  of  each  lung  run  parallel,  and,  although  not  so  close  in 
the  child  as  in  the  adult,  overlap  the  great  vessels  at  the  root  of  the  heart 

(see  Fig.  18). 

THE   HEART. 

In  the  early  stages  of  foetal  formation  the  heart  occupies  nearly  the 
whole  of  the  thoracic  cavity,  and,  comjjaratively  speaking',  is  much  larger 
than  at  later  periods  or  subsequent  to  birth.  The  auricular  portion  exceeds 
the  ventricular,  and  the  right  auricle  is  more  capacious  than  the  left,  the 
right  ventricle  being  smaller  than  its  fellow.  The  organ  is  also  placed 
vertically  within  the  thorax  in  its  early  stages.  Just  before  birth,  however, 
these  peculiarities  d  sappear,  and  the  ventricular  portion  becomes  the  larger 
part,  the  left  having  the  thickest  walls,  and  the  whole  organ  rapidly 
approaches  its  normal  condition  for  life.  The  internal  structure  of  the 
foetal  heart  is  chiefly  different  from  that  of  the  adult  in  having  an  oval 
opening  (foramen  ovale)  between  the  two  auricles,  which  allows  a  communi- 
cation from  side  to  side,  and  in  the  large  size  of  the  Eustachian  valve  which 
directs  the  blood  froni  the  inferior  vena  cava  through  the  foramen  ovale. 
The  latter  generally  becomes  closed  within  the  first  week  or  ten  days  after 
birth,  but  may  remain  open  longer,  and  in  some  instances  has  been  found 
to  be  slightly  pervious  at  a  great  age.  The  Eustachian  valve  speedily 
dwindles  after  the  establishment  of  the  functions  of  the  lungs  and  the 
proper  circulation  of  the  blood. 

Contemporary  with  these  structural  alterations  are  changes  in  the  great 
vessels  upon  which  the  independent  circulation  of  the  blood  also  depends. 
The  pulmonary  artery  of  the  foetus,  after  leaving  the  right  ventricle,  gives 
off  the  right  pulmonary  branch,  and  then  divides  into  two  other  branches, 
the  first  of  which  is  quite  as  large  as  the  pulmonary  artery  itself,  about 
half  an  inch  long,  and  directly  joins  the  aorta  at  the  termination  of  its  arch, 
while  the  other  goes  to  the  left  lung.  The  connecting  branch  between  the 
pulmonary  artery  and  the  aorta  is  named  the  ductus  arteriosus  (see  Fig.  22). 


Fig.  19. 


Photograph  of  Girl  Baby,  Sf.ven  ]\roNTHS  old,  showing  the  Topographral  Rela- 
tions OF  some  of  the  Organs  and  Landmarks  in  Front.— 1,  left  nipple  puslied  upwards 
by  the  mother's  hand;  2,  position  of  apex-beat  of  the  heart;  3,  ensiform  cartilage ;  4,  posi- 
tion of  stomach  in  contact  with  abdominal  wall ;  5,  umbilicus;  C,  position  of  the  bladder; 
7.  fatty  fold  noticeable  before  child  can  walk;  8,  position  of  the  base  of  the  heart;  9,  dia- 
phragm; 10,  lower  margin  of  costal  cartilages;  11,  lower  border  of  the  liver;  12,  position  of 
the  vermiform  appendix ;  13,  position  of  the  sigmoid  flexure  of  the  colon  in  the  infant. 


ox    THE    AXATOMY    OF    CHILDREN. 


27 


It  is  really  the  continuatiou  of  the  pulmonary  artery,  and  is  in  such  close 
relation  with  the  left  branch  of  that  vessel  that  in  later  life  the  fibrous 


Fig.  22. 


The  Fcetal  Circulation,  showing  the  Relative  Position  of  the  Organs,  drawn  by  Dr.  McClellan 
from  difssections  and  preparations  in  his  cabinet.-l,  the  trachea,  with  the  carotid  arteries  on  either 
side;  2,  the  right  innominate  vein,  overlying  the  innominate  artery  ;  3,  the  arch  of  the  aorta ;  4,  the 
superior  vena  cava:  5,  the  right  auricle;  6,  the  right  pulmonary  vessels  passing  into  the  unexpanded 
lung;  7,  the  right  lung  packed  in  the  back  of  the  thorax;  8,  the  diaphragm;  9,  hepatic  veins;  10,  the 
riglit  lobe  of  the  liver,  dissected  to  show  branches  of  portal  and  hepatic  veins;  11,  inferior  vena  cava; 
12,  right  branch  of  portal  vein  ;  l.S.  portixl  vein  coming  from  the  intestines,  which  are  removed ;  11,  riglU 
kidney;  15,  bifurcation  of  aorta  into  the  two  common  iliac  arteries;  10,  riglit  ureter;  17,  rectum  tied  ; 
18,  right  external  iliac  artery  and  vein;  19,  bladder;  20,  right  hypogastric  artery;  21,  left  recurrent 
laryngeal  nerve;  22,  left  pneumogastric  nerve;  23.  left  clavicle;  24,  first  rib;  25,  ductus  arteriosus;  26, 
second  rib;  27,  left  pulmonary  vessels;  28,  left  auricle;  29,  third  rib;  30,  left  ventricle;  31,  fourth  rib; 
32,  fifth  rib;  33,  crura  of  diaphragm ;  34,  ductus  venosus  (the  left  lobe  of  the  liver,  stomach,  pancreas! 
and  spleen  are  removed):  35,  left  supra-renal  capsule;  36,  left  kidney;  37,  left  renal  vessels ;  38,  inferior 
mesenteric  artery:  39,  umbilical  vein  •  40,  loft  hypogastric  artery;  41,  umbilical  cord. 


28  ON    THE    AXATOMY    OF    CHILDEEX, 

cord  which  indicates  its  remains  is  attached  to  the  root  at  the  arch  of  the 
aorta. 

The  blood  which  has  circulated  in  the  foetal  system  is  curiously  returned 
to  the  placenta  by  means  of  the  hypogastric  arteries,  which  are  the  continu- 
ation of  the  superior  vesical  branches  of  the  internal  iliac  arteries.  They 
pass  out  of  the  abdomen  at  the  umbilicus  and  coil  round  the  vein  which 
brings  the  blood  to  the  fcetus  from  the  placenta.  The  umbilical  vein  up  to 
the  moment  of  birth  distributes  the  blood  chiefly  to  the  liver  of  the  fcetus 
by  branches  to  the  portal  vein  and  to  the  lobes  of  the  organ,  but  a  portion 
is  conveyed  by  a  small  communicating  branch  to  the  inferior  vena  cava 
without  passing  at  all  through  the  substance  of  the  liver,  and  this  is  called 
the  ductus  venosus  (see  Fig.  22). 

At  birth  the  only  blood  which  goes  to  the  liver  is  by  means  of  the 
portal  vein,  and  after  being  purified  it  is  conveyed  by  the  hepatic  veins  to 
the  vena  cava.  The  umbilical  vein  and  the  ductus  venosus  become  empty 
and  contract,  and  are  ultimately  converted  into  the  fibrous  cords  which 
occupy  the  fissure  of  the  ductus  venosus  of  the  liver  and  become  its  round 
ligament.  They  are  usually  obliterated  about  the  fifth  day  after  birth. 
Holden  wisely  says,  "  It  is  well  to  bear  in  mind  that  these  important  vascu- 
lar changes  do  not  take  place  suddenly  at  birth,  but  that  they  are  the  result 
of  gradual  development  which  is  completed  at  or  soon  after  birth,  mainly 
by  the  act  of  inspiration,  whereby  the  blood  passes  through  the  lungs,  the 
placental  circulation  at  the  same  time  being  interrupted."  A  just  reflection 
upon  this  subject  should  help  to  interpret  the  anomalies  which  are  met  with 
in  these  parts  and  the  jiossible  results  following  interference  with  the  natural 
order  of  things,  and  will  show  the  importance  of  active  and  varied  exercise 
in  children  to  assist  the  healthftil  development  of  the  thoracic  organs,  upon 
which  so  much  in  after-life  depends. 

The  heart  of  the  child  beats  more  rapidly  than  in  adult  age,  and  is  ac- 
celerated by  general  muscular  activity.  The  pulse-rate  has  been  estimated 
to  be  130  to  140  in  the  new-born  infant,  100  to  115  in  the  second  year,  80 
to  90  from  the  seventh  to  the  fourteenth  year,  and  75  to  80  after  that, 
although  there  are  many  exceptions. 

Normally,  the  heart  is  situated  obliquely  between  the  lungs  behind  the 
lower  half  of  the  sternum,  and  occupies  more  of  the  left  than  the  right  side 
of  the  thorax.  It  is  held  in  position  by  the  pericardium,  which  is  attached 
to  the  central  tendon  of  the  diaphragm,  and  by  the  thoracic  fascia,  which  is 
continuous  with  the  deep  cervical  fascia,  and  embraces  the  great  vessels  at 
its  base.  In  the  adult  the  apex  of  the  heart  may  be  felt  beating  at  each 
contraction  between  the  cartilages  of  the  fifth  and  sixth  ribs  to  the  left  of 
the  sternum,  and  its  base  corresponds  to  the  junction  of  the  third  costal 
cartilao:e  on  the  ridit  side  with  the  sternum.  In  earlv  iufancv  the  heart  is 
of  greater  breadth  in  comparison  with  the  chest,  and  therefore  the  apex- 
beat  in  relation  to  the  nipple  is  changed.  The  normal  apex-beat  in  the 
adult  is  about  an  inch  internal  to  the  mararaillary  line,  while  in  children  it 


Fig.  20. 


Fig.  28. 


■im      •* 


Photograph   of  Boy,  Anrn   Fm  i;    ^'i  aks, 

SHOAVING  THE  TOPOGRAPHICAL    Po.SITION  OF  SOME 

OF  THE  Organs  and  Landmarks  in  Front.— 1, 
supra-sternal  notch  ;  2,  left  nipple;  3,  position  of 
apex-beat  of  heart ;  4,  spleen  ;  5,  left  kidney  ;  6, 
umbilicus;  7,  base  of  heart;  8,  fliaphrnp;m  ;  9, 
ensiform  cartilage;  10,  margin  of  ninth  rib;  11, 
lower  border  of  liver  ;  12,  position  of  vermiform 
appendix;  13,  internal  abdominal  opening;  14, 
external  abdominal  opening. 


Photograph  of  Boy,  aged  Four  Years, 
showing  the  topographical  relations  of 
some  of  the  organs  and  landmarks  be- 
HIND.—1,  spine  of  the  seventh  cervical  verte- 
bra; 2,  inferior  angle  of  the  scapula  ;  3,  poste- 
rior point  of  liver  duhie.ss;  4.  right  kidney;  5, 
twelfth  spine  of  the  dorsal  vertebra;  6,  crest 
of  ilium;  7,  position  of  great  trochanter  of  the 
femur ;  8,  tuberosity  of  the  ischium  ;  9,  inferior 
angle  of  the  left  scapula;  10,  position  of  left 
kidney. 


ox   THE    ANATOMY    OF    CHILDREX.  29 

is  often  directly  at  this  Hue,  or  even  external  to  it.  Careful  observation 
upon  vouug  children  has  detected  the  apex-beat  at  the  fourth  interspace ; 
and  this  is  probably  due  to  the  mounting  up  of  the  diaphragm  as  well  as  to 
the  more  oblique  shape  and  position  of  the  ribs  (see  Figs.  19  and  20).  Dis- 
sections made  upon  fresh  bodies  of  infants,  with  the  thoracic  viscera  held 
in  place  by  being  transfixed  with  long  pins,  have  shown  the  author  that 
the  position  of  the  heart  is  higher  than  in  later  life,  so  that  the  apex  would 
probably  be  felt  above  the  fifth  rib  (see  Fig.  23). 

It  is  difficult  at  any  age  to  fix  definitely  the  points  where  the  sounds  of 
the  cardiac  valves  can  be  detected  by  the  ear  applied  to  the  chest,  owing  to 
the  interposition  of  lung-tissue  between  the  chest-walls  and  the  heart.  This 
difficulty  is  greatly  increased  in  examining  young  children,  in  whom  the 
higher  position  of  the  heart  still  further  confuses  the  sounds  of  its  valves 
with  those  of  the  respiratory  organs.  The  position  of  the  heart  always 
varies  with  the  position  of  the  body,  and  in  children  there  is  perhaps  a 
greater  laxity  of  the  supporting  membranous  attachments  of  the  heart, 
which  permits  still  further  latitude. 

THE  DIAPHKAGM. 
The  diaphragm  occupies  comparatively  a  higher  position  in  children 
than  in  adults,  and  is  naturally  well  developed,  because  it  plays  such  an 
important  role  in  their  respiration,  as  has  already  been  pointed  out.  The 
lungs  in  their  pleurae  rest  upon  the  muscular  portions  of  the  diaphragm 
upon  each  side  in  childhood  as  in  later  years,  while  the  heart  in  the  pericar- 
dium lies  above  the  central  tendon  (see  Figs.  22  and  23).  After  death  the 
diaphragm  mounts  higher  within  the  thorax,  owing  to  the  collapsed  state 
of  the  lungs  from  expiration.  During  life,  when  the  diaphragm  contracts 
there  is  a  general  descent  of  the  muscular  partition,  more  especially  at  the 
sides.  The  ever-changing  position  of  the  diaphragm  in  life  renders  the 
study  of  its  relations  to  the  adjacent  viscera  of  the  thoracic  and  abdominal 
cavities  of  peculiar  interest. 

THE   ABDOMEN. 

The  protuljerance  of  the  abdomen  which  is  so  marked  in  young  children 
is  mainly  due  to  the  relatively  large  size  of  the  liver  and  the  small  size  of 
the  pelvis.  In  infancy  the  bladder  and  upper  portion  of  the  rectum  are  in 
the  abdominal  region. 

The  skin  over  the  front  of  the  abdomen  is  elastic  and  loosely  attached 
in  the  groins,  but  partially  adherent  to  the  subjacent  fasciae  in  the  middle 
line.  The  superficial  fascia  generally  contains  much  fat,  and  between  its 
two  layers  over  the  lower  part  of  the  abdomen  are  the  superficial  vessels 
and  nerves.  The  thickness  of  the  abdominal  wall  depends  upon  the  amount 
of  sulx'utaneous  fat,  and  not  on  the  nuiscles,  the  three  layers  of  which  are 
quite  thin  at  all  times. 

The  linea  alba  is  the  fusion  of  the  aponeuroses  of  the  abdominal  muscles, 


30 


ON    THE    ANATOMY    OF    CHILDREN. 


and  is  marked  by  a  forrow  above  the  umbilicus,  where  the  recti  muscles 
slightly  diverge.  It  is  the  safe  line  in  this  region,  owing  to  its  freedom 
from  blood-vessels. 

The  umbilicus  is  the  cicatrix  in  the  centre  of  the  linea  alba,  resulting 
from  the  obliteration  of  the  umbilical  vessels  and  cord  at  birth.  It  consists 
of  a  dense  fibrous  ring  resulting  from  adhesion  of  all  the  adjacent  structures, 
skin,  fascia,  and  peritoneum.  The  umbilicus  is  an  imjjortant  landmark, 
and  is  deeper  and  wider  in  the  female  than  in  the  male ;  it  is  nearer  to 
the  pubes  than  to  the  ensiform  cartilage.  From  birth  until  the  end  of  the 
second  year  it  occupies  the  central  point  of  the  body,  but  as  the  legs  grow 
longer  the  latter  point  is  at  or  about  the  pubes.  It  is  sometimes  the  seat  of 
congenital  hernia,  which  works  its  way  through  the  structures  of  the  cord, 
separating  the  umbilical  vein  and  arteries,  and  forming  a  cavity  in  the 

gelatinous  and  cellular  tissue.     Cases 
FiG-  24.  have  been  reported  where  the  bowel 

was  involved  in  the  ligature  of  the 
cord  at  birth.  The  infantile  form  of 
hernia  in  this  region  is  usually  caused 
by  straining,  and  occurs  at  the  umbi- 
licus a  few  months  after  birth,  before 
its  constituents  have  become  firmly 
cicatrized.  These  hernise  may  be  re- 
ferred to  the  persistence  of  one  or 
other  of  the  foetal  conditions,  for  about 
the  eighth  or  ninth  week  of  embryonic 
life  there  is  found  a  coil  of  intestine 
within  the  umbilical  cord  (see  Fig. 
24).  Owing  to  the  cords  which  rep- 
resent the  obliterated  hypogastric  ar- 
teries and  urachus  being  attached  to 
the  lower  part  of  the  umbilicus,  it  is 
thicker  than  the  upper  part,  and  on 
this  account  umbilical  hernia  in  the  adult  occurs  at  the  upper  part  of  the 
umbilicus.  The  part  of  intestine  involved  in  this  variety  of  hernia  is 
usually  from  the  jejunum,  and  the  hernia  is  very  generally  fatal,  since  a 
lesion  of  the  bowel  is  more  serious  the  nearer  it  approaches  the  stomach. 

There  are  rare  cases  met  with  of  urinary  fistulae  existing  at  the  navel, 
which  are  due  to  the  urachus  not  being  entirely  closed  at  birth,  and  allow- 
ing the  urine  to  dribble  out  from  the  bladder ;  and  faecal  fistulee  have  also 
been  known,  which  are  caused  by  persistence  of  MeckeFs  diverticulum, 
which  "  springs  from  the  ileum  from  one  to  three  feet  above  the  ileo-csecal 
valve"  (Treves). 

There  is  a  close  similarity  between  the  vessels,  arteries,  and  veins  of  the 
abdominal  walls  in  the  child  and  adult,  and  the  same  may  be  said  of  the 
nerves,  but,  as  so  many  symptoms  relating  to  the  diseases  of  childhood  can 


Ht'MAN  Embryo  of  the  Ninth  Week,  show- 
ing A  Coil  of  Intestine  in  the  Umbilical  Cord. 


Fig.  21. 


Photograph  of  a  Boy  aged  Ten  Years,  showing  the  Topographical  Position  o;- 
SOME  OF  THE  ORGANS  AND  LANDMARKS  IN  FRONT.— 1,  hyoid  bone ;  2,  top  of  tlivroid  car- 
tilage; 3,  cricoid  cartilage;  4,  isthmus  of  thyroid  body;  5,  supra-sternal  notch  ;  G,  nipple; 
7,  position  of  apex-beat  of  heart;  8,  ensiform  cartilage;  9,  position  where  the  stomach  is  in 
contact  with  the  abdominal  wall;  10,  border  of  ninth  costal  cartilage;  11,  umbilicus;  12, 
internal  inguinal  opening;  13,  external  inguinal  opening;  14,  position  of  base  of  the  heart; 
15,  diaphragm:  16,  duodenum;  17,  lower  border  of  the  liver;  18,  gall-bladder;  19,  position 
of  vermiform  appendix;  20,  femoral  ring;  21,  apex  of  Scarpa's  triangle;  22,  position  of  great 
IriH  liiuiter. 


ON    THE    AXATOMY    OF    CHILDREN.  31 

be  interpreted  only  through  a  kuowledge  of  the  position  of  the  nerves,  they 
are  here  more  particularly  described.  They  are  derived  from  the  lowest 
seven  intercostal  and  upper  two  lumbar  nerves,  and  are  placed  parallel  to 
each  other,  running  obliquely  downward  and  inward  to  the  middle  line, 
supplying  not  only  the  skin,  but  also  the  overlying  muscles.  This  intimate 
association  serves  to  protect  the  viscera  from  many  injuries,  such  as  are  due 
to  contusions  and  burns.  Owing  to  their  origin,  the  intercostal  muscles  are 
associated  in  the  movements  of  respiration  with  the  muscles  of  the  abdomen. 
In  Pott's  disease  of  the  spine,  the  nerves  may  be  pressed  upon  at  the  verte- 
l)ral  foramina,  giving  rise  to  a  sense  of  constriction  about  the  abdomen,  and 
children  suffering  with  this  aifection  often  complain  of  pain  in  the  region  of 
the  navel.  The  position  of  the  caries  may  be  determined  by  a  careful  study 
of  the  symptoms,  as  the  cutaneous  pain  indicates  what  particular  nerve  or 
nerves  are  involved.  The  sixth  and  seventh  intercostal  nerves  supply  the 
skin  over  the  epigastrium,  the  tenth  nerve  that  about  the  umbilicus,  and 
the  upper  lumbar  nerves  are  distributed  along  Poupart's  ligament.  Loco- 
motor ataxia  and  spinal  sclerosis  are  often  attended  by  the  sense  of  constric- 
tion due  to  some  nerve-disturbances  in  the  same  way.  Moreover,  the  con- 
nection between  the  sympathetic  system  and  the  spinal  nerves,  in  the  dorsal 
region  especially,  brings  into  relation  the  parietes  of  the  abdomen  and  the 
viscera  which  they  overlie.  This  is  seen  in  peritonitis,  where  the  skin  over 
the  abdomen  is  extremely  sensitive  and  the  respirations  are  entirely  thoracic. 

THE   GKOIN. 

The  anatomy  of  the  groin  in  the  child  is  in  many  respects  similar  to 
that  of  the  same  region  in  the  adult,  modified  only  by  growth.  Poupart's 
ligament  is  the  reflection  of  that  part  of  the  sheath  of  the  external  abdominal 
muscle  which  is  inserted  into  the  spine  of  the  ilium,  and,  curving  down- 
ward, with  the  concavity  towards  the  abdomen,  separates  into  two  portiout?, 
the  lower  one  going  to  the  spine  of  the  pubes  and  the  upper  one  to  the 
pubic  symphysis  and  interlacing  with  the  fibres  of  its  fellow-muscle  from 
the  opposite  side.  The  space  between  these  portions  is  called  the  outer 
abdominal  opening  (or  ring).  It  can  be  recognized  by  feeling  for  the  inser- 
tion of  the  tendon  of  the  adductor  longus  muscle  while  the  thigh  is  abducted ; 
and  in  the  male  the  cord,  or  in  the  female  the  round  ligament,  will  be 
detected  issuing  from  the  external  opening.  These  latter  structures  occupy 
the  so-called  inguinal  canal,  which  is  rather  a  tract  of  tissue  congenitally 
arranged  for  their  passage,  and  capable  of  being  distended  or  ruptured  in 
various  forms  of  hernia.  It  extends  obliquely  upward  about  the  patient's 
finger's-breadth  above,  and  to  a  point  corres}x)uding  to  the  middle  of,  Pou- 
j5art's  ligament.  This  is  over  the  opening  in  the  extra-peritoneal  fascia 
known  as  the  internal  abdominal  opening  (or  ring)  (see  Figs.  20  and  21). 

In  the  fijetus  the  testicle  is  formed  below  the  kidneys  in  the  lumbar 
region,  and  about  tiie  ciglith  month  ])re8eiits  at  the  internal'  opening,  gradu- 
ally finding  its  way  into  tlie  scrotum.     The  descent  of  the  testicle  is  natu- 


32  ON    THE   ANATOMY    OF    CHILDREN. 

rally  accompanied  with  the  formation  of  the  cord  by  the  aggregation  of 
its  developing  constituents, — i.e.,  vas  deferens,  veins,  arteries,  lymphatics, 
nerves,  and  gelatinous  tissue,: — and  the  progress  of  the  testicle  through  the 
tract  devised  for  it  is  liable  to  be  attended  with  some  congenital  defect, 
which  sooner  or  later  may  allow  a  portion  of  intestine  to  escape  from  the 
abdomen. 

While  it  may  be  asserted  that  every  hernia  is  due  to  some  congenital  or 
abnormal  condition  of  the  parts  concerned,  and  that  the  effort  which  occa- 
sions the  affection  would  not  so  operate  except  for  the  existence  of  some 
such  condition,  the  ordinary  forms  of  hernia  which  are  described  as  con- 
genital are  assigned  to  defects  in  the  vaginal  process  of  the  peritoneum.  The 
inguinal  canal  is  relatively  shorter  and  less  oblique  in  the  foetus  and  young 
child  than  it  is  in  the  adult,  and  in  the  female  it  is  always  smaller  and 
narrower.  In  fact,  about  the  time  the  testicle  reaches  the  groin  the  internal 
abdominal  opening  is  just  behind  the  external  opening,  and  its  course  from 
where  it  was  originally  formed  below  the  kidney  to  its  final  normal  position 
in  the  scrotum  is  more  direct  than  indirect.  The  process  of  the  peritoneum 
which  passes  through  the  inguinal  tract,  known  as  the  vaginal  process  in 
the  male,  and  in  the  female  as  the  canal  of  Nuck,  always  precedes  the 
descent  of  the  testicle,  and  would  seem  to  lead  the  way  for  it,  although  it 
is  not  pushed  before  it,  as  usually  described,  for  in  certain  well-recognized 
cases,  where  the  testicle  was  retained  within  the  abdomen  and  subsequently 
descended  into  the  scrotum,  years  after  birth,  the  vaginal  process  had  already 
occupied  its  normal  position  in  the  scrotum. 

After  the  passage  of  the  testicle  along  the  inguinal  tract  from  the  in- 
ternal to  the  external  opening,  and  thence  into  the  scrotum,  it  drops  upon 
the  vaginal  process  of  the  peritoneum.  Ordinarily  this  process,  after  the 
descent  of  the  testicle,  becomes  adherent  to  the  adjacent  structures  at  the 
internal  opening  in  the  extra-peritoneal  fascia,  and  is  separated  distinctly 
from  the  rest  of  the  peritoneum,  becoming  gradually  blended  with  the  cord 
above  the  testicle.  When  the  vaginal  process  has  not  become  separated 
from  the  general  peritoneum,  and  there  is  no  adhesion  between  it  and  the 
structures  of  the  inguinal  tract,  there  is  naturally  a  direct  passage-way  be- 
tween the  abdomen  and  the  scrotum,  and  if,  at  any  age,  a  loop  of  intestine 
descends  by  it,  the  condition  is  called  a  congenital  hernia.  In  this  form  of 
hernia  the  testicle  is  enveloped  by  the  intestine,  and  there  is  no  other  sac 
than  the  vaginal  process. 

When  the  original  vaginal  process  is  only  occluded  at  the  internal  open- 
ing and  there  is  a  continuation  of  its  pouch  above  the  testicle  along  the  cord, 
there  is  apparently  onl}-  a  thin  septum  between  its  cavity  and  that  of  the 
peritoneum.  A  portion  of  intestine  will  sometimes  push  down  this  septum 
(encysted  hernia),  or  it  may  be  forced  down  behind  the  adhesion  of  the  vagi- 
nal process  at  the  internal  opening,  forming  infantile  hernia.  In  the  latter 
it  will  be  readily  seen  that  there  will  be  three  layers  of  peritoneum  covering 
the  intestine, — viz.,  the  two  layers  of  the  vaginal  process,  and  the  proper 


Diagram  of  Fig.  23. 


Fig.  23. 


Photograph  from  a  Recent  Dissection,  in  which  the  Viscera  were  held  in  Posi- 
tion BY  Transfixion  avith  Pins:  from  a  new-born  child.— 1,  trachea;  2,  innominate  ves- 
sels ;  3,  right  auricle ;  4,  right  lung  (turned  back  to  show  heart),  the  pericardium  is  removed  ; 
.'),  central  tendon  of  diaphragm  ;  6,  round  lignment  of  liver  ;  7,  right  lobe  of  liver;  8,  right 
kidney;  9. first  rib;  10,  second  rib  ;  11, third  rib;  12,  left  lung  (turned  back') ;  13,  fourth  rib: 
14,  fifth  rib;  15,  left  lobe  of  liver;  16,  .stomach;  17,  sigmoid  flexure  of  colon;  18,  clavicle. 
'I'he  small  intestines  are  removed. 


ON   THE   ANATOMY  .OP    CHILDREN.  33 

sac  of  the  hernia  itself.  It  has  been  suggested  that  the  anatomical  arrange- 
ment of  the  parts  in  the  encysted  variety  favors  the  rupture  of  the  septum 
above  mentioned,  and  may  explain  the  occurrence  of  a  congenital  hernia  in 
adult  life.  The  process  of  the  peritoneum  which  accompanies  the  cord  is 
sometimes  not  completely  obliterated,  and  only  closed  at  the  top  of  the  tes- 
ticle. It  is  known  as  the  funicular  process,  and  gives  its  name  to  that  form 
of  rupture  which  it  accommodates.  The  complete  closure  of  the  tunica 
vaginalis  is  peculiar  to  man,  and  has  been  considered  as  connected  with  his 
adaptation  to  the  erect  posture.  The  most  common  form  of  hernia  in  female 
children,  occurring  in  the  inguinal  region,  is  occasioned  by  the  patent  condi- 
tion of  the  canal  of  jSTuck,  which  allows  the  intestine  to  escape  along  the 
course  of  the  round  ligament. 

All  truly  congenital  hernise  in  the  groin  are  indirect.  There  is  appar- 
ently less  resistance  in  the  abdominal  wall  opposite  Hesselbach's  triangle, 
especially  at  the  outer  margin  of  the  conjoined  tendon  of  the  internal  ob- 
lique and  transverse  muscles,  but  the  direct  form  of  hernia  is  not  only  very 
rare  at  any  age,  but,  as  has  been  said,  does  not  occur  congenitally.  It  is 
probable,  however,  that  some  undue  weakness  may  exist  which  predisposes 
to  rupture  between  the  deep  epigastric  vessels  and  the  cord  resulting  from 
the  obliteration  of  the  hypogastric  artery,  or  between  the  latter  and  the 
border  of  the  rectus  and  pyramidalis  muscles.  Such  weakness  may  be 
caused  by  slight  change  of  position  of  the  cord  of  the  hypogastric  artery 
in  its  relation  to  the  deep  epigastric,  as  it  clearly  aids  in  the  production  of 
the  pouch  in  the  peritoneum  easily  demonstrated  at  this  point.  The  course 
of  the  deep  epigastric  artery  is  always  from  the  inner  margin  of  the  internal 
abdominal  opening  running  between  the  extra-peritoneal  fascia  and  the  peri- 
toneum towards  the  umbilicus.  When  it  reaches  the  border  of  the  rectus 
muscle  it  pierces  it  and  passes  upward  to  join  with  the  internal  mammary 
artery.  In  herniotomy,  the  constriction  usually  occurring  at  the  inner  open- 
ing, the  incision  should  be  made  parallel  to  the  course  of  the  artery.  The 
coverings  to  a  hernia  in  the  inguinal  region  are  practically  those  of  the 
testicles,  and,  in  operating,  the  only  one  Avhich  is  recognizable  is  the  cremas- 
teric fascia.  Much  undue  stress  has  been  laid  upon  the  number  and  origins 
of  these  coverings.  It  would  be  more  useful  to  master  the  exact  positions 
of  the  openings,  and  to  understand  the  construction  of  the  inguinal  tract. 

THE   PERITOlSrEUM. 

The  folds  of  the  peritoneum  can  best  be  understood  by  reference  to  the 
development  of  the  alimentary  canal.  When  the  latter  first  assumes  the 
tubular  form  it  is  a  simple  straight  cylinder,  placed  in  front  of  the  vertebral 
column,  attached  to  it  and  to  the  rest  of  the  embryo  by  a  membranous  fold 
or  rudimental  mesentery.  By  degrees  the  intestine,  growing  in  length,  be- 
comes looped  at  the  centre  and  straiglit  at  its  upper  and  lower  ends,  Avhilst 
the  portion  which  is  destined  to  become  the  stomach  is  dilated.  This  por- 
tion gradually  turns  over  on  its  right  side,  so  that  the  border  which  is  con- 
YoL.  I.-3 


34  ON   THE   ANATOMY   OF   CHILDREN. 

nected  to  the  spine  by  the  membranous  fold  comes  to  be  turned  to  the  left. 
The  stomach  becoming  further  dilated  is  at  first  placed  vertically,  then 
obliquely,  and  then  transversely,  carrying  with  it  in  all  its  changes  the 
membranous  fold,  from  which  the  omenta  are  afterwards  produced.  In  the 
early  embryo  the  calibre  of  the  upper  part  of  the  intestine  is  greater  than 
that  of  the  lower,  and  there  is  no  distinction  between  the  two  until  the  for- 
mation of  the  c£ecum,  which  is  at  first  about  the  centre  of  the  canal,  and  is  a 
simple  tubular  diverticulum  which  later  dwindles  at  its  free  part,  becoming 
the  vermiform  appendix.  After  the  appearance  of  the  csecum  the  primi- 
tive intestinal  canal  undergoes  great  changes  :  the  lower  portion  increases  in 
calibre,  and  the  upper  becomes  more  looped,  sending  some  of  its  coils  with 
the  caecum  into  the  umbilical  cord  (see  Fig.  24). 

About  the  beginning  of  the  third  month  the  ileo-cascal  valve  is  discerni- 
ble, and  the  colon,  first  lying  to  the  left  of  the  small  intestines,  gradually 
crosses  over  their  upper  part,  and,  steadily  growing  in  length,  assumes  about 
the  fifth  month  the  normal  position  found  in  the  adult.  The  curvatures  of 
the  stomach  follow  as  a  sequence  upon  its  dilatation  and  change  of  position, 
and  the  mesial  fold  of  the  peritoneum  surrounding  it  becomes  the  sac  of 
the  omentum,  the  portion  covering  the  right  side  of  the  stomach  being 
turned  inward  and  the  portion  over  the  left  side  passing  over  the  front  wall 
of  the  stomach,  so  that  its  free  edge  becomes  the  anterior  boundary  of  the 
foramen  of  Winslow,  the  opening  between  the  lesser  and  greater  involutions, 
or  cavities  of  the  peritoneum,  as  they  are  called.  These  involutions  are 
partly  due  to  the  unequal  constriction  of  the  pyloric  and  oesophageal  ends 
of  the  stomach  and  the  beginning  of  the  duodenum.  The  mesenter}^  about 
the  larger  intestine  is  variously  arranged  and  prolonged  during  the  growth 
of  the  abdominal  organs  of  the  foetus,  and  the  many  congenital  defects  and 
abnormal  conditions  offer  the  best  means  of  explaining  what  are  usually 
described  as  its  normal  relations.  It  has  been  suggested  that  an  abnormally 
•long  mesentery  may  predispose  to  herniee ;  and  it  is  certain  that  the  peri- 
toneum will  allow  of  very  considerable  stretching  if  it  is  gradually  exerted. 

THE   STOMACH. 

The  stomach,  as  has  been  described,  is  originally  placed  vertically  in 
the  abdomen.  This  position  may  continue  in  adult  life,  and  it  probably 
does  so  more  often  than  has  been  observed,  but  the  author  is  firmly  con- 
vinced, from  numerous  autopsies  and  dissections,  that  its  normal  position 
after  birth  is  as  seen  in  the  illustration  (see  Fig.  25). 

It  is  thought  that  the  peculiar  shape  of  the  fundus  of  the  organ  is  due 
to  the  muscular  action  of  the  layers  of  the  stomach  on  the  food,  and  in 
newly-born  children  the  fundus  does  not  exist.  Its  dimensions  and  rela- 
tions are  subject  to  constant  alterations,  principally  due  to  the  changes  in 
the  position  of  the  diaphragm,  to  Avhich  it  is  closely  attached,  but  also  con- 
sequent upon  its  empty  or  distended  state.  It  has  been  shown  by  Braune 
that  the  cardiac  orifice  of  the  stomach  is  of  valvular  construction,  and  so 


£ 

J2 
O 

y. 

fcr 

r- 

-^ 

a 

2 

S. 

<U 

— 

( J 

"^ 

S 

'^ 

Z 

K 

*"* 

« 

ox    THE    ANATOMY    OF    CHILDREN.  35 

arranged  that  regurgitation  of  fluids  into  the  oesophagus  is  somewhat  diffi- 
cult. ,  j\Iore  recently  Gubaroff  has  stated  that  this  valvular  arrangement  is 
deficient  in  infants,  and  thus  the  facility  with  which  they  vomit  may  be 

accounted  for. 

THE   SMALL   INTESTINE. 

The  small  intestine  varies  greatly  in  length.  According  to  Treves,  it 
measures  at  birth  nine  feet  five  inches,  and  it  grows  about  four  feet  in  the 
first  two  months.  The  divisions  into  jejunum  and  ileum  are  arbitrary,  but 
the  upper  part  of  the  small  bowel  usually  occupies  the  left  iliac  fossa,  and 
the  lower  the  right.  The  ileum  is  that  part  of  the  intestine  which  is  most 
frequently  involved  in  external  hernia.  The  duodenum  contains  the  glands 
of  Brunner,  which  are  commonly  the  seat  of  perforating  ulcer  in  cases  of 
burn.  They  occupy  principally  the  first  part  of  the  duodenum,  which  is 
covered  by  the  peritoneum. 

THE   LAEGE   INTESTINE. 

The  large  intestine  from  the  caecum  in  the  right  iliac  fossa  to  the  sigmoid 
flexure  in  the  left  is  accessible  to  pressure  through  the  abdominal  walls,  and 
in  cases  of  collection  of  flatus  giving  rise  to  colicky  pains,  in  young  children, 
much  relief  can  be  easily  aiforded  by  gentle  rubbing  over  the  course  of  the 
colon.  The  usual  course  of  the  colon  is  upward  from  the  right  iliac  fossa 
to  the  liver,  where  the  bowel  arches  transversely  across  the  abdomen  to  the 
spleen,  forming,  at  the  bends,  the  hepatic  and  splenic  flexures,  and  thence 
downward  to  the  left  iliac  fossa,  where  the  sigmoid  flexure  usually  occurs 
before  the  bowel  terminates  in  the  rectum.  Very  often  the  disposition  of 
the  colon  varies,  and  it  may  lie  diagonally  across  the  abdomen,  passing  from 
the  region  of  the  liver  to  the  left  groin.  In  children  it  is  frequently  different 
from  the  condition  usually  found  in  the  adult  described  above.  Treves 
states  that  the  csecum  and  colon  at  birth  measure  one  foot  exclusive  of  the 
sigmoid  flexure,  which  is  about  ten  inches.  During  the  first  four  months 
this  portion  of  the  bowel  does  not  increase  in  length,  but  the  sigmoid  flexure 
diminishes,  owing  to  a  readjustment  of  the  mesentery.  Measurements  of 
the  bowel  can  only  be  approximative ;  for  the  longitudinal  muscular  fibres 
are  easily  damaged  in  removing  the  viscera  from  the  body. 

The  crecum  has  a  large  and  loose  mesentery  in  its  early  formation,  and 
this  condition  sometimes  persists  during  life.  The  ctecum  is  covered  with 
peritoneum,  except  at  its  posterior  surface,  which  is  connected  by  a  quantity 
of  areolar  tissue  to  the  iliac  fossa.  Here  perityplilitis  manifests  itself  This 
part  is  susceptible  of  great  distention,  and  it  is  a  frequent  seat  for  concre- 
tions. The  vermiform  appendix  usually  lies  behind  the  caecum,  directed 
upward.  It  can  be  readily  reached  by  an  incision  made  in  the  semilunar 
line  upon  the  right  side  at  a  point  midway  between  the  umbilicus  and  the 
spine  of  the  ilium. 

The  usual  point  of  stricture  of  the  colon  is  where  the  sigmoid  flexure 
terminates  in  the  rectum.     It  is  probably  due  to  the  arrangement  of  the 


36  ox   THE    ANATOMY    OF    CHILDREN. 

bands  of  peritoneum  (sigmoid  mesocolon),  which  brings  the  loops  of  the 
bowel  so  closely  together  that  they  are  readily  twisted  upon  their  axes. 
The  so-called  sigmoid  flexure  usually  consists  of  a  large  loop  puckered  up 
into  folds,  and  occupies  rather  the  pelvis  than  the  iliac  fossa.  It  is  fre- 
quently misplaced  in  children  (see  Fig.  25).  The  sigmoid  flexure  passes 
directly  over  the  left  spermatic  vein,  and  in  consequence  of  constipation  the 
pressure  may  produce  varicocele  on  the  left  side  in  young  adults. 
The  RECTUM  is  considered  with  the  pelvis. 

THE   LIVEE. 

This  important  glandular  organ  begins  to  be  formed  at  a  very  early 
period  of  foetal  life  by  a  process  from  the  intestinal  tube.  It  grows  very 
rapidly,  so  that  at  the  third  or  fourth  week  in  the  foetus  the  liver  constitutes 
nearly  one-half  of  the  entire  body-weight,  almost  filling  the  abdominal 
cavity.  From  that  period  towards  birth  it  decreases  proportionately,  how- 
ever, its  relative  weight  to  that  of  the  body  being  then  as  one  to  eighteen. 
Its  position  in  the  abdomen  in  the  foetus  is  more  symmetrical  than  that 
which  it  occupies  later,  owing  to  its  right  and  left  lobes  being  of  nearly  equal 
size  (see  Fig.  26).  In  infancy  and  early  childhood  the  large  size  of  the  liver 
has  much  to  do  with  the  differences  in  the  relations  of  the  abdominal  viscera 
as  compared  with  adults.  Its  size  is  variable,  even  within  the  limits  of 
health,  and  it  is  difficult  to  define  its  position  at  different  periods  of  life, 
owing  to  its  rising  and  falling  with  the  diaphragm,  to  which  it  is  attached 
by  folds  of  the  peritoneum,  and  also  to  the  shape  of  the  thorax  (see  Fig.  13). 
In  young  children  in  life  it  is  generally  found  by  percussion  in  the  upright 
posture  to  be  somewhat  lower  than  would  be  supposed  from  the  usual  de- 
scription in  the  text-books,  its  lower  border  reaching  nearly  to  the  crest  of 
the  ilium  and  its  left  lobe  extending  across  to  the  costal  cartilages  of  the 
left  lower  ribs  (see  Figs.  20,  21,  27,  and  28).  The  liver  is  moulded  to  the 
arch  of  the  diaphragm,  which  separates  it  from  the  thin  margin  of  the  base 
of  the  right  lung,  which  descends  in  front  of  it.  Ordinarily  it  extends  to 
the  left  a  little  over  an  inch  beyond  the  margin  of  the  sternum.  In  the 
middle  line  the  liver  is  in  close  relation  to  the  skin  in  front  of  the  stomach 
and  reaches  about  half-way  between  the  ensiform  cartilage  and  the  um- 
bilicus. Its  lower  edge  corresponds  to  a  line  drawn  from  the  ninth  right 
to  the  eighth  left  costal  cartilage  (Quain). 

When  the  body  is  erect,  the  lower  edge  of  the  liver  can  be  felt  about 
half  an  inch  below  the  costal  cartilages.  In  the  recumbent  position  it 
cannot  be  felt  beyond  the  margins  of  the  ribs  in  the  adult. 

The  position  of  the  fundus  of  the  gall-bladder  is  in  relation  to  the  sur- 
face about  that  of  the  ninth  costal  cartilage  near  the  border  of  the  right 

rectus  muscle. 

THE   SPLEEN. 

The  first  appearance  of  the  spleen  in  the  foetus  is  about  the  eighth  week, 
on  the  left  side  of  the  dilated  portion  of  the  alimentary  canal  or  stomach. 


Fig.  27. 


Photograph  of  Baby  Seven  Month.s  old,  showinl  uu;  'I'MroiuiAi'iuiAi,  Kelation.s  of.some  of 
THE  Organs  and  Landmarks  behind.— 1,  superior  angle  nf  riglu  scapula;  2,  lower  point  of  liver- 
dulness ;  3,  position  of  right  kidney  ;  4,  inferior  angle  of  left  scapula;  5,  left  iliac  crest ;  6,  position  of 
great  trochanter. 


ON   THE   ANATOMY    OF   CHILDREN.  37 

It  increases  rapidly  in  size  after  birth,  and  soon  attains  the  same  propor- 
tional weight  to  the  body  as  in  the  adult.  The  spleen  varies  more  than 
any  other  organ  in  the  body  according  to  the  state  of  nutrition,  being  larger 
in  well-nourished  and  smaller  in  wasted  children.  Its'  size  always  increases 
after  digestion,  and  it  is  in  this  state  that  its  substance  is  most  likely  to  be 
injured  by  violence.  It  is  a  ver}^  vascular  organ,  but  it  contains  most  blood 
during  digestion.  The  spleen  is  nearest  the  surface  in  the  neighborhood  of 
the  tenth  and  eleventh  ribs,  above  which  it  is  overlapped  by  the  edge  of  the 
lung.  The  diaphragm  intervenes  between  it  and  the  parietes  everywhere. 
The  splenic  flexure  of  the  colon  and  the  stomach  are  in  front  of  the  organ. 
It  is  invested  and  suspended  by  the  peritoneum,  so  that  the  normal  organ  is 
rarely  injured.  There  is  muscular  tissue  in  the  capsule  of  the  spleen,  to  the 
contractile  power  of  which  is  attributed  the  recovery  of  patients  suffering 
from  punctured  or  pistol-shot  wounds.  It  is  said  that  in  children  the  spleen 
when  enlarged  encroaches  more  upon  the  thoracic  cavity  than  in  the  adult, 
owing  to  the  greater  resistance  offered  by  the  costo-colic  fold  of  the  perito- 
neum upon  which  it  rests. 

THE   PANCEEAS. 

The  pancreas  is  Avell  formed  about  the  second  month  in  the  foetus,  about 
the  same  time  as  the  salivary  glands,  which  it  resembles  very  much  in 
arrangement  and  function.  Its  situation  is  in  front  of  the  first  lumbar 
vertebra,  behind  the  stomach,  and  corresponds  to  a  point  about  a  hand's- 
breadth  above  the  umbilicus  (see  Fig.  13). 

THE    KIDNEYS. 

It  is  a  curious  fact  that  the  development  of  the  urinary  organs,  as  well 
as  those  of  generation,  is  preceded  by  the  formation  and  temporary  existence 
of  two  glandular  and  vascular  bodies,  called  Wolffian,  afler  their  discoverer. 
In  the  foetus  they  exist  only  in  the  early  stage  of  development,  and  reach 
their  full  size  about  the  fifth  w^eek.  They  occupy  the  abdominal  cavity 
upon  either  side  of  the  vertebral  column,  and,  after  reaching  their  full  size, 
speedily  shrink  into  its  lower  part,  soon  becoming  entirely  wasted.  They 
take  no  part  in  the  formation  of  the  kidneys  or  their  overlying  capsules, 
merely  preceding  and  perhaps  substituting  them  in  embryonic  life.  The 
foetal  kidneys  about  the  seventh  week  are  found  as  two  small  oval  masses 
behind  the  upper  part  of  the  Wolffian  bodies,  which  completely  cover  them. 
They  very  soon  become  lobulated,  and  continue  so  until  a  little  while  after 
birth,  when  their  lobulated  condition  disappears,  being  thereafter  indicated 
by  the  pyramids  of  Malpighi.  The  kidneys  of  new-born  infants  are  larger 
than  those  of  adults,  relatively  speaking,  and  are  situated  lower  down  than 
in  after-life  (see  Fig.  22).  It  should  be  remembered,  however,  that  the 
lumbar  part  of  the  spine  at  birth  is  relatively  small,  and  that  on  this  account 
the  kidneys  appear  to  be  lower  in  relation  to  the  iliac  crests  than  in  adult 
life.  A  few  years  after  birth  the  position  and  relations  of  the  kidneys  ap- 
proximate those  of  the  adult.     The  deep  position  of  the  kidneys  and  their 


38  ON    THE    ANATOMY    OF    CHILDEEN. 

relation  to  the  spine  where  the  flexion  of  the  cohunn  is  most  acute  render 
them  liable  to  injury  when  the  back  is  struck  with  the  spine  bent  forward. 
Hsematuria  often  follows  such  injuries,  and  may  be  thus  explained.  The 
common  description  of  the  right  kidney  being  somewhat  lower  than  the  left 
owing  to  impingement  of  the  liver  has  not  been  found  to  correspond  with 
observations  made  upon  frozen  sections  of  children's  bodies.  Even  in  cases 
where  the  liver  was  greatly  enlarged,  the  colon  being  pushed  down  by  it, 
the  kidney  has  not  been  displaced  but  covered  by  the  overlapping  liver 
(see  Fig.  23).  The  kidneys,  although  having  the  peritoneum  in  front  and 
on  their  external  borders,  lie  behind  it,  embedded  in  a  large  quantity  of 
loose  fatty  tissue.  This  fatty  tissue  is  the  chief  support  Avhich  holds  these 
organs  in  place,  and  if  it  is  interfered  with  or  absorbed,  the  kidneys  may 
be  displaced  very  readily.  In  operating  for  any  cause  upon  the  kidneys,  in 
the  normal  position,  the  patient's  body  should  be  extended  over  a  pillow 
upon  the  unaffected  side,  so  as  to  curve  the  spine  laterally,  and  the  incision 
should  be  made  along  the  outer  margin  of  the  quadratus  lumborum  muscle, 
the  patient's  hand's-breadth  from  the  spine.  There  are  varieties  in  form, 
position,  size,  and  number  of  the  kidneys,  which  are  not  incompatible  with 
the  healthy  performance  of  the  function  of  the  organ. 

The  only  peculiarity  of  the  suprarenal  capsules  in  children  is  their 
relatively  large  size.  In  new-born  infants  they  generally  quite  cover  the 
kidneys  as  well  as  surmount  them. 

THE   PELVIS. 

The  pelvis  of  the  foetus  and  young  child  is  of  very  small  capacity  pro- 
portionally to  the  size  of  the  body,  and  its  obliquity  is  considerably  greater 
than  in  the  adult  (see  Fig.  30).  The  alteration  in  form  M^hich  the  pelvis 
undergoes  is  in  accordance  with  its  adaptation  to  the  transmission  of  the 
weight  of  the  body  both  in  the  standing  and  sitting  postures. 

There  are  two  arches  available  for  these  postures.  In  standing,  the 
arch  is  represented  by  the  sacrum  and  its  junction  with  the  two  iliac  bones, 
the  acetabula,  and  the  intervening  masses  of  bone.  In  sitting,  the  arch  con- 
sists of  the  sacrum  and  its  iliac  articulations,  the  tubera  ischii,  and  the  inter- 
vening masses  of  bone.  These  arches  have  been  called  the  femoro-sacral 
and  the  ischio-sacral  (Morris). 

The  sacrum  and  the  symphysis  pubis  are  common  to  both  arches. 

In  rickety  deformity  of  the  pelvis,  it  yields  in  front  at  the  symphysis, 
which  is  pushed  forward,  and  the  two  acetabula  approach  each  other,  the 
cavity  of  the  pelvis  becoming  greatly  contracted.  When  this  deformity 
occurs  in  young  infants  it  has  been  ascribed  to  contraction  of  the  ilio-psoas, 
erector  spinse,  gluteus  medius,  and  other  muscles. 

THE   BLADDEK. 

The  bladder  is  originally  derived  from  the  urachus,  which  is  part  of  the 
membranous  sac  appended  to  the  umbilicus  in  the  early  foetal  state,  and 


Fig.  30. 


Skeleton  of  Chii.k  aiiuut  Five  Months  old,  showing  the  comparatively 
Larue  Size  of  the  Cranial  Bones,  the  General  Cartilaginous  Condition 
of  the  Epiphyses,  the  Segmentation  of  the  Sternum,  and  the  Obliquity 
OF  the  Pelvis.    (Photographed  by  Dr.  McClellan.j 


ON    THE    ANATOMY    OF    CHILDREN.  39 

called  allautois.  The  allantois  appears  to  be  formed  at  first  as  a  solid  mass 
projecting  from  the  posterior  extremity  of  the  body.  Very  soon  this  mass 
becomes  hollowed  into  a  vesicle  covered  with  blood-vessels,  and  is  con- 
nected with  the  intestine,  which  also  begins  to  be  formed  about  this  time. 
This  vesicle  protrudes  through  the  umbilicus,  conveying  vessels  to  the 
chorion  and  forming  the  foetal  part  of  the  placenta.  At  a  very  early  period 
the  allantois  closes  beyond  the  umbilicus.  The  part  within  the  abdomen 
widens,  to  form  the  bladder,  and  the  tubular  formation,  the  urachus,  remains 
as  a  ligament  on  its  anterior  surface.  The  Wolffian  bodies  which  precede 
the  kidneys  in  their  development  furnish  the  ureters  out  of  their  eiferent 
ducts  to  the  rudimentary  bladder. 

From  this  brief  account  of  the  formation  of  the  bladder  it  will  be  under- 
stood that  that  organ  is  at  first  an  elongated  tube  situated  in  the  lower  part 
of  the  abdomen. 

In  the  infant  the  bladder  is  not  pyriform,  as  used  to  be  described,  but 
egg-shaped,  having  the  larger  end  resting  in  the  pelvis  (see  Figs.  13  and  22). 
The  upper  part  is  narrowed  by  the  hypogastric  arteries,  which  converge 
towards  the  umbilicus.  There  is  no  marked  fundus  or  base  to  the  bladder 
in  the  young  child,  and  it  is  situated  mainly  in  the  abdomen,  the  pelvis 
being  small  and  shallow  (see  Fig.  29).  As  the  pelvic  cavity  increases  in 
size,  the  bladder  gradually  descends  into  it,  and,  the  infant  about  this  time 
assuming  the  perpendicular  attitude,  it  has  been  thought  that  the  weight 
of  the  urine  tends  to  make  the  lower  part  more  capacious.  Observations 
upon  the  dimensions  and  position  of  the  bladder  will  naturally  vary  with 
the  empty  or  distended  state  of  the  organ.  Throughout  childhood  until 
towards  puberty,  when  the  organs  of  generation  are  developed  and  the 
neighboring  parts  assume  their  normal  adult  relations,  the  urinary  bladder 
is  always  so  loosely  attached  to  the  pelvic  walls  that,  although  it  may  have 
settled  into  the  pelvis,  it  will  require  very  little  force  to  push  it  upward  into 
the  abdomen.  This  lax  condition  of  the  bladder-attachments  is  of  great 
importance  in  the  consideration  of  surgical  interference  in  this  region.  In 
the  young  child  the  anterior  wall  of  the  abdomen,  from  the  symphysis  pubis 
almost  to  the  umbilicus,  is  in  close  relation  to  the  bladder,  and  the  neck  of 
the  bladder  and  urethral  orifice  is  about  on  a  level  with  the  upper  border  of 
the  pubic  symphysis  (sec  Figs.  13  and  29). 

The  peritoneum  is  reflected  entirely  over  the  posterior  surface  of  the  blad- 
der in  the  child,  passing  behind  the  urachus  downward  to  the  level  of  the 
neck  of  the  bladder,  and  thence  on  to  the  upper  part  of  the  rectum.  This 
latter  fold  (the  recto-vesical  pouch)  usually  embraces  the  prostatic  region 
very  closely,  and  is  liable  to  injury  in  children  during  the  operation  of 
lithotomy,  causing  peritonitis,  the  most  frequent  fatal  termination  in  that 
operation. 

The  anterior  surface  of  the  bladder  is  always  uncovered  by  the  perito- 
neum in  children,  and  wlicn  the  viscus  is  distended  in  adults  it  is  also 
uncovered  for  the  most  part.     The  bladder  is  capable  of  very  great  disten- 


40  ox    THE   ANATOMY    OF    CHILDREN. 

tion  in  adult  life, — in  fact,  after  the  age  of  fifteen ;  and  cases  have  been 
reported  where  the  summit  of  the  organ  reached  to  the  umbilicus,  and  even 
to  the  ensiform  cartilage.  When  it  becomes  so  distended  it  presses  against 
the  anterior  wall  of  the  abdomen  and  dissects  the  serous  membrane  away 
from  the  parietes.  In  the  adult,  when  the  bladder  is  empty  its  anterior 
surface  is  covered  by  the  peritoneum  down  to  the  symphysis  pubis.  The 
capacity  of  the  bladder  in  infancy  is  smaller  than  in  after-years,  and  this 
may  account  for  the  frequency  with  which  young  children  micturate. 

The  prostate  gland  is  very  small  in  children.  According  to  Sir  Henry 
Thompson,  this  gland  "  at  the  age  of  seven  years  weighs  only  about  thii*ty 
grains,  and  between  eighteen  and  twenty  years  it  weighs  two  hundred  and 
fifty  grains,  or  nearly  nine  times  as  much." 

The  urethra  appears  to  increase  slowly  in  length  from  birth  until  puberty 
is  reached.  Its  canal  is  more  dilatable  than  is  supposed  in  both  adults  and 
children.  The  meatus  is  often  constricted  so  that  only  a  small-size  catheter 
or  sound  can  be  introduced,  but  if  the  orifice  is  incised  quite  a  large  instru- 
ment will  readily  pass.  The  membranous  part  of  the  urethra  in  children  is 
very  long,  owing  to  the  smalluess  of  the  prostate  gland  at  that  period  of  life. 
In  sounding  the  bladder  in  a  child,  it  should  be  remembered  that  the  uretkra 
lies  close  to  the  rectum,  and  that  its  walls  are  exceedingly  thin  and  delicate. 

It  has  been  pointed  out  by  recent  observers  that  the  condition  of  the 
bladder  and  rectum  influences  the  cui'\'atures  of  the  urethra.  If  the  lower 
part  of  the  rectum  is  distended,  the  prostatic  part  of  the  urethra  is  pushed 
upward  and  forward,  as  well  as  lengthened  (Garson) ;  and  if  the  bladder  is 
filled  it  is  shortened  (Symington).  On  the  whole,  the  degree  of  curvature" 
is  greater  in  the  child  than  in  the  adult,  but  there  are  variations  in  this 
respect  naturally  following,  as  do  those  pertaining  to  the  contiguous  parts, 
upon  growth  or  immature  development.  The  female  urethra  is  embedded 
in  the  anterior  wall  of  the  vagina,  which  is  sometimes  of  large  size  in  child- 
hood, and  corresponds  to  the  upper  part  of  the  prostatic  part  of  the  male 
passage.     It  is  very  distensible. 

THE   PENIS. 

In  children  the  skin  over  this  organ  is  very  thin  and  loose,  as  should 
be  remembered  in  performing  the  operation  of  circumcision.  The  mucous 
membrane  is  veiy  apt  to  become  adherent  to  that  over  the  glans  penis,  so 
that  most  male  infants,  if  not  properly  attended  to  after  birth,  are  liable  to 
the  condition  of  phimosis.  This  may  give  rise  to  accumulation  of  secretion 
beneath  the  prepuce,  and  cause  vesical  irritation,  and  other  distressing  symp- 
toms, through  reflex  involvement  of  the  prostatic  nerve  plexus,  or  by  direct 
impression  upon  the  pudic  nerve. 

The  penis  is  often  the  seat  of  arrested  development, — hypospadias  being 
the  condition  ^vhen  the  interior  wall  of  the  urethra  and  relative  part  of  the 
corpus  spongiosum  are  wanting,  and  epispjadias  when  there  is  a  deficiency 
in  the  superior  wall  of  the  canal  and  adjacent  parts  of  the  corpora  cavernosa. 


Fir;    in. 


Photographed  from  PreparatK)N-  ix  Mutter  Ml-sfa-.m.  College  of  Physicians  of 
Philadelphia,  showing  Lymphatic  Vessels  of  the  Vertex  of  the  .^kull  and  of  the 
Face  and  Neck,  in  a  Child  Six  Years  old. 


ON    THE    ANATOMY    OF    CHILDREN.  41 

The  scrotum  in  children  varies  with  the  general  condition  of  the  health. 
It  will  be  noticed  to  be  smooth  and  pendulous  in  strumous  and  enfeebled 
states  of  the  system,  while  in  the  healthy  and  vigorous  the  rugse  are  pro- 
nounced, owing  to  the  contractions  of  the  muscle-fibres  in  the  dartos. 

THE    llECTUM. 

The  lower  part  of  the  large  intestine  is  situated  in  the  abdomen  in 
infancy,  and  its  name  rectum  is  more  applicable  then,  for  it  is  more  truly 
straight  at  that  period  than  it  afterwards  becomes  on  the  full  development 
of  the  pelvis  and  its  other  proper  contents.  To  this  vertical  position  of  the 
rectum  has  been  ascribed  the  frequency  with  which  children  suffer  with 
prolapsus  aui.  The  sacrum  is  nearly  straight  in  children,  and  this  prob- 
ably has  to  do  with  the  direction  of  the  bowel  and  its  liability  to  prolapse. 
Examinations  of  frozen  sections  of  young  children  have  revealed  that  the 
second  portion  of  the  rectum  is  very  short,  and  it  has  been  inferred  that  if 
this  is  distended  the  distinction  between  the  upper  two  portions  is  obliter- 
ated and  the  whole  of  the  rectum  is  comparatively  straight  (Cunningham). 

The  peritoneum  is  reflected  over  the  upper  portion  of  the  rectum,  and  is 
relatively  to  the  adult  condition  lower  down  in  children.  It  is  in  all  cases 
not  so  low  behind  as  it  is  in  front,  where  it  forms  the  recto-vesical  pouch. 
The  attachments  of  the  rectum  to  the  surrounding  parts  do  not  extend  so 
high  in  children  as  in  older  persons.  As  age  advances,  the  three  portions 
of  the  rectum  approximate  the  conditions  and  relations  found  in  the  adult. 

DEVELOPMENT  OF  THE  0E6ANS  OF  GENEEATION. 

The  role  which  is  played  by  the  Wolffian  bodies  is  one  of  the  most  in- 
teresting of  the  facts  in  embryology.  In  referring  to  the  urinary  organs  it 
was  noted  that  the  Wolffian  bodies  take  no  part  in  their  formation,  except 
to  contribute  from  their  ducts  the  ureters.  Prior  to  the  appearance  of  the 
kidneys,  two  small  oval  masses  of  blastema  are  placed  on  the  inner  border 
of  the  Wolffian  bodies.  These  are  the  rudimentary  testes  or  ovaries,  which- 
ever they  are  to  become ;  and  as  the  kidneys  are  formed  just  above  them 
and  grow  rapidly  they  are  pushed  outward.  After  the  kidneys  become 
established  the  Wolffian  bodies  shrink  away,  leaving  only  mere  vestiges  of 
their  lower  parts,  which  consist  of  two  sets  of  canals  known  respectively  as 
the  AVolffian  and  Muellerian  ducts.  From  the  Wolffian  ducts  are  formed 
the  epididymis  andvasa  deferentia;  and  from  the  INluellcrian  ducts  are  pro- 
duced the  vagina,  uterus,  and  Fallopian  tubes.  The  sexual  differentiation 
does  not  take  place  until  about  the  fourteenth  week  of  embryonic  life,  and 
depends  upon  the  development  of  one  or  other  of  these  sets  of  foetal  ducts. 

THE   TESTICLES. 

It  will  be  seen  from  the  above  account  that  tliese  organs  are  formed 
within  the  abdomen  in  the  lumbar  region,  and  occupy  the  position  below 


42  ox    THE    ANATOMY    OF    CHILDEEX. 

the  kidneys  about  the  seventh  week  of  foetal  life.  They  lie  behind  the 
peritoneum,  pouches  of  which  pass  down  into  the  scrotum,  as  has  been 
stated  in  the  note  upon  inguinal  hernia,  and  appear  to  lead  the  way  for 
the  testicles.  These  organs  about  the  fifth  month  in  the  embryo  begin  to 
leave  their  original  position,  and  gradually  descend  to  opposite  the  internal 
inguinal  opening  in  the  extra-peritoneal  fascia,  which  they  reach  about  the 
seventh  month.  At  the  eighth  month  they  are  usually  found  within  the 
scrotum,  the  peritoneal  prolongations  becoming  their  vaginal  tunics  already 
described.  The  testicles  may  be  retained  within  the  abdominal  cavity,  or 
may  lodge  for  varying  periods  of  time,  or  for  life,  in  the  inguinal  tract. 

'the  ovaries. 

The  ovaries,  like  the  testicles,  are  at  first  situated  in  the  abdomen,  and 
in  the  process  of  development  also  descend,  but  only  so  far  as  the  brim 
of  the  true  pelvis  in  new-born  infants.  After  birth  they  gradually  reach 
the  side  wall  of  the  pelvis  and  become  relatively  near  to  the  external  iliac 
arteries. 

THE   UTEEUS. 

Until  the  approach  of  puberty  this  organ  exists  as  an  undeveloped 
rudimentary  body  placed  between  the  bladder  and  the  rectum  in  the  upper 
part  of  the  pelvis  (see  Fig.  29).  In  the  child  it  is  wholly  unlike  what  it 
becomes  in  the  adult,  not  only  in  size,  but  also  in  its  external  and  internal 
configuration.  The  cervix  is  longer,  thicker,  and  firmer  than  that  of  the 
body.  In  truth,  there  can  hardly  be  said  to  be  any  body  to  the  organ  in 
early  life,  for  the  arbor  vitse  reaches  to  the  top  of  the  uterus,  and  there  is  no 
internal  os.  The  upper  portion  is  generally  thinner  and  more  flexible,  and 
may  be  considered  as  representing  the  body.  About  the  time  of  puberty 
the  uterus  undergoes  rapid  changes  and  acquires  its  adult  cliaracter,  the 
body  growing  faster  than  the  cervix,  together  with  the  development  of 
its  appendages.  The  histology  and  physiology  of  this  organ  have  been 
laboriously  studied  by  numerous  investigators,  and  the  result  of  their  views 
inclines  to  the  belief  that  the  uterus  is  normally  anteflexed. 

The  state  of  the  bladder  and  rectum  will  have  much  to  do  in  deter- 
mining the  position  of  the  uterus.  The  attachments  of  the  uterus,  con- 
sisting mainly  of  peritoneal  folds  to  the  rectum,  bladder,  and  pelvic  walls, 
are  so  arranged  as  ordinarily  to  allow  a  greater  mobility  of  the  organ  in 
girlhood.  Obsen-ation  made  upon  the  cadaver  with  the  bladder  gradually 
distended  demonstrates  the  manner  in  which  the  vesico-uterine  fold  of  peri- 
toneum acts  upon  the  body  of  the  uterus,  raising  up  the  fundus.  In  cases 
of  acute  retroflexion  this  fact  may  sometimes  be  of  service.  The  mucous 
membrane  lining  the  uterine  cavity  appears  to  resemble  the  so-called  ade- 
noid tissues,  and  has  been  carefully  studied  recently  by  Johnstone,  who 
calls  it  the  "  menstrual  organ"  because  of  its  proper  function  which  is 
established  at  puberty. 


ox    THE    ANATOMY    OF    CHILDREN.  43 


THE   PEKINEUM. 


In  children  the  anatomy  of  this  region  varies  from  that  of  older  persons 
mainly  in  the  changes  relative  to  the  rectum  and  bladder  and  to  the  general 
looseness  of  the  fasciae  at  the  outlet  of  the  pelvis.  The  operator  for  stone  in 
the  bladder  in  childhood  who  selects  this  region  should  remember  that  the 
pelvis  is  narrower  in  them  than  in  the  adult ;  that  the  neck  of  the  bladder 
is  high  up,  and  capable  of  being  pushed  up  still  higher ;  that  the  bulb  of 
the  sj)ongy  portion  of  the  urethra  is  very  small ;  and  that  the  recto-vesical 
fold  of  the  peritoneum  embraces  the  prostate  gland,  which  is  only  in  a 
rudimentarv  state.  From  these  considerations  it  is  imperative  that  the 
knife  should  be  entered  close  to  the  median  raphe,  if  lateral  lithotomy  is 
chosen,  upon  a  staff  held  closely  under  the  pubes,  and,  with  the  rectum, 
previously  emptied,  pulled  downward  by  the  finger  of  the  other  hand,  cut 
outward  to  a  point  midway  between  the  anus  and  tuber  ischii.  In  children 
it  is  better  to  cut  well  into  the  neck  of  the  bladder,  in  order  to  avoid  open- 
ing up  the  pelvic  fascia  by  passing  beyond  the  prostatic  area.  In  cases 
where  the  stone  proves  large  it  is  well  to  cut  across  the  median  line,  keeping 
within  the  limits  of  the  other  prostate  lobe.  In  all  operations  for  stone  in 
the  perineum  the  bulbar  artery  and  the  rectum  are  the  chief  parts  to  avoid 
wounding. 

THE   SPINE. 

In  the  embr}'o,  the  vertebral  column  begins  to  become  cartilaginous  in 
the  sixth  or  seventh  week.  There  are,  generally  speaking,  three  nuclei  or 
centres  of  ossification  in  each  typical  vertebra, — one  for  the  body  and  two 
for  the  arches  or  laminae  and  transverse  processes.  The  deposit  of  bone  in 
the  laminae  of  the  vertebrae  commences  above  and  proceeds  gradually  down- 
ward ;  hence  we  often  meet  with  cases  of  spina  bifida  in  the  lower  part  of 
the  column  in  consequence  of  arrest  of  development  in  the  lumbar  arches 
and  upper  part  of  the  sacrum.  Ossification  of  the  bodies  of  the  vertebrae, 
on  the  other  hand,  usually  begins  about  the  centre  (the  ninth  dorsal  vertebra), 
and  extends  ujjward  and  downward.  A  recent  observer  states  that  there  are 
some  fifteen  segments  in  the  coccyx  of  the  foetus  from  the  fifth  to  the  ninth 
week.  These  become  subsequently  absorbed  or  coalesce  into  the  four  per- 
manent vertebrae  belonging  to  the  coccyx. 

At  birth  the  infant's  spine  is  quite  straight,  serving  merely  to  connect 
the  head,  limbs,  and  ribs,  and  as  a  protecting  column  to  the  spinal  cord.  It 
is  very  flexible  at  this  time,  and  totally  without  the  important  factors  of 
gravity  and  muscular  contraction,  which,  as  the  child  begins  to  sit  and  stand 
and  walk,  tend  to  produce  the  characteristic  curvatures  in  the  neck,  back, 
and  loins.  These  curvatures  are  not  fully  developed  until  adult  life,  and, 
as  the  spinal  column  owes  to  them  its  elasticity  and  power  of  withstanding 
various  forces  communicated  to  it,  they  are  deserving  of  special  attention. 
In  the  back  of  the  young  child,  especially  if  it  be  delicate  or  the  subject  of 
rickets,  there  will  always  be  noticed  a  general  curving  of  the  column  back- 


44  ox    THE    ANATOMY    OF    CHILDREN. 

ward.  In  fact,  it  may  be  said  that  this  convex  curvature  of  the  back  is 
that  which  persons  naturally  assume  when  feeble  or  weary  at  any  period  of 
life,  and  habit  or  occupation  often  makes  it  very  pronounced.  The  dorsal 
curvature  and  the  pelvic  curvature,  made  up  of  the  sacro-coccygeal  vertebrae, 
are  the  natural  ones  found  in  an  infant.  In  the  embryo,  at  the  very  begin- 
ning of  the  formation  of  the  column  it  assumes  this  dorsal  convexity,  and 
as  soon  as  the  sacral  promontory  is  developed  it  is  only  modified  by  the 
addition  of  the  sacral  and  coccygeal  curves. 

The  normal  curvatures  of  the  spine  are  maintained  to  a  great  extent 
by  the  disks  of  intervertebral  substance,  which  are  most  developed  in  the 
regions  where  most  movement  is  allowed.  The  intervertebral  substance  is 
composed  at  its  circumference  of  fibrous  tissue  and  fibro-cartilage,  and  at 
its  centre  of  a  soft,  pulpy  matter.  The  disks  act  as  buffers,  and  resist 
shocks  to  the  spine.  The  natural  curves  are  all  antero-posterior,  with  a 
very  slight  lateral  one  to  the  right  in  the  dorsal  region.  The  erector  spinse 
mass  of  muscles  are  inserted  into  the  spines  and  transverse  processes,  and 
tend  to  establish  equilibrium.  The  motions  of  which  the  spine  is  capable 
are  lateral,  antero-posterior,  and  rotatory.  The  greatest  degree  of  rotation 
and  lateral  flexion  is  found  in  the  neck  and  loins.  Structural  changes  and 
unequal  muscular  exercise  produce  deformity.  When  the  curv'atures  are 
exaggerated,  they  take  the  names  of  cyphosis,  lordosis,  and  scoliosis,  ac- 
cording as  the  convexity  is  directed  backward,  foi'ward,  or  laterally.  The 
first  deformity  is  seen  in  rickets  and  in  caries  of  the  vertebras.  The  lordosis, 
or  saddle-back,  is  determined  very  often  by  inflammation  of  the  hip  (in 
coxalgia),  and  the  scoliosis,  the  most  frequent,  is  generally  met  with  among 
young  men  and  boys  who  assume  vicious  attitudes.  It  is  an  invariable  rule 
with  regard  to  spinal  deformities  that  if  we  have  a  weakness  occurring  at  a 
point  which  occasions  deviation  there  will  arise  compensating  deviations 
above  and  below  it.  In  marked  cases  there  will  occur  also  a  rotatory  curva- 
ture, caused  by  contraction  of  the  slips  from  the  longissimus  dorsi  which 
are  inserted  into  the  angles  of  the  ribs.  This  may  be  so  powerftd  as  to 
place  the  transverse  processes  in  the  site  of  the  spine. 

Lateral  curvatures  in  the  dorsal  region  occur  about  the  fourth  or  fifth 

vertebra. 

THE   LIMBS. 

The  earliest  traces  of  the  limbs  in  the  embr}^o  are  found  about  the  fifth 
week.  They  undergo  rapid  metamorphoses  so  that  about  the  eighth  week 
not  only  are  there  rudimentary  arms  and  forearms,  thighs  and  legs,  but  also 
a  separation  of  digits  for  hands  and  feet.  The  lower  limbs  are  a  little  later 
than  the  upper  in  their  formation. 

Of  the  skeleton  generally  it  may  be  said  that  the  bones  composing  it  do 
not  acquire  their  final  complete  development  until  adult  age  is  reached. 
During  childhood  there  are  marked  changes  occurring  in  the  bony  framework 
at  various  periods. 

The  growth  and  development  of  bone  constitute  at  all  times  an  important 


ox    THE    ANATOMY    OF    CHILDEEX.  45 

subject,  which  the  surgeon  may  have  to  contemplate,  but  in  no  connection 
can  they  be  more  suitably  considered  than  in  the  limbs  of  children.  From 
the  time  of  Berzelius  the  chemical  composition  of  bone  has  been  described 
as  one-third  animal  matter  and  tAA'o-thirds  earthy  matter,  but  it  has  been 
found  b}'  recent  observers  that  the  relative  proportion  of  these  constituents 
differs  in  the  different  bones.  There  i«  a  great  difference  of  opinion  about 
the  variable  quantity  at  different  ages,  but  it  has  been  pretty  clearly  demon- 
strated that  there  is  no  change  in  the  proportion  in  the  individual  bones 
from  infancy  to  old  age,  and  that  rickets  and  osteomalacia  are  due  not  to  a 
change  in  the  bony  composition,  but  to  an  inherent  diathesis,  as  scrofula  or 
syphilis.  In  other  words,  it  is  rather  the  quality  than  the  quantity  of  the 
constituents  which  occasions  the  peculiar  characteristic  lesions  of  bone  in 
these  affections.  The  proportion  of  animal  matter  is  usually  described  as 
being  in  excess  in  the  bones  of  children,  and  the  earthy  elements  are  sup- 
posed to  increase  with  advancing  age,  but  it  should  be  recollected  that  the 
bones  during  infancy  are  exceedingly  vascular,  and  that  it  is  almost  imj^os- 
sible  thoroughly  to  remove  the  vessels  ift  order  to  determine  by  experiment 
the  exact  proportion  of  the  constituents  of  bone  at  that  period  of  life. 

In  the  foetus  the  skeleton  is  mapped  out  for  the  cranial  bones  in  mem- 
brane, and  for  the  long  bones  of  the  limbs  in  cartilage.  A  long  bone  affords 
the  best  example  of  the  process  of  ossification,  for  it  may  be  said  to  depend 
upon  both  membranous  and  cartilaginous  formation.  The  process  begins 
in  the  centre  of  the  shaft  of  the  bone  (diaphysis),  and  proceeds  towards  the 
extremities  (epiphyses),  which  remain  cartilaginous  until  some  time  later, 
when  centres  of  ossification  occur  in  them  and  the  process  involves  them 
also.  The  extremities  are  separated  from  the  shaft  by  a  layer  of  epiphyseal 
cartilage  until  the  growth  of  the  bone  is  completed  (see  Fig.  30).  Simul- 
taneously with  the  ossific  changes  in  the  centre  of  the  cartilage  of  the  foetal 
bone,  a  very  vascular  membrane  is  developed  around  the  shaft.  This  is  called 
the  periosteum,  and  consists  of  two  layers  which  serve  as  a  nidus  for  the  rami- 
fications of  vessels  v.diich  pass  from  it  into  the  bone.  In  young  children  it  is 
thick  and  veiy  vascular,  and  is  only  connected  at  the  epiphyseal  cartilages  at 
either  end  of  the  shaft,  being  separated  from  the  latter  by  a  layer  of  soft  blas- 
tema containing  "  osteoblasts,"  from  which  ossification  proceeds  on  the  sur- 
face of  the  growing  bone.  Green-stick  or  incomplete  fractures,  which  occur 
sometimes  in  children,  are  probably  due  as  much  to  this  condition  of  the 
periosteum  as  to  the  apparent  excess  of  animal  matter  in  the  bone  itself. 
Later  in  life  the  periosteum  is  thinner,  less  vascular,  and  more  adherent  to 
the  surface  of  the  bone.  The  tendons  and  ligaments  have  firmer  hold  upon 
the  bones,  because  they  become  incoqiorated  and  continuous  with  the  perios- 
teum at  their  attachment.  Cartilage  is  now  considered  as  only  a  temporary 
substitute  for  bone  in  the  early  stages  of  the  formation  of  the  skeleton. 

Bones  grow  in  length  by  deposition  taking  place  from  the  ends  towards 
the  centre.  The  shaft  increases  in  circumference  l)v  deposition  from  the 
periosteum  on  the  external  surface,  while  the  medullaiy  canal  is  produced 


46  ON   THE    ANATOMY    OF    CHILDREN. 

by  absorption  from  within.  Owing  to  the  ends  of  a  long  bone  having 
separate  centres  of  ossification,  and  the  interposition  of  the  layers  of  carti- 
lage between  them  and  the  shaft  until  its  full  length  is  attained,  the  bone  is 
indurated  in  the  parts  where  the  greatest  strength  is  required,  whilst  the 
longitudinal  growth  is  facilitated. 

About  the  centre  of  the  shafb  of  the  long  bones  there  is  a  large  foramen 
leading  obliquely  into  the  medullary  canal,  which  accommodates  the  medul- 
laiy  arter}'^,  usually  a  branch  of  the  main  artery  of  the  part  of  the  limb  to 
which  the  bone  belongs.  This  medullary  artery  sends  branches  upward 
and  downward  through  the  marrow,  which  are  generally  considered  to 
anastomose  with  the  arteries  of  the  cancellous  and  compact  tissues.  The 
veins  emerge  from  the  long  bones  by  foramina  at  the  extremities  and  upon 
the  surface  of  the  shaft  and  by  the  foramen  for  the  medullary  artery. 
Owing  to  the  veins  being  enclosed  in  the  bony  tissues,  their  coats  are  ex- 
ceedingly thin,  and  consequently  in  cases  of  amputation  where  there  is 
suppuration  there  is  danger  of  purulent  absorption.  In  children  and  young 
persons,  ^vhere  the  periostemn  is  thick  enough  to  admit  of  being  dissected 
readily  from  the  bone,  it  is  advisable  to  make  a  flap  of  the  periosteum  to 
cover  over  the  end  of  the  bone  before  adjusting  the  skin  and  muscle  flaps 
of  the  stump. 

The  medullary  canals  of  the  long  bones  in  the  infant  are  filled  with  a 
reddish,  oily  fluid.  By  degrees  this  becomes  transformed  into  a  fatty  sub- 
stance of  a  yellow  color. 

THE   UPPEE   EXTKEMITY. 

There  is  very  little  about  the  scapula,  which,  together  with  the  clavicle, 
the  upper  end  of  the  humerus,  and  the  structures  surrounding  them,  forms 
the  region  of  the  shoulder,  that  is  peculiar  to  childhood,  other  than  that  the 
several  centres  of  ossification  from  which  it  is  developed  are  not  completed 
in  their  office  until  about  the  seventeenth  year.  The  acromion  is  rarely 
joined  to  the  bone  proper  before  the  twenty-second  year,  and  sometimes 
there  is  only  a  fibrous, connection  between  it  and  the  spine,  which  may  give 
rise  to  supposed  fracture.  It  is  worthy  of  note  that  the  latissimus  dorsi 
muscle  passes  over  the  inferior  angle  of  the  scapula,  and  is  usually  attached 
to  it,  so  that  the  bone  is  held  in  contact  with  the  thorax.  As  a  result  from 
injury,  the  angle  may  slip  from  beneatli  the  muscle  and  project  under  tlie 
skin.  In  poorly-nourished  children,  where  the  muscles  are  flabby,  the 
scapulse  often  jut  like  two  prominent  wings. 

The  clavicle  is  peculiar  in  that  it  is  not  only  the  first  bone  in  the  skeleton 
to  ossify,  but  that  ossification  in  it  begins  in  its  primary  fibrous  substance 
before  the  deposition  of  cartilage.  At  birth  the  entire  shaft  is  bony, 
although  the  ends  arc  cartilaginous.  The  sternal  end  is  the  sole  epiphysis 
to  the  clavicle,  and  it  is  joined  to  the  sliaft  about  the  twenty-fifth  year.  It  is 
rarely  separated  from  the  shaft  by  accident,  owing  to  the  close  ligamentous 
attachments  of  the  sterno-clavicular  joint,  but  the  powerful  pectoralis  major 


ox    THE    ANATOMY    OF    CHILDREX.  47 

muscle  might  produce  displacement  in  a  young  person.  This  bone  is  fre- 
quently the  seat  of  green-stick  fracture,  owing  to  the  loose  and  exceedingly 
thick  periosteum  which  surrounds  it  in  the  young,  as  well  as  its  more 
early  ossification.  The  presence  of  the  protecting  periosteum  renders  injury 
to  the  subjacent  structures  in  case  of  fracture  of  the  bone  in  children  very 
improbable. 

The  humerus  at  birth  is  nearly  ossified  in  its  whole  length,  the  extremi- 
ties being  entirely  cartilaginous.  Ossification  does  not  commence  in  the  head 
of  the  bone  before  the  second  year,  and  in  the  tuberosities  in  the  third  year. 
Generally  there  is  one  centre  of  ossification  for  the  two  tuberosities,  but 
there  may  be  one  for  each  tuberosity.  About  the  fifth  year  the  centres  for 
the  head  and  tuberosities  become  joined,  and  form  the  upper  epiphysis, 
which  is  not  united  to  the  shaft  until  the  twentieth  year,  and  sometunes 
later.  The  lower  end  of  the  humerus  is  developed  by  a  centre  of  ossifi- 
cation in  the  radial  portion  of  the  articular  surface  about  the  third  year, 
and  another  centre  for  the  inner  articular  surface  appearing  as  late  as  the 
twelfth  year.  The  inner  condyle  is  formed  about  the  fifth  year,  and  the 
outer  condyle  in  the  fourteenth  year.  In  the  sixteenth  or  seventeenth  year 
the  condyles  and  articular  surfaces,  having  joined,  unite  with  the  shaft. 

In  early  childhood  the  ligaments  and  tendons  about  the  joints  are 
stronger  and  more  resisting  than  the  contiguous  bone.  Falls  upon  the 
shoulder  or  upon  the  arm  held  close  to  the  side  of  the  body  in  children 
may  result  in  detachment  of  the  upper  epiphysis  of  the  humerus.  In  one 
case  within  the  writer's  practice,  a  little  girl,  aged  five  years,  sustained  a 
fracture  of  the  shaft  of  the  humerus,  with  separation  of  both  the  upper  and 
lower  epiphyses.  This  form  of  accident  is  commoner  in  childhood  than 
fracture  of  the  surgical  neok  of  the  humerus,  and  therefore  the  importance 
generally  given  to  the  distinction  between  this  and  the  anatomical  neck  in- 
tended to  indicate  the  danger  of  fracture  of  the  former  rather  than  of  the 
latter  is  unnecessary,  until  after  the  consolidation  of  the  shaft  with  the 
epiphysis  at  puberty.  Arrest  of  development  of  the  arm-bone  may  follow 
upon  interference  wath  either  epiphyseal  line,  the  upper  one  of  which  is  at 
the  base  of  the  great  tuberosity  and  the  lower  just  above  the  condyles. 

Lifting  children  by  the  arms  is  a  hazardous  proceeding,  and  the  reason 
why  it  is  so  infrequently  followed  by  dislocation  or  epiphyseal  detachment  is 
probably  due  to  the  ligamentous  function  of  the  long  tendon  of  the  biccjis 
muscle  and  the  protecting  influence  of  the  deltoid.  There  is  a  large  bursa 
under  the  deltoid  and  over  the  insertions  of  the  supra-  and  infra-spinatus 
muscles,  which  sometimes  communicates  with  the  shoulder-joint.  Acute 
arthritis  in  infants  may  be  due  to  strain  or  wrench  involving  the  bursa  or 
inciting  epiphysitis,  which  involves  the  joint-structures.  It  is  less  common 
in  the  shoulder  than  in  the  hip. 

The  Elbow. — Owing  to  the  cartilaginous  condition  of  the  olecranon 
process  of  the  ulna,  which  forms  a  hinge  with  the  lower  end  of  the 
humerus,  the  elbow-joint  in  cliildhood  owes  its  main  strength  to  the  lateral 


48  ON   THE    ANATOMY    OF    CHILDREN. 

ligaments  and  the  tendons  of  the  muscles  which  pass  over  it.  Just  below 
the  external  condyle  of  the  humerus  there  is  a  pit  or  dimple  in  the  skin  of 
the  child  when  the  elbow  is  extended.  This  pit  is  an  important  landmark^ 
as  the  head  of  the  radius  can  be  felt  rolling  in  pronation  and  supination  of 
the  forearm.  There  is  a  large  bursa  over  the  olecranon  and  another  beneath 
the  insertion  of  the  triceps,  neither  of  which  ordinarily  communicates  with 
the  joint.  It  is  well  to  note  that  the  epiphyses  which  meet  at  the  elbow- 
joint  unite  with  their  shafts  earlier  than  those  at  the  opposite  ends  of  the 
bones ;  also  that  the  foramina  of  the  medullary  arteries  are  directed  towards 
the  elbow. 

The  development  of  the  ulna  occurs  from  three  centres, — one  for  the 
shaft  and  one  for  either  end.  At  birth  the  ends  are  entirely  cartilaginous. 
The  olecranon  does  not  begin  to  ossify  until  the  tenth  year,  and  it  is  joined 
to  the  shaft  about  the  sixteenth  year.  The  lower  end  ossifies  in  the  fourth 
year,  and  joins  the  shaft  in  the  twentieth  year. 

The  radius  is  developed  from  three  centres.  The  head  is  ossified  in  the 
fifth  year,  and  joins  the  shaft  about  the  eighteenth  year.  The  lower  end  is 
ossified  during  the  second  year,  but  does  not  unite  with  the  shaft  before 
the  twentieth  year. 

The  Wrist. — The  bones  of  the  wrist  are  all  cartilaginous  at  birth,  and 
they  become  ossified  at  varying  periods,  as  follows  :  the  os  magnum  in  the 
first  year,  the  unciform  in  the  second,  the  cuneiform  in  the  third,  the  trape- 
zium in  the  fourth,  the  semilunar  in  the  fifth,  the  scaphoid  in  the  sixth,  the 
trapezoid  in  the  seventh,  and  the  pisiform  not  generally  before  the  twelfth 
year.  The  bursse  at  the  wrist  do  not  connect  with  the  joint,  but  are  in  rela- 
tion with  the  adjacent  tendons. 

The  metacarpal  bones  and  the  phalanges  are  usually  composed  of  a  shaft 
and  an  upper  epiphysis.  The  shafts  are  ossified  soon  after  birth,  and  the 
epiphyses  are  all  united  about  the  twentieth  year. 

THE    LOWEE   EXTEEMITIES. 

The  hip-joint  is  so  deeply  placed  and  thickly  covered  by  soft  parts  that 
it  is  more  exempt  from  acute  inflammation  in  childhood  than  other  joints. 
It  follows,  however,  from  its  peculiar  construction  that  when  disease  attacks 
the  hip-joint,  and  is  attended  with  formation  of  pus,  the  destructive  changes 
are  very  great,  because  the  pus  is  so  pent  up  that  it  is  long  before  it  reaches 
the  surface.  The  capsule  is  thinnest  in  front  and  behind,  aud  in  cases  of 
effusion  into  the  joint  the  swelling  first  shows  itself  in  these  localities. 

In  chronic  hip-disease  in  children  the  limb  assumes  certain  false  posi- 
tions, which  have  been  described  by  Treves  as  follows :  first,  the  thigh  is 
flexed,  abducted,  and  a  little  everted  ;  associated  with  this  there  is  apparent 
lengthening  of  the  limb,  then  lordosis  of  the  spine  occurs,  then  the  thigh 
becomes  abducted  and  inverted,  and  incident  to  this  there  is  apparent  short- 
ening of  the  limb  ;  tliis  is  followed  by  real  shortening  of  t4ie  limb. 
•     The  disease,  when  it  begins  in  bone,  usually  involves  the  epiphyseal  line 


ON    THE    ANATOMY   OF    CHILDREN.  49 

that  unites  the  head  of  the  femur  to  the  neck.  This  epiphysis. is  joined  to  the 
shaft  about  the  eighteenth  or  nineteenth  year.  In  hip-disease  pain  is  referred 
to  the  front  of  the  knee  by  the  anterior  crural  nerve,  and  to  the  back  of 
the  joint  by  the  obturator  and  sciatic  nerves,  these  nerves  supplying  both 
joints. 

The  three  bones  composing  the  acetabulum  are  united  by  a  Y-shaped 
cartilage  until  the  age  of  puberty,  and  in  some  cases  of  destructive  hip- 
disease  may  become  separated ;  and  there  is  a  large  bursa  between  the  front 
of  the  capsule  and  the  tendon  of  the  ilio-psoas  muscle.  It  communicates 
with  the  joint.  There  are  also  bursse  between  the  great  trochanter  and  the 
gluteus  maximus  muscle,  and  over  the  tuberosity  of  the  ischium.  JSTeither 
of  these  is  normally  connected  with  the  joint. 

The  acetabulum  is  generally  completely  ossified  by  the  eighteenth  year. 

The  femur  is  developed  by  five  centres,  one  for  the  shaft,  one  for  each 
extremity,  and  one  for  each  trochanter.  It  begins  to  ossify  next  after  the 
clavicle  in  the  foetus.  The  centre  for  the  lower  end  of  the  bone  appears  just 
before  birth,  and  forms  the  condyles  and  tuberosities. 

The  head  of  the  femur  begins  to  ossify  about  the  end  of  the  first  year, 
the  great  trochanter  about  the  fourth  year,  and  the  lesser  trochanter  between 
the  thirteenth  and  fourteenth  years.  The  epiphyses  are  not  joined  to  the 
shaft  until  after  puberty, — the  first  being  the  lesser  trochanter,  the  next  the 
greater  trochanter,  the  next  the  head,  the  lower  extremity  (which  is  the  first 
to  show  ossification)  not  consolidating  with  the  shaft  before  the  twentieth 
year.  On  account  of  the  length  of  time  which  the  lower  epiphysis  takes 
to  ossify,  the  growth  of  the  femur  is  greatest  in  the  lower  part  of  the  shaft. 
In  operating  for  knock-knee  or  bowed-leg,  it  is  well  to  avoid  interfering 
with  the  epiphyseal  cartilage,  so  as  not  to  modify  the  growth  of  the  limb. 

The  tibia  and  fibula,  like  the  bones  of  the  forearm,  have  three  centres 
of  ossification.  The  centre  for  the  upper  end  of  the  tibia  appears  at  birth, 
and  is  completed  and  joined  to  the  shaft  about  the  twentieth  year.  The 
lower  end  shows  ossification  in  the  second  year,  and  joins  the  shaft  in  the 
eighteenth  year.  The  upper  end  of  the  fibula  begins  to  show  ossification 
about  the  fourth  year,  and  unites  about  the  twenty-fifth  year.  The  lower 
end  appears  in  the  second  year,  and  unites  about  the  twentieth  year. 

About  the  knee  there  are  many  bursse ;  in  fact,  they  are  placed  between 
the  bony  prominences  and  tendons  of  all  the  muscles  attached  in  the  neigh- 
borhood of  this  joint.  Some  of  these  communicate  with  the  articulation, 
but  those  which  most  frequently  do  so  are  the  bursse  which  are  placed  be- 
tween the  quadriceps  and  the  femur  and  between  the  ligamentum  patellae 
and  the  tubercle  of  the  tibia.  The  first  of  these  is  just  above  the  pouch  of 
synovial  membrane  Avhich  extends  above  the  patella,  beneath  the  extensor 
tendon.  Joint-disease  is  veiy  apt  to  affect  the  knee,  owing  to  its  exposed 
position.  In  neglected  cases,  the  hamstring  muscles  are  frequently  con- 
tracted, owing  to  tlieir  receiving  branches  from  the  great  sciatic  nerve,  which 
also  supplies  the  joint.  In  some  cases  of  progressive  disease,  the  contraction 
YoL.  I.— 4 


50  ox    THE   AXAT03IY    OF    CHILDEEX, 

of  these  muscles  will  produce  a  partial  luxation  by  drawing  the  tibia  back- 
ward. 

When  effusion  takes  place  in  the  ankle-joint,  the  swelling  first  appears 
in  front  beneath  the  extensor  tendon,  and  aflersvards  behind  on  either  side 
of  the  tendo  Achillis.  The  lateral  ligaments  are  too  strong  to  be  affected 
by  effusion  within  the  joint. 

The  Foot. — The  normal  arch  of  the  foot  is  in  great  measure  maintained 
by  the  central  part  of  the  plantar  fascia.  It  is  exaggerated  bv  marked 
contraction  of  this  fascia  in  club-foot,  such  as  congenital  varus  and  talipes 
equinus.  In  order  to  divide  the  membrane,  the  knife  should  be  introduced 
from  the  inner  side,  so  as  to  avoid  the  external  plantar  artery,  about  a 
iinger's-breadth  from  the  os  calcis. 

In  dividing  the  tendo  Achillis,  the  knife  should  be  introduced  a  finger' s- 
breadth  above  its  insertion. 

The  posterior  tibial  vessel  runs  midway  between  the  os  calcis  and  the 
internal  malleolus.  The  tibialis  posticus  tendon  may  be  easily  divided 
above  the  base  of  the  inner  malleolus.  It  can  be  cut  also  on  the  side  of 
the  foot  between  the  annular  ligament  and  the  scaphoid  bone.  The  tendon 
of  the  tibialis  anticus  may  be  divided  in  front  of  the  ankle  or  at  its  insertion 
into  the  internal  cuneiform  bone. 

The  tarsal  bones,  excepting  the  os  calcis,  all  have  one  centre  of  ossifica- 
tion. The  OS  calcis  has  an  epiphysis  which  appears  during  the  tenth  year 
and  unites  with  the  rest  of  the  bone  after  puberty.  The  order  in  which 
the  ankle-bones  ossify  is  as  follows  :  the  body  of  the  os  calcis  in  the  sixth 
month  of  fcetal  life,  the  astragalus  in  the  seventh  month,  the  cuboid  in  the 
ninth  month,  the  external  cuneiform  in  the  first  year,  the  internal  cuneiform 
in  the  third  year,  the  middle  cuneiform  in  the  fourth  year.  The  metatarsal 
bones  and  phalanges  have  each  one  centre  for  their  shafts  and  one  for  theii" 
epiphyses.  The  epiphyses  appear  about  the  sixth  year,. and  become  united 
between  the  eighteenth  and  twentieth  years. 

In  conclusion,  the  author  ventures  to  state  that  the  illustrations,  most 
of  which  are  original,  are  adapted  from  his  forthcoming  work  on  Anatomy. 
The  photographs  of  living  children,  indicating  topographically  the  position 
of  the  thoracic  and  abdominal  organs  and  the  important  surgical  landmarks, 
are  intended  to  serve  as  diagrams.  The  rise  and  fall  of  the  dia2)hragm  and 
the  distention  of  the  stomach  during  digestion  render  it  difficult,  however, 
to  map  out  with  accuracy  the  position  of  the  viscera  on  the  living  body. 


THE  PHYSIOLOGY  OF  INFANCY. 

By  angel  money,  M.D. 


PRELIMIXAEY  EE3IAEKS. 

The  more  one  studies  the  literature  of  the  physiology  of  infancy  and 
childhood,  the  more  the  truth  is  forced  home  on  one  that  but  little  that  can 
be  of  value  in  practice  is  known. 

Xor  are  we  likely  much  to  advance  in  our  really  useful  knowledge 
until  further  steps  in  the  direction  of  a  molecular  physiology  have  been 
made. 

Few  of  the  text-books  upon  children's  diseases  have  much  space  allotted 
to  the  study  of  physiology.  The  growth  and  development  of  the  infant 
are  subjects  of  importance ;  the  chemistry  of  its  secretions  bears  upon  the 
great  question  of  dietetics ;  the  study  of  its  excretions  gives  us  an  index 
to  its  tissue-changes.  The  guide  to  the  maintenance  of  its  health  is  a 
knowledge  of  its  physiology. 

Whilst  there  is  much  that  is  of  absorbing  interest  to  the  student  of 
biology  in  what  has  already  been  ascertained  of  the  physiology  of  infancy, 
most  of  it  is  of  a  theoretical  or  not  clearly  applicable  nature,  and  moreover 
would  require  a  large  volume  to  expound.  In  this  work  nothing  but  what 
has  practical  bearings  or  actual  utility  can  be  given,  for  the  author  prefers 
to  present  a  clear  if  meagre  outline  rather  than  a  confused  picture  of  details. 

GROWTH. 

The  ne^^-born  male  child  measures  on  an  average  50  centimetres,  and 

the  female  49.     The  rate  of  growth  in  length  has  been  determined  by 

Liharzik  to  follow  a  certain  law,  increasing  seven  and  a  half  centimetres  in 

certain  spaces  of  time,  following  an  arithmetical  series,  so  that  at  the  end 

of  the  first  month  the  body  measures  57|  cm.  in  length ;  at  the  third  month, 

65  cm. ;  at  the  sixth  month,  72^^  cm. ;  at  the  tentli  month,  80  cm. ;  at  the 

fifteenth  month,  87|  cm. ;  at  the  twenty-first  month,  95  cm.     During  the 

next  arithmetical  series,  from  21  to  276  months,  the  increase  is  at  the  rate 

of  five  centimetres  per  interval,  tlic  number  of  intervals  being  seventeen. 

The  interval  required  for  the  added  unit  of  growth  is  seen  to  increase  in 

arithmetical  progression. 

51 


52  THE   PHYSIOLOGY   OF   INFANCY. 

Gro-wth  in  "Weight. — Three  thousand  two  hundred  grammes  is  given 
as  an  average  weight  of  the  full-term  male  child,  and  two  thousand  nine 
hundred  for  the  female.  But  this  seven  pounds  is  often  exceeded.  A 
natural  loss  of  weight  occurs  for  three  or  four  days  after  birth,  being  rather 
more  than  six  per  cent,  of  the  body-weight.  In  grammes  the  total  loss  has 
been  estimated  by  Haake,  Winckel,  and  Quetelet,  at  222.  Then  follows 
an  increase  in  weight  which  appears  to  vary  greatly ;  for  some  assert  that 
the  growth  is  gradual  and  regular,  whilst  others  have  observed  it  to  take 
place  by  leaps  intermittently.  Sometimes  much  flesh  is  added  during  the 
second  month  of  life;  but  the  fourth  month  often  witnesses  the  greatest 
rate  of  increase  in  weight. 

Russow  noticed  a  considerable  difference  in  the  increase  in  weight  of 
infants  according  to  the  mode  of  rearing  them :  in  the  breast-fed  the 
growth  is  more  steady  and  always  transcends  that  of  the  hand-fed. 

Speaking  generally,  the  weight  of  the  body  is  doubled  by  the  fifth 
month  and  trebled  by  the  twelfth ;  Russow  avers  that  hand-fed  babes  do 
not  treble  their  birth- weight  till  the  second  year  of  life ;  the  same  difference 
obtains  in  after-years,  so  that  a  child  four  years  old  which  was  suckled  by 
the  mother  (for  the  usual  period)  weighed  generally  two  thousand  grammes 
more  than  a  child  Avho  was  artificially  fed  from  birth. 

In  weighing  infants,  allowance  must  be  made  for  the  passage  of  urine 
and  fseces,  so  that  a  difference  of  20  to  30  grammes  counts  for  nothing. 

Whilst  using  weight  as  a  guide  for  appraising  the  welfare  of  children, 
it  should  be  remembered  that  rickety  and  scrofulous  children  are  often 
heavy  from  a  richness  in  fat :  we  should  therefore  compare  the  growth  in 
weight  Avith  that  in  stature. 

Estimating  the  weight  at  birth  as  three  thousand  one  hundred  grammes, 
Hahner's  investigations  gave  the  following  results  showing  the  daily  and 
monthly  rate  of  increase  : 

1st  month,  3835  grammes,  showing  an  increase  of    73-5  at  the  dailj^  rate  of  24.5 


2d 

4930 

3d 

5540 

4th 

6010 

5th 

6680 

6th 

7005 

7th 

7680 

8th 

8100 

9th 

8370 

10th 

8680 

11th 

9170 

12th 

9470 

1095 

36.5 

610 

20.3 

470 

15.6 

670 

22.3 

325 

10.8 

675 

22.5 

420 

14.0 

270 

9.0 

310 

10.3 

490 

16.3 

300 

10.0 

Zeising's  table  shows  that  the  absolute  growth  in  length  of  the  whole 
of  the  members  of  the  body  is  greatest  during  the  first  triennium ;  the 
smallest  growth  in  length  of  most  parts  of  the  trunk  occurs  in  the  third 
triennium.  The  increase  in  length  of  all  parts  in  the  first  fifteen  years  is 
much  greater  than  the  further  growth  of  the  body  up  to  its  completion. 


THE    PHYSIOLOGY    OF    IXFAXCY.  53 

A  comparison  between  the  gain  in  Aveight  and  the  growth  in  length  is  in- 
structive, since  these  increments  seldom  proceed  in  close  relationship  to  each 
other,  though  a  certain  parallelism  between  the  two  should  be  observed. 
An  increase  in  weight  often  precedes  further  growth,  and  rapid  groMi;h  is 
often  interrupted  bv  an  increase  in  flesh. 

Generally  the  gain  in  weight  after  birth  is  more  evident  than  the  increase 
in  length ;  these  two  elements  of  groAAi:h  have  no  very  definite  proportion 
to  each  other,  but  a  certain  relation  between  them  may  be  observed.  A 
vigorous  child  generally  gains  four  pounds  in  weight  in  three  months,  and 
an  increase  of  a  pound  every  month  causes  the  child  to  double  its  birth- 
weight  in  five  months,  and  treble  it  in  twelve.  After  the  fourth  day  the 
body  grows  in  weight  at  the  rate  of  three  ounces  for  the  second  week,  four 
ounces  for  the  third,  five  ounces  for  the  fourth,  and  during  the  second  month 
an  ounce  a  day  is  about  the  right  quota  of  growth  in  weight.  In  the  third 
and  fourth  months  about  five  ounces  a  week  is  the  amount ;  this  drops  in 
the  next  three  months  to  an  average  of  three  ounces  a  week ;  then  about  the 
teething  period  a  slight  pause  in  growth  and  weight  may  be  noted.  Growth 
in  length  may  be  accompanied  by  a  slight  falling  off  in  weight.  In  spring 
and  early  summer  the  length  of  the  body  increases  often  in  a  marked  man- 
ner, recalling  something  of  a  similar  process  in  the  vegetable  world ;  in 
northern  latitudes,  growth  in  children  seems  to  occur  at  these  periods  only. 

A  child  in  health  generally  gains  twenty  pounds  in  weight  and  ten  inches 
in  height  in  the  first  ts\^o  years  of  life ;  in  the  third  year  four  pounds  and 
four  inches  are  about  the  usual  additions  to  the  weight  and  stature.  During 
the  next  six  years  the  body  increases  by  annual  increments  of  four  pounds 
in  weight  and  two  or  three  inches  in  height.  After  ten  years  the  body  puts 
on  flesh  at  the  rate  of  eight  pounds  a  year. 

AVERAGES  OF  HEIGHT  A^B  WEIGHT  OF  BOYS  A]S^D  GIPvLS  OF  EXGLISH- 
SPEAKING  EACES;  CALCULATED  BY  DR.  WILLIAM  STEPHEXSON 
FROM  TOTALS  OF  BRITISH  AXD  AMERICAN  STATISTICS. 

Boys. 

Age.  Height  in  Gain  in  Weiglit  in  Gain  in 

Years.  Inches.  Height.  Pounds.  Weight. 

5 41.30  .    .              40.49               .    . 

6 43.88  2.58            44.79  4.30 

7 45.86  L98            49.39  4.60 

8 47.41  1..5D            54.41  5.02 

9 49.69  2.28             59.82  5.41 

10 .51.76  2.07             66.40  6.58 

11 53.47  1.71             71.09  4.69 

12 55.05  1.58            76.81  5.72 

13 57.06  2.01             83.72  0.91 

14 59.60  2.54            93.46  9.74 

15 62.27  2.07  104.90  11.44 

16 64.66  2.39  120.00  15.10 

17 66.20  1.54  129.19  9.19 

18 66.81  .61  134.97  5.78 


54  THE   PHYSIOLOGY   OF   IXFAXCY. 

GlELS. 


Age.  Height  in  Gain  in  Weight  in  Gain  in 

Years.  Inches.  Height.  Ponnds.  Weight. 

5  .    .    : 41.05  .    .  39.63  .    . 

6 42.99  1.94  42.84  .    3.21 

7 44.98  1.99  47.08  '    4.24 

8 47.09  2.11  52.12  5.04 

9 49.05  1.96  56.28  4.16 

10 51.19  2.14  62.17  5.89 

11 53.26  2.07  68.47  6.30 

•      12 55.77  2.51  77.35  8.88 

13 57.96  2.19  87.82  10.47 

14 59.87  1.91  97.56  9.74 

15 61.01  1.14  105.44  7.88 

16 61.67  .66  112.36  6.92 

17 62.22  .55  115.21  2.85 

18 62.19  .    .  116.43  1.22 

About  the  ninth  year  in  girls  and  the  eleventh  in  boys  there  is  a  period 
of  diminution  in  the  rate  of  growth,  and  in  the  thirteenth  year  in  girls  and 
the  sixteenth  in  boys  the  activity  of  grow-th  is  at  its  greatest,  corresponding 
to  the  assumption  of  womanhood  and  manliood  by  the  processes  associated 
with  puberty.  Dr.  Stephenson's  article  in  the  Lancet,  September  22,  1888, 
gives  interesting  information  of  the  relation  of  w^eight  to  height  during  ado- 
lescence. Stature  increases  steadily  with  age,  but  not  at  a  uniform  rate,  and 
the  Aveight  also  increases  Avith  age,  but  not  uniformly  or  in  arithmetical  pro- 
portion to  the  height.  The  ratio  of  w-eight  to  height  increases  with  age,  so 
that  whilst  between  five  and  six  years  tlie  W' eight  of  the  inch  is  one  pound, 
at  eighteen  it  is  two  pounds.  After  various  w^  orkings  the  follow' ing  law  was 
found  to  hold  good  :  between  five  and  eighteen  years  inclusive  the  weight 
varies  directly  as  the  height  squared,  and  inversely  as  the  amount  by  which 
the  age  falls  short  of  a  certain  number  that  can  be  easily  ascertained. 

Let  H  represent  height,  W  weight,  n  age,  and  m  the  ascertained  number. 

The  formula  is  ^TF.     As  the  rate  of  growth  is  not  uniform,  the 

.  m — n 

value  of  m  is  not  constant.     It  can  be  readily  found  for  each  year  from  the 

typical  standard  of  the  formula  - —  =  m — n. 
-'^  w 

Reclus  and  others  have  observ^ed  febrile  appearances  during  rapid  growth 
of  the  body,  but  it  must  be  questionable  whether  there  was  not  some  obscure 
disturbance  exciting  the  fever,  for  Bouilly  states  that  pains  about  the  grow- 
ing ends  of  the  bones  attend  the  rapid  rate  of  grow^th  in  the  limbs.  Never- 
theless the  facts  deserve  attention,  as  does  also  the  interesting  grow'th  of  the 
body  in  length  during  acute  febrile  processes  which  cause  w'asting  :  perhaps 
the  actual  pyrexia  stimulates  the  growing  ends  of  the  bones  to  increased 
activity,  and  the  increase  in  length  of  single  bones  from  chronic  inflamma- 
tion deserves  consideration  in  this  connection. 

The   richness   of  the   muscles   and   other   tissues   in   glycogen   grows 


THE   PHYSIOLOGY   OF   INFANCY.  55 

rapidly  less  after  birth.  The  muscles  of  the  infant  are  richer  in  M'ater 
and  poorer  in  myosin  than  in  adnlts,  there  being  more  extractive  matters, 
fats,  and  inorganic  constituents.  The  muscles  are  very  poorly  developed 
in  the  new-born,  so  that  great  absolute  and  relative  increase  takes  place 
during  childhood  and  youth.  Fatigue  is  more  easily  induced  in  children 
than  in  adults.  This  may  be  due  to  a  greater  production  of  metabolic 
products.  Ranke  believes  that  sarcolactic  acid  is  the  material  on  which  the 
tired  feeling  depends ;  the  reaction  of  working  muscles  should  be  less  alka- 
line than  in  adults,  owing  to  the  greater  production  of  acid  products.  The 
elasticity  of  muscle  shoidd  also  be  less ;  muscular  activity  produces  rela- 
tively more  heat  and  less  mechanical  motion ;  rigor  mortis  occurs  and  dis- 
appears more  rapidly. 

The  circumference  of  the  head  of  the  new-born  child  averages  35  cm. 
for  the  male  and  34  for  the  female.  Again  Liharzik's  law  of  growth  steps 
in,  and  informs  us  that  for  each  period  the  rate  of  growth  to  the  twenty- 
first  month  is  2J  cm. ;  during  the  second  arithmetical  series  the  rate  being 
^  cm.  It  may  be  calculated  that  at  the  twenty-first  month,  or  after 
six  arithmetical  intervals,  the  circumference  of  the  head  measures  50  cm. 

Elsasser  showed  that  the  anterior  fontanel  normally  grows  in  size  till  the 
ninth  month,  and  in  general  it  then  begins  to  close,  being  ossified  from  the 
borders  and  thus  filled  in  on  an  average  at  about  the  age  of  eighteen  months. 

The  circumference  of  the  thorax  of  the  new-born  child  averages  31  cm., 
and  the  rate  of  increase  follows  the  same  arithmetical  progression,  the  unit 
of  addition  being  '3-^^  cm.  for  six  intervals,  so  that  at  the  twenty-first 
month  the  circumference  measures  about  42  cm. ;  from  this  age  to  the  one 
hundred  and  fifty-third  month  the  increment  is  1-^  for  each  interval,  so 
that  the  circumference  would  then  be  about  55  cm.  Then  at  puberty  the 
rate  of  increase  is  5f  up  to  the  end  of  the  increase  in  growth.  It  will  be 
seen  that  the  chest-circumference  increases  only  moderately  until  the  thir- 
teenth year,  and  then  very  rapidly,  chiefly  in  correspondence  with  the 
development  and  growth  of  the  lungs  and  heart. 

In  growth  it  will  be  perceived  that  the  chest-circumference  races  that  of 
the  head,  so  that  normally  it  beats  the  latter  in  the  second  year,  and  it  is 
a  sign  of  constitutional  disease  if  the  circumference  of  the  thorax  does  not 
exceed  that  of  the  head  in  the  third  year  of  life. 

The  numbers  thus  given  must  only  be  taken  as  approximately  accurate, 
since  nationality,  individual  peculiarity,  climate,  and  food  have  considerable 
influence  on  the  process  of  growth. 

Russow  showed  that  the  breast-fed  infant  grew  some  two  to  eight  centi- 
metres more  during  the  first  year  of  life  than  the  hand-fed. 

Frobelius  maintains  that  the  circumference  of  the  chest  of  the  normal 
new-born  must  be  at  least  2.5  cm.  less  than  the  head-circumference,  and 
that  half  tlie  length  of  the  body  must  exceed  the  circumference  of  the  chest 
by  7  centimetres.  In  both  sexes  the  antero-posterior  chest-diameter  is  cpial 
to  the  antero-posterior  pelvic  diameter. 


56  THE    PHYSIOLOGY    OF    INFANCY. 

Most  parts  of  the  body  in  the  new-born  are  proportionally  wider  than 

in  the  adult.  . 

THE   NERVOUS   SYSTEM. 

In  order  to  study  the  development  of  the  will  in  children,  we  must 
observe  carefully  the  movements  of  the  new-born  and  of  the  infant. 

The  congenital  movements  are  purely  involuntary  and  impulsive,  being 
pure  reflex  or  automatic  acts.  The  incessant  small  movements  of  various 
parts  of  the  body,  especially  of  the  face, — ^grimaces  (microkinesis), — ^belong 
to  this  category.  They  are  due  to  nerve-discharges  in  the  spinal  motor 
centres,  which  either  spontaneously  explode  or  are  made  to  discharge  by 
insignificant  irritations  either  of  their  afferent  nerves  or  perhaps  by  varia- 
tions in  the  vascular  conditions  on  Avhich  their  functions  depend. 

More  obvious  reflex  acts  exist  also,  as  when  movements  result  from  well- 
marked  peripheral  impressions, — light,  sound,  and  touch.  These  acts  occur 
just  as  in  brainless  animals,  and  indeed  are  altogether  comparable  to  the 
movements  of  a  decapitated  frog. 

The  time  required  for  the  performance  of  these  reflex  movements  seems 
to  be  somewhat  longer  than  after  they  have  been  frequently  repeated.  It  is 
probable  that  some  reflexes  are  more  perfectly  developed  at  birth  than  others. 
In  the  first  days  of  life,  reflex  movements  can  be  obtained  from  all  the 
sense-organs, — optic  nerve,  auditory,  olfactory,  taste,  trigeminal,  and  cuta- 
neous nerves  of  the  surface  of  the  body.  But  the  stimulation  must  either 
be  stronger  in  intensity  or  affect  wider  areas  than  in  later  life :  in  the  skin 
and  retina,  at  all  events,  a  larger  number  of  nerve-fibres  must  be  simul- 
taneously stimulated  in  order  to  obtain  an  undoubted  reflex.  The  reflex 
excitability  of  the  skin  of  the  face  is  relatively  greater  than  that  of  other 
parts  of  the  cutaneous  surface. 

A  third  variety  of  congenital  movements  is  the  instinctive,  which  occur, 
it  is  true,  after  irritation  of  sensory  peripheral  nerves,  but  not  with  the 
machine-like  regularity  of  reflex  movements.  Laughing  as  the  result  of 
tickling  the  sole  of  the  foot  does  not  always  occur.  Sucking  is  perhaj)s 
the  best  example  of  an  instinctive  movement.  The  act  of  licking  is  also 
similar. 

Probably,  at  birth  a  pure  act  of  volition  cannot  occur  either  in  man  or 
in  animal. 

Willed  movements  can  take  place  only  when  the  development  of  the 
senses  has  gone  so  far  that  not  only  are  the  qualities  of  individual  sensa- 
tions clearly  recognized,  but  also  complete  perception  has  become  established  ; 
by  which  we  must  be  understood  to  mean  the  power  of  comparing  sensations 
and  of  referring  them  to  their  proper  causes.  Without  the  power  of  idea- 
tion there  can  be  no  will,  without  sense-activity  there  can  be  no  ideation  : 
so  that  the  will  is  inseparably  interwoven  with  and  dependent  on  the  senses. 
Only  after  the  first  three  months  of  life  have  passed  does  evidence  exist  of 
the  possession  of  a  will ;  and  then  the  acquisition  does  not  come  suddenly, 
but  gradually. 


THE    PHYSIOLOGY    OF    INFANCY, 


57 


CLASSIFICATION   OF   MOVEMENTS   IN   CHILDEEN. 

The  following  schema  (after  Preyer)  will  help  the  study  of  the  various 
movements  : 

Imijulsive  movements'  involve  action  only  in  M  and  P,  the  lowest  parts 
of  the  motor  nervous  apparatus,  and  it  is  supposed  that  no  recognizable 
sensory  stimulus  is  required ;  such 
movements  are  also  entirely  un- 
conscious. In  reflex  movements 
the  parts  involved  are  those  des- 
ignated by  the  letters  E  8  M  P. 
Instinctive  movements  necessi- 
tate the  action  of  certain  sensory 
impressions  and  of  at  least  three 
centres  which  stand  in  morpho- 
losrical  relation  with  one  another. 
Lower  sensory,  higher  sensory, 
and  lower  motor  centres  must 
concert  in  order  to  produce  the 
simplest  instinctive  movement, 
R  S  G  M  P,  in  which  first  a 
sensory  impression  calls  forth  a 
sensation,  and  thence  ensues  the 
simple  instinctive  or  reflex  move- 
ment.    It  will  be  perceived  that 

,       ,  .    I                                         J.1,       xi  i?,  the  termination  of  the  sensory  nerves;  S,  the  lowest 

tne  Ulgnest  sensory,  or  ratlier  tlie  sensory  centre;  G,  the  highest  sensory  centre  in  the  cor- 

perceptive,  centre  need   not   be  in  tex;   V,  the  perceptive  centre  in  the  cortex;   W,  the 

.                .                               1  •   !  higher  motor  centre;  ilf,  the  lower  motor  centre ;  P,  the 

action,  as  in  sucking,  which  most  terminations  of  the  motor  nerves. 

probably  is  entirely  unconscious. 

In  more  complex  movements  requiring  the  aid  of  consciousness  the 
whole  of  the  centres  and  paths  will  be  in  action,  as  in  imitative  movements. 
It  will  be  inferred  also  that  the  highest  centres  may  act  as  the  result  of 
alterations  occurring  in  them  without  actual  impressions  from  without ;  and 
this  corresponds  to  complex  movements  involving  memory  and  comparison 
of  perceptions. 

The  following  impulsive  movements  may  be  observed  in  the  new- 
born : 

Stretching  and  bending  of  the  arms  and  legs,  like  those  occurring  during 
intra-uterine  life,  and  recalling  the  movements  of  animals  awakening  from 
hibernation  ;  tlicy  occur  also  during  sleep. 

Straightening  of  the  legs  immediately  after  waking,  seen  repeatedly  in 
the  second  week ;  it  remains  unchanged  all  through,  and  may  be  seen  to 
occur  even  without  waking.  Ocular  movements  occurring  before  tlie 
opening  of  the  eyes  when  waking  are  impulsive,  and  may  be  seen  in  adults. 

The  movements  of  the  new-born  in  a  bath  of  the  same  temperature  as 


58  THE    PHYSIOLOGY    OF    INFANCY. 

the  uterus  can  hardly  be  simply  reflex.  These  movements  may  be  dimly 
expressive  of  pleasure,  but  they  remain  even  for  four  months  as  purposeless 
and  as  asymmetrical  as  on  the  first  day  of  life. 

The  body  may  exhibit  to-and-fro  pushing  and  drawing  movements  in 
the  second  month ;  sometimes  this  movement  becomes  so  constant  and  last- 
ing as  to  constitute  disease.  I  have  been  consulted  several  times  on  account 
of  this  movement,  which  suggested  genital  irritation. 

Facial  movements,  asymmetrical  or  symmetrical,  may  also  be  seen  during 
sleep. 

Independent  movements  of  the  nose — apart  from  the  action  of  the  alee 
nasi  seen  in  sucking,  snuffling,  and  deep  breathing — were  not  observed  by 
Preyer  till  the  seventh  month. 

The  wrinkling  of  the  forehead  and  the  closure  of  the  eyes  in  the  first 
hours  of  life  are  not  always  impulsive,  but  sometimes  of  reflex  origin. 
Only  the  remarkably  asymmetrical  grimaces  of  the  new-born  are  probably 
purely  impulsive. 

The  bilaterally  symmetrical  movements  of  the  face  and  arm  of  reflex 
source  are  much  earlier  developed  and  more  differentiated  than  those  of  the 
legs.  The  same  holds  good  for  the  adduction,  abduction,  supination,  and 
rotation  of  the  arms. 

The  waking  suckling  performs  during  the  third  quarter  of  the  first  year 
striking  purposeless  movements  with  the  arms,  whereas  in  the  legs,  whether 
the  child  is  in  the  bath  or  in  bed,  alternating  extension  and  flexion  is  the 
rule. 

Crowing  and  other  vocal  sounds  are  during  the  first  year  due  to  dis- 
charges in  the  motor  nerve  cells  of  impulsive,  not  reflex,  kind,  just  as  are 
the  squeaking  of  new-born  animals  and  the  piping  of  chickens  still 
unhatched. 

Certain  associated  movements  require  notice  because  of  their  seemingly 
involuntary  and  impulsive  character.  The  extension  of  the  little  finger 
whilst  carrying  a  spoon  to  the  mouth  is  very  common  in  infants  even  up  to 
the  age  of  three  years ;  and  this  may  persist  till  much  later.  Other  asso- 
ciated movements  may  be  observed  in  the  last  months  of  the  first  year  of 
life,  and  also  later. 

We  all  have  witnessed  the  involuntary  movements  of  the  hands  and 
fingers  which  may  accompany  the  act  of  feeding,  and  which  give  the  child 
the  air  of  eagerness  to  get  food ;  the  movements  involuntarily  evoked  by 
music  are  probably  of  the  same  order. 

Although  at  birth  many  reflex  movements  obtain,  yet  the  reflex  excita- 
bility of  the  new-born  is  less  marked  than  a  little  later  in  life.  During  the 
last  months  of  foetal  life  reflex  activity  must  be  rapidly  increasing.  Preyer's 
experiments  on  unhatched  chicks,  and  on  immature  foetuses  of  rabbits  and 
dogs,  prove  that  many  reflexes,  such  as  swallowing,  and  even  inspiration, 
exist  before  birth.  The  human  foetus  undoubtedly  can  swallow,  since  it  is 
clear  that  the  meconium  coutaius  some  of  the  contents  of  the  liquor  amnii 


THE   PHYSIOLOGY   OF   IXFAXCY.  59 

in  the  form  of  epithelial  scales  and  fine  hairs  and  other  parts  of  the  vernix 
caseosa.  At  birth  a  new  reflex  (automatic?)  movement  commences  with 
the  establishment  of  respiration.  Perhaps  the  first  forcible  expiration 
causing  a  cry  is  purely  reflex  in  origin.  Sometimes  instead  of  crying  a 
definite  sneeze  takes  place,  as  Darwin  pointed  out.  In  sneezing,  as  in 
swallowing,  the  reflex  action  inyolyes  the  co-ordination  of  many  muscles, 
demonstrating  the  perfection  of  deyelopment  thus  early  at  birth  of  certain 
parts  of  the  nervous  centres  and  paths.  In  sneezing,  the  eyes  of  infants  are 
closed  every  time,  just  as  happens  in  apes  according  to  Darsvin.  Donders 
showed  that  the  filling  of  the  ocular  vessels  was  lessened  by  shutting  the 
eyes ;  and  thus  this  reflex  act  seems  somewhat  purposive.  Champneys 
noticed  flexion  and  extension  movements  of  the  limbs  to  accompany  the  act 
of  sneezing;  in  his  infant  during  the  first  nine  months  of  life. 

Sniffing,  yawning,  and  coughing  may  be  noted  in  the  first  days  of 
life ;  snorting  was  noted  on  the  twenty-fourth  day  by  Preyer ;  hawking  or 
expectoration,  however,  has  to  be  acquired,  and  often  its  appearance  is  very 
late ;  but  involuntary  coughing  even  as  early  as  the  fourth  day  of  life  has 
been  accidentally  attended  with  expectoration. 

The  involuntary  tossing  out  of  the  nipple  accomplished  by  the  tongue 
is  a  much  more  skilful  movement  than  is  the  spitting  out  of  the  skin 
of  a  grape,  though  the  latter  is  a  voluntary  act  of  later  acquisition,  which 
becomes  perfected  about  the  nineteenth  month. 

Sobbing  and  sighing,  which  in  later  life  have  psychical  associations,  have 
in  infants  not  any  such  meaning ;  sighing  may  be  noted  first  in  the  seventh 
month,  especially  on  raising  the  infant  from  the  recumbent  into  the  half- 
sitting  posture. 

In  early  life  the  respiratoiy  movements  have  no  relations  whatever  to 
the  emotions  :  the  heaving  of  the  breast  in  j^assion,  the  holding  of  the  breath 
from  attention,  and  such-like  movements,  are  not  to  be  observed  at  that 
period.  Indeed,  the  respiration  in  the  first  weeks  is  very  irregular :  now 
stormy,  next  feeble,  and  then  ceasing,  the  respiratory  rhythm  of  the  newly- 
born  exhibits  all  the  possible  physiological  and  pathological  variations. 
Vomiting  easily  induced,  choking,  and  hiccough  are  well-developed  reflexes 
even  at  birth.  Choking  movements  may  be  evoked  by  tickling  the  palate 
and  root. of  the  tongue,  or  by  applying  bitter  stuff*  to  the  same  parts,  or  by 
moistening  the  upper  lip  with  bad-smelling  substances.  Vomiting  may  be 
induced  by  filling  the  stomach  ^yith  water,  or  by  tickling  the  throat,  even  in 
the  youngest  infants,  and  eructations  from  the  stomach  are  quite  common. 
Hiccough  is  very  common  during  the  first  three  months  of  life ;  it  has  been 
noticed  within  twenty  hours  of  birth  :  even  when  bad  it  may  be  arrested  by 
a  teaspoonful  of  lukcM'arm  sugared  water. 

Other  movements  than  tlie  above  are,  however,  of  far  greater  psycho- 
logical importance, — the  reflex  movements  of  the  eyes  and  the  movements 
of  the  head  and  limbs  following  cutaneous  stimulation.  According  to 
Pfliiger,  if  one  side  of  the  head  be  tickled  whilst  the  infant  is  asleep,  the 


60  THE    PHYSIOLOGY    OF    INFANCY, 

hand  of  the  same  side  will  be  raised  towards  the  tickled  spot,  just  as  in  the 
case  of  a  decapitated  frog  stimulating  with  acetic  acid  the  inner  part  of 
the  thigh  causes  attempts  on  the  part  of  the  same  foot  to  remove  the  irri- 
tant. Preyer  tried  the  experiment  on  his  infant  at  the  age  of  fourteen  days 
and  afterwards :  sometimes  the  law  of  Pfliiger  held  good,  but  by  no  means 
always,  for  the  right  hand  might  move  at  the  irritation  of  the  left  temple 
(or  left  side  of  the  nose),  and  sometimes  no  response  followed.  During 
sleep  Rosenbach  has  observed  an  absence  of  the  abdominal,  cremasteric,  and 
patellar  reflexes ;  but  this  is  certainly  not  customary,  though  an  inequality 
of  the  superficial  reflexes  may  obtain  on  the  two  sides  during  sleep.  The 
knee-jerk  is  almost  invariably  more  ready  during  sleep,  and  it  may  be 
obtained  immediately  after  birth. 

The  rapid  closing  and  shutting  of  the  eyes  at  the  age  of  two  months  is 
a  sign  of  perfected  vision,  because  it  shows  a  perception  of  rajaid  movements  . 
on  the  part  of  the  child.     Agreeable  sensations  tend  to  cause  the  eyes  to  be 
opened  wider  than  under  uncomfortable  impressions. 

The  movements  of  the  eyes  of  the.  new-born  are  not  properly  co- 
ordinated :  each  eyeball  may  in  the  first  days  of  life  move  independently  of 
the  other,,  so  that  squinting  may  occur.  Perhaps  this  immaturity  is  the 
reason  why  ento-  or  ecto-peripheral  irritation  may  cause  squinting ;  for  it  is 
certain  that  very  slight  causes  may  disturb  the  motor  equilibrium  of  any 
nervous  centre  in  infants. 

It  must  take  some  time  before  the  infant  learns  to  fix  an  object  and  to 
exercise  accommodation  for  near  vision  fully.  The  young  infant  may  con- 
verge the  eyeballs  whilst  the  pupils  remain  dilated.  The  function  of  ac- 
commodation, involving  convergence  and  narrowing  of  the  pupil,  is  not 
congenital,  and  many  weeks  may  elapse  before  these  associated  movements 
are  perfected. 

Touching  the  tip  of  the  nose  of  the  new-born  child  causes  both  eyes  to 
be  screwed  up ;  if  one  nostril  only  is  touched,  the  eye  of  the  same  side  only 
is  closed,  but  if  the  irritant  is  stronger  both  eyes  tighten  and  the  head  is 
thrown  back.  In  the  new-born,  touching  the  conjunctiva,  the  cornea,  or  an 
eyelash  causes  shutting  of  the  eyes ;  but  the  irritation  of  the  eyelashes  and 
lids  does  not  always  cause  this  reflex,  and  these  parts  are  certainly  less 
sensitive  than  the  cornea.  If  a  stream  of  air  is  blown  upon  the  face  the 
eyes  shut,  but  only  if  the  cornea,  conjunctiva,  or  eyelids  are  aflected,  and  the 
eye  most  blown  upon  shuts  more  quickly  and  more  tightly  than  the  other. 
From  researches  on  new-born  chicks  and  guinea-pigs,  Preyer  finds  that  the 
closing  of  the  eyes  from  irritation  occurs  less  promptly  than  later  on.  In 
the  suckling  eleven  days  old  he  noticed  that  the  reflex  closure  of  the  lids 
was  percepti])ly  slower  than  in  the  grown-up.  On  the  fiftieth  day  the 
slightest  touch  of  an  eyelid  caused  rapid  shutting.  The  sensitivity  is  in 
contrast  with  the  observation  that  in  the  first  weeks  of  life,  the  infant  being 
in  the  bath,  some  lukewarm  water  may  fall  on  the  conjunctiva  of  the  open 
eye  without  causing  closure. 


THE    PHYSIOLOGY    OF    INFANCY.  61 

All  new-born  birds  and  mammals  appear  not  to  have  the  power  of 
iiolding  up  the  head ;  the  newly-hatched  chick  learns  to  do  this  in  a  few 
hours,  but  the  human  infant  takes  many  weeks  before  it  can  perform  this 
act.  Since  powerful  movements  may  be  seen  in  the  neck-muscles  in  the 
first  and  second  weeks,  it  is  most  probable  that  the  congenital  disability  to 
balance  the  head  on  the  neck  is  not  due  to  muscular  weakness,  but  simply  to 
a  want  of  co-ordinating  power  which  doubtless  has  its  structural  equivalent 
in  the  motor  centres  of  the  brain  proper.  Even  in  the  twelfth  week  the 
head  is  not  properly  balanced,  but  falls  sometimes  forwards,  backwards,  or 
sideways  when  the  infant  is  set  up.  About  the  sixteenth  week  the  head  may 
be  held  up  in  a  well-balanced  position.  That  the  act  is  dependent  upon  an 
effort,  however  slioht,  of  the  will  seems  clear  from  the  observation  that  in 
sleep  the  head  lolls  on  one  side  even  in  adults.  In  children  of  poor  develop- 
ment the  date  of  acquisition  of  this  function  of  balancing  the  head  is  post- 
poned by  one  or  more  months. 

The  first  attempt  to  sit  up  may  be  noticed  about  the  sixteenth  week,  but 
it  may  be  earlier  or  much  later  than  this ;  the  successful  fulfilment  of  this 
function  also  varies,  the  fortieth  week  of  life  being  a  fairly  early  date.  When 
first  learned,  this  act,  like  others,  is  not  very  stable,  so  that  slight  influences 
may  cause  its  failure,  and  a  really  firm  seat  does  not  obtain  generally  till  the 
tenth  or  eleventh  month.  In  sitting  upright,  it  may  be  noticed  that  the 
soles  of  the  feet  are  turned  towards  each  other,  recalling  the  posture  of  the 
ape  and  that  obtaining  in  utero  ;  and  even  long  after  birth,  when  the  babe  is 
free  from  impediments,  the  intra-uterine  position  of  the  limbs  may  be  noted 
in  the  adducted  legs  and  flexed  and  adducted  arms. 

Attempts  to  stand  may  be  made  as  early  as  the  thirty-eighth  week  of 
life,  but  its  successful  accomplishment  is  often  much  later,  and  varies  with 
the  strength  and  rate  of  development  of  the  child ;  by  the  eleventh  or 
twelfth  month  standing  should  be  an  accomplished  fact.  With  support, 
attempts  to  stand  may  be  found  as  early  as  the  twentieth  week,  and  perhaps 
earlier  (Sigismund). 

A  few  children  never  creep  on  the  floor :  the  date  of  appearance  of 
creeping  varies  much  in  different  children  even  in  the  same  family ;  and  the 
mode  of  creeping  differs  in  different  nations,  since  in  crawling  one  or  both 
knees  may  be  used.  ForM^ard  progression  on  hands  and  knees  does  not 
occur  until  some  time  after  walking.  The  movements  of  putting  one  leg  in 
front  of  another  are  instinctive,  and  may  be  witnessed  in  infants  long  be- 
fore they  can  stand,  by  holding  them  out  naked,  the  hands  of  the  holder 
supporting  the  child  under  the  armpits. 

Walking  may  be  developed  as  early  as  the  eighth  month,  but  usually  it 
is  the  twelfth,  and  it  may  be  much  later  than  this.  At  the  age  of  nine 
months  most  children  begin  to  crawl,  and  from  six  to  eight  months  later 
they  will  be  able  to  walk  by  themselves. 

The  idiosyncrasies  of  children  and  families  must  be  remembered  ;  for 
some  children  walk  long  before  others  can  stand,  and  some  run  before  others 


62  THE   PHYSIOLOGY   OF   INFANCY. 

walk.  Dr.  Cbampneys's  child  stood  upright  with  some  axillary  support,  its 
soles  touching  the  ground,  in  the  nineteenth  week,  and  it  then  moved  its  feet 
fonvard  without  irregularity,  though  the  feet  were  sometimes  raised  too 
high. 

There  can  scarcely  be  any  doubt  that  the  acts  of  sitting,  standing,  crawl- 
ing, running,  walking,  jumping,  climbing,  and  throwing  are  instinctive  in 
origin  and  do  not  have  to  be  learned  by  imitation,  the  truth  being  that  such 
acts  are  not  performed  at  birth  simply  because  of  the  want  of  development 
of  those  parts  of  the  brain  on  which  such  acts  depend. 

The  muscular  sense  begins  to  develop  itself  probably  before  birth  when 
fcEtal  movements  commence,  but  becomes  perfected  only  with  the  perfect 
development  of  the  various  movements  of  the  body. 

A  few  hours  after  birth  new-born  infants  react  to  strong  impressions 
made  on  the  olfactory  organs.  Although  before  birth  hearing  does  not  exist, 
yet  several  hours  after  reflex  movements  can  be  obtained  as  the  effect  of  loud 
sounds  :  the  imperfection  of  hearing  in  the  new-born  is  partly  to  be  accounted 
for  by  the  horizontal  position  of  the  membrana  tympani  and  by  the  circum- 
stance that  the  tympanic  cavity  is  ftill  of  a  gummy  fluid.  Immediately 
after  birth  the  reactions  obtained  by  giving  a  baby  sweet  substances  are  quite 
different  from  those  following  the  administration  of  bitters. 

Sight  in  the  proper  sense  of  the  word  does  not  exist  for  the  new-born, 
which  can,  however,  differentiate  light  from  darkness,  but  only  when  a  con- 
siderable portion  of  the  field  of  vision  is  illuminated  or  darkened.  If  the 
brightness  is  very  much  stronger  than  its  surroundings,  as,  for  example,  a 
bright  flame  in  a  dark  room,  then  even  in  the  first  weeks  of  life  it  is  recog- 
nized. The  separation  of  colors  is  very  incomplete  during  the  first  months  of 
life,  and  perhaps  is  limited  to  the  appreciation  of  unequal  intensity  of  light. 

Yellow,  red,  and  the  pure  white,  gray,  and  black,  are  the  first  to  be 
recognized,  whereas  green  and  blue  are  not  perceived  till  much  later. 
Probably  even  when  a  year  old  considerable  difficulty  exists  in  separating 
green  and  blue  from  gray ;  and  whilst  during  the  second  year  of  life  a  child 
may  name  correctly  the  four  primary  colors,  yet  any  normal  child  of  four 
without  special  training  would  find  it  easier  to  name  them  than  to  recognize 
mixed  tints. 

The  rapid  closure  of  the  eyelids  due  to  the  rapid  approach  of  any  object 
towards  the  eye  is  not  present  during  the  first  weeks  of  life,  it  being  a  reflex 
movement  having  a  defensive  object  which  first  originates  in  consequence  of 
an  unpleasant  feeling  due  to  changes  in  the  field  of  vision. 

New-born  infants  possess  but  feeble  perception  of  light.  Exposing  a 
babe  to  the  action  of  twilight  five  minutes  after  birth,  Preyer  observed  the 
eyes  to  open  and  shut  so  that  the  palpebral  fissure  at  times  measured  five 
millimetres,  and  a  little  later  the  eyes  were  noticed  to  be  wide  open  and  the 
forehead  wrinkled.  Before  the  end  of  the  first  day  it  was  evident  from  the 
l^lay  of  the  features  that  a  difference  in  the  intensity  of  light  was  appreciated 
by  the  babe.     On  the  second  day  the  eyes  rapidly  closed  on  bringing  a 


THE   PHYSIOLOGY    OF   INFANCY.  63 

candle-flame  near ;  aud  on  the  ninth  day  the  head  was  energetically  turned 
away  from  the  flame  and  the  eyes  tightly  closed.  The  sensitiveness  to  light 
was  greater  in  the  waking  state  than  immediately  after  sleep,  so  that  the 
same  object  which  at  one  time  caused  dislike  at  another  excited  pleasure. 
On  the  eleventh  day  the  infant  showed  signs  of  pleasure  at  the  sight  of  a 
burning  candle  and  also  of  a  bright  curtain-holder.  On  the  tenth  day  if 
was  noted  that  the  throwing  of  a  strong  light  on  the  eyes  of  a  sleeping 
infant  caused  contraction  of  the  orbicularis  joalpebrarum.  The  pupils  of 
new-born  infants  soon  react  to  light,  but  are  apt  to  vary  much  in  size ;  they 
may  contract  to  the  diameter  of  two  millimetres  soon  after  birth.  At  the 
age  of  two  months  bright  objects  excite  signs  indicative  of  mirth. 

In  normal  infants  by  the  end  of  the  first  week  the  closure  of  the  eyes 
as  the  eifect  of  sudden  loud  sound  may  be  observed.  Preyer  finds  that  it 
takes  at  least  three-quarters  of  a  year  before  a  child  recognizes  the  tones  of 
a  harp  ;  aud  it  is  questionable  whether  it  can  differentiate  the  tones  properly 
before  the  second  year.  Nevertheless,  many  children  sing  before  they  speak, 
aud  they  distinguish  the  noise  and  sounds  of  speech  long  before  they  can 
reproduce  them.  The  direction  from  which  a  sound  comes  may  be  deter- 
mined by  an  infant  two  or  three  months  old. 

The  sense  of  touch  during  the  first  hours  of  life  is  feebly  developed, 
and  the  sense  of  temperature  is  said  not  to  exist,  owing  to  the  surface  having 
been  kept  at  a  uniform  temperature.  The  new-born  is  not  very  sensitive 
to  painful  stimulation  aifecting  only  a  few  skin-nerves  (as  a  pinch),  yet  it 
cannot  be  doubted  that  it  knows  thoroughly  the  difference  between  pleas- 
urable aud  painful  sensations.  These  defects  of  sensation  are  to  be  ascribed 
to  defective  development,  not  only  of  the  skin,  but  also  of  the  brain. 

Taste  is  well  developed  in  the  new-born,  since  sweet,  bitter,  acid,  and 
salty  things  give  different  reactions  :  in  this  respect  the  human  new-born  is 
better  off  than  many  animals.  Although  this  distinguishing  power  obtains, 
yet  there  is  but  small  capacity  for  perceiving  differences  in  intensity. 

Immediately  after  birth  the  new-born  cannot  smell,  probably  as  the 
effect  of  the  liquor  amnii  having  filled  the  nasal  passages ;  but  a  little  later 
agreeable  smells  can  be  separated  from  disagreeable  ones. 

In  the  first  three  months  of  life  the  number  of  pleasurable  feelings  is 
not  numerous :  the  staying  of  hunger,  the  enjoyment  of  sucking,  the  sweet 
taste  of  the  milk,  the  pleasure  of  the  warm  bath,  the  joy  at  beholding 
bright  masses  of  light,  and  somewhat  later  that  dependent  on  the  move- 
ment of  objects  before  the  eyes,  the  pleasure  of  undress  which  provokes 
lively  movements,  and  also  the  comfort  of  being  dried  after  the  bath. 
vVcoustic  impressions  increase  the  sense  of  joy  in  the  second  month  of  life. 
It  cannot  be  till  the  third  month  that  the  infant  derives  pleasure  from 
recognizing  his  mother.  The  first  period  of  life  is  one  of  the  least  pleas- 
urable, since  the  number  of  enjoyments  and  the  capacity  fi)r  the  same  arc  of 
tlie  smallest.  With  attempts  at  graspiug  the  infant  finds  a  new  source  of 
jileasure  in  the  second  (piarter  of  life. 


64  THE    PHYSIOLOGY   OF    IXFA^sCY. 

The  most  powerful  factor  in  the  development  of  the  understanding  is 
the  capacity  the  infant  has  for  astonishment  and  its  related  emotion,  fear. 

THE    CIECULATIOiSr. 

The  changes  of  the  foetal  circulation  which  follow  the  expansion  of  the 
lungs  are  too  well  known  to  need  repetition  here.  There  are  other  facts  of 
diiference  between  the  infantile  and  the  adult  circulation  which  are  of  great 
physiological  and  pathological  importance.  The  relation  between  the  size 
of  the  heart  and  the  width  of  the  arteries  in  children  is;  roughly  speaking, 
the  very  reverse  of  what  obtains  in  the  adult.  Expressed  in  numbers,  the 
volume  of  the  heart  to  the  width  of  the  ascending  aorta  is  in  infants  as 
25  :  20.  Before  the  onset  of  puberty  the  ratio  is  approximately  140  :  50  ; 
after  puberty,  290  :  61.  From  these  facts  it  follows  that  the  blood-jDressure 
in  the  systemic  arteries  is  much  less  in  children  than  in  adults.  The  case 
is  very  different  in  the  pulmonary  circulation.  With  the  cessation  of  the 
foetal  circulation  there  commences  a  slow  M'idening  of  the  aorta. 

In  childhood  the  ascending  aorta  is  relatively  to  the  pulmonary  artery 
much  narrower  than  in  later  life ;  the  circumference  of  the  pulmonary  artery 
is  to  that  of  the  ascending  aorta,  reckoning  the  length  of  the  body  at  100 
centimetres,  at  the  end  of  the  first  year  of  life  as  46  is  to  40 ;  in  the  adult, 
as  35.9  is  to  36.2.  It  is  held  to  follov^^  from  this  diiference  that  the  blood- 
pressure  is  higher  in  the  child's  than  in  the  adult's  lungs.  Beneke  has 
shown  that  at  ijuberty  the  heart  rapidly  increases  in  size,  so  that  the  aorta 
becomes  relatively  narrow  and  the  blood-pressure  in  the  systemic  circulation 
greatly  raised.  The  annual  increase  in  the  size  of  the  heart  between  seven 
and  fourteen  years  of  age  is  only  eight  per  cent. ;  whilst  during  the  develop- 
ment of  puberty  the  rate  of  growth  is  nearly  one  hundred  per  cent.  It  is 
interesting  to  regard  this  great  and  rapid  growth  ^^"ith  corresponding  in- 
crease in  blood-pressure  side  by  side  with  the  great  mental,  muscular,  and 
sexual  changes :  it  seems  clear  that  the  remarkable  increase  in  the  activity 
of  man's  highest  functions  demands  a  more  efficient  circulation  conducted 
at  higher  pressure.  That  the  liability  of  infants  "to  take  cold"  and  their 
proneness  to  collapse  from  suddenly-acting  causes  are  largely  to  be  attributed 
to  their  relatively  feeble  heart  and  circulation  is  highly  probable. 

THE    BLOOD. 

The  longer  the  new-born  infant  remains  attached  to  the  placenta  of  the 
mother,  the  larger  will  be  the  quantity  of  blood  which  passes  into  its  circu- 
lation ;  and  indeed  it  seems  that  its  vessels  may  become  overfull.  A  con- 
siderable disturbance  in  the  distribution  of  blood  occurs  after  the  separation 
of  the  child  from  the  mother,  and  it  appears  as  though  the  circulatory  sys- 
tem did  not  easily  become  accustomed  to  the  great  alterations  of  pressure 
and  redistribution  of  labor :  sometimes  this  natural  oscillation  passes  beyond 
normal  bounds,  and  hemorrhage  from  the  various  surfaces  or  into  the  various 
tissues  ensues.     When  nothing  alarming  happens,  still  the  researdies  of 


THE    PHYSIOLOGY    OF    INFANCY.  65 

Cohnheim,  Zuntz,  and  others  have  shown  that  remarkable  altemtions  occur. 
During  the  first  days  of  life  some  of  the  fluid  of  the  blood  is  excreted,  so 
that  its  mass  becomes  less,  a  sort  of  thickening  or  concentration  taking  place. 
The  total  quantity  of  blood  in  an  infant  is  in  relation  to  the  body-weight 
most  probably  somewhat  less  than  in  adults :  this  has  been  variously  esti- 
mated by  different  observers.  Roughly,  the  weight  of  the  blood  compared 
with  that  of  the  body  in  the  newly-born  is  about  five  per  cent.,  or  1  :  19.5, 
whereas  in  adults  it  is  about  eight  per  cent.,  or  1  :  13.  The  specific  gravity 
of  the  child's  blood  is  somewhat  lower,  also,  as  may  be  represented  by  the 
numbers  1048  :  1055,  and  this  corresponds  with  a  smaller  percentage  of  salts, 
haemoglobin  (excej)t  in  the  newly-born),  albumen,  and  fibrin.  The  red 
blood-corpuscles  are  found  to  exist  in  greater  numbers  on  the  first  day  of 
life  than  on  the  fourth  and  succeeding  days,  the  numbers  being  six  to  seven 
millions  per  cubic  centimetre,  as  against  four  to  five  millions.  Silbermann 
and  Ponfick  have  discovered  many  forms  or  shadows  of  red  blood-corpuscles 
from  which  the  haemoglobin  had  been  robbed  :  they  are  often  difficult  to  see, 
but  there  can  be  no  doubt  of  these  delicate  ring-like  shapes  being  the  stroma 
of  red  blood-disks.  Silbermann  observed  them  to  be  more  numerous  the 
more  deranged  was  the  child's  condition  during  the  first  few  days  of  life. 
Hofmeier  noted  that  the  red  blood-corpuscles  varied  greatly  in  size,  were 
more  spherical  than  in  the  blood  of  adults,  and  showed  little  tendency  to  run 
into  rouleaux.  The  white  blood-corpuscles  are  generally  more  numerous 
than  in  the  blood  of  adults,  more  prone  to  run  together  in  masses,  more 
viscid,  deliquescent,  and  less  stable.  These  changes  are  of  great  pathologi- 
cal importance,  and  may  explain  much  that  is  obscure  in  our  knowledge  of 
icterus  neonatorum.  There  evidently  is  a  great  destruction  of  red  blood- 
corpuscles  leading  to  haemoglobinsemia ;  and  then  the  circulating  blood,  as 
Schmidt  maintains,  may  hold  a  large  quantity  of  fibrin-ferment  resulting 
from  the  destruction  of  both  kinds  of  blood-corpuscle.  Silbermann  injected 
haemoglobin  into  the  blood  of  frogs,  dogs,  and  puppies,  and  then  found  that 
the  state  of  their  blood,  urine,  and  liver  had  a  close  similarity  to  the  condi- 
tions found  in  the  first  days  of  life.  Silbermann  therefore  urges  that  the 
state  of  blood  of  the  newly-born  is  such  as  to  predispose  them  to  disease. 
But  it  seems  doubtful,  according  to  others,  whether  the  blood  has  any  in- 
creased tendency  to  clot  in  the  vessels  as  the  consequence  of  the  alleged 
increase  in  the  fibrin-ferment.  Relatively,  the  number  of  red  blood-cor- 
puscles is  said  to  be  greater  in  children  even  after  the  first  days  of  life  than 
in  adults,  but  later  still  a  falling  off  has  been  observed.  According  to 
Demmo,  there  are  on  an  average  135  to  210  colored  to  one  colorless  cor- 
puscle during  the  period  comprised  between  twelve  hours  and  one  hundred 
and  fifty  days  of  age, — as  compared  with  the  numbers  in  the  adult,  330  to 
350  red  to  one  white.  Slight  fluctuations  are  met  with  according  to  whether 
the  enumeration  is  made  before  or  after  meals.  The  nature  of  the  nourish- 
ment also  has  an  influence,  breast-fed  infants  having  relatively  more  red 
blood-disks  than  children  brought  up  by  hand.  Although  so  much  haemo- 
VoL.  I.— 5 


QQ  THE    PHYSIOLOGY    OF    INFANCY. 

globin  exists  at  first  only  to  be  destroyed  in  the  first  days  of  life,  still  at  the 
end  of  the  first  week  a  rise,  though  not  to  the  original  figure,  is  to  be  noted. 
The  physiological  loss  of  weight  noted  soon  after  birth  (see  page  52)  is 
probably  intimately  connected  with,  if  it  be  not  due  to,  the  remarkable 
changes  in  the  blood  and  probably  other  tissues ;  the  variations  in  the  tem- 
perature of  the  body  should  perhaps  also  be  considered  in  the  same  light. 

THE    PULSE. 

The  pulse  of  infants  and  children  is  very  irritable,  variable,  and  irregular 
in  rhythm,  the  nervous  centres  on  which  it  is  dependent  being  very  unsta- 
ble :  perhaps  the  great  frequency  at  birth  and  during  the  early  months  is 
due  to  a  want  of  development  of  the  physiological  inhibition  which  may 
show  itself  in  actual  structural  imperfection  of  the  nerves.  This  suggestion 
appears  to  receive  confirmation  from  experimental  researches  on  some  young 
animals ;  for  some  observers  have  found  that  stimulation  of  the  vagus  nerve 
and  centre  has  not  that  restraining  influence  which  later  in  life  it  comes  to 
possess. 

Any  slight  influence,  even  physiological,  such  as  crying  or  sucking, 
often  so  perturbs  the  pulse-rate  that  in  infants  the  mere  pulse  loses  much 
of  its  pathological  significance.  During  fever,  if  the  child  is  asleep  or 
drowsy  and  not  disturbed  by  external  circumstances,  the  pulse-rate  is  found 
to  be  raised ;  and  this  is  proportional  to  the  rise  in  body-temperature. 

The  normal  frequency  of  the  pulse  during  the  first  weeks  of  life  may 
fluctuate  between  150  and  120,  being  rather  more  frequent  in  females  and 
in  smaller  infants.  It  does  not  appear  to  vary  with  the  posture  of  the 
sucking  infant :  later  in  infancy  posture  exercises  its  usual  influence.  At 
the  end  of  the  first  year  of  life  the  rate  varies  from  100  to  120.  After  this 
the  pulse  beats  about  100,  and  tends  to  get  less  frequent,  till  at  five  years 
the  normal  frequency  may  be  reckoned  at  90.  The  researches  of  Rameaux, 
Volkmann,  and  others  have  shown  that  a  certain  relation  exists  between  the 
length  of  the  body  and  the  rate  of  the  pulse,  but  in  clinical  work  this  inter- 
esting physiological  information  is  of  no  value. 

KESPIHATION. 

The  narrowness  of  the  nasal  respiratory  passages,  the  smallness  of 
the  nasal  cavities,  and  the  slight  development  of  the  Roman  arch  of  the 
pharynx  and  of  the  cavities  opening  into  the  nose  must  be  considered  in 
qliscussing  the  physiology  of  infantile  respiration.  The  lungs,  originally 
small,  grow  very  rapidly  during  the  first  months  of  life ;  nevertheless  they 
remain  during  childhood,  as  Beneke  showed,  relatively  to  the  weight  and 
length  of  the  body,  less  than  in  adults.  The  breathing  of  male  and  female 
infants  and  children  is  mostly  efl'ected  by  the  diaphragm  and  lower  chest,  as 
in; the  adult  male.  The  rhythm  of  breathing,  like  that  of  the  circulation, 
i§.  very  irregular  and  variable,  especially  at  birth  and  for  the  next  few 
weeks ;   and  this  has  to  be  remembered  in  estimating  the  nature  of  any 


THE    PHYSIOLOGY    OF    INFANCY.  67 

disease  from  which  infants  may  snffer.  After  the  first  half-year  the  rhythm 
should  be  fairly  regular,  whilst  during  the  first  months  an  approach  to 
the  Cheyne-Stokes  rhythm,  if  not  normal,  may  at  "least  be  induced  by 
very  trivial  pathological  causes.  Breathing  is  effected  through  the  nasal 
passages,  so  that  considerable  swelling  of  their  linings  and  of  the  naso- 
pharynx may  cause  much  suffering  and  shortness  of  breath,  since  the  habit 
of  breathing  through  the  mouth  has  not  been  acquired,  and,  indeed,  seems 
somewhat  difficult  of  acquirement. 

The  number  of  respirations  per  minute  is  greater  than  in  the  grown-up, 
and  varies  in  the  newly-born  between  30  and  50,  being  fewer  during  sleep 
and  then  also  more  regular;  in  the  first  year  of  life  it  ranges  between 
25  and  35 ;  but  these  numbers  are  increased  by  crying  and  laughing  aud 
diminished  by  fixing  the  infant's  attention.  Not  uncommonly  in  young 
children  during  physical  examination  of  the  lungs  long  pauses  between  ex- 
piration and  inspiration  may  be  observed,  and  the  breathing  may  be  stopped 
for  many  seconds.  The  increased  frequency  of  respiration  has  been  ascribed 
to  the  smallness  of  their  lungs  and  to  their  great  need  of  oxygen,  whilst 
the  loudness  of  their  breath-sounds  (puerile  respiration)  may  be  explained 
by  the  force  of  their  inspiration  and  expiration,  the  frequency  of  their 
breathing,  and  the  narrowness  of  their  air-passages.  The  epiglottis  being 
folded  on  itself,  like  a  leaf  on  its  midrib,  is  an  anatomical  fact  on  which 
sufficient  stress  has  not  been  laid ;  and  this  anatomical  feature  is  the  more 
marked  the  younger  is  the  infant.^ 

Von  Pettenkofer  has  estimated  that  a  child  produces  in  proportion  to  its 
body-weight  nearly  twice  as  much  carbonic  acid  as  an  adult. 

THE   DIGESTIVE   SYSTEM. 

The  relative  dryness  of  the  cavity  of  the  mouth  in  the  first  months  of 
life  is  attributed  by  Korowin,  Zweifel,  and  others  to  the  slightness  of  the 
salivary  secretion,  which,  however,  begins  to  increase  towards  the  end  of  the 
second  month  of  life.  Although  the  salivary  secretion  at  birth,  slight  as  it 
is,  does  possess  some  power  of  transforming  starch  into  sugar  (probably 
maltose,  not  glucose),  yet  this  power  is  only  properly  gained  when  the  secre- 
tion becomes  freer.  The  same  is  held  to  be  the  case  with  the  pancreatic 
diastatic  ferment,  and  the  pancreatic  power  of  digesting  fat  appears  also  to 
be  almost  in  abeyance  for  the  first  months  of  life  :  nevertheless  the  observa- 
tions of  Kramstyk  show  that  the  alimentary  tract  possesses  great  facility  for 
the  absorption  of  fatty  particles. 

According  to  Korowin's  experiments,  the  pancreatic  juice  does  not  attain 
its  full  powers  for  converting  starch  into  sugar  until  the  end  of  the  first 
year  of  life,  although  a  trace  of  diastatic  ferment  exists  in  the  second  month, 
and  this  is  increased  in  the  third  month.  Zweifel  found  that  in  strong 
children  the  pancreatic  extract  digested  albumen  in  the  first  month. 

'  See  the  tiuthor\s  Trctitmcnt  of  Disease  in  Children,  Lewis,  London,  1887. 


68  THE    PHYSIOLOGY    OF    INFANCY. 

The  stomach  of  the  child  is  undeveloped  in  many  ways,  and  its  capacity- 
is  said  to  be  not  greater  than  35  to  45  cubic  centimetres  at  birth,  but 
rapidly  becomes  greater,  so  that  at  the  end  of  a  fortnight  Beneke's  meas- 
urements were  153  to  160  c.cm.,  and  at  the  age  of  two  years  740  c.cm. 
Langendorf  and  others  seem  to  have  demonstrated  that  the  gastric  juice 
of  infants  contains  pepsin  and  hydrochloric  acid  and  to  possess  the  usual 
digestive  properties  on  proteids.  The  alimentary  tract  of  the  infant  is,  rela- 
tively to  the  length  of  the  body,  longer  than  that  of  the  adult.  Beneke's 
numbers  in  the  new-born  are  570  :  100 ;  in  the  second  year,  660  :  100 ;  in 
the  seventh,  510  :  100;  and  in  the  thirtieth,  470  :  100;  and  Forster  uses 
these  facts  to  account  for  the  greater  ease  with  which  children  appropriate 
a  milk  diet.  The  muscular  structure  of  the  stomach  and  intestines  is  but 
feebly  developed ;  Brunner's  and  Lieberkiihn's  glands  are  only  developing 
during  the  first  periods  of  life,  whilst  a  great  richness  of  lymphoid  tissue 
in  the  solitary  and  agminate  follicles  perhaps  accounts  for  the  readiness  with 
which  fat  is  absorbed,  since  it  is  held  by  some  that  the  lymphoid  corpuscles 
are  the  carriers  of  fat  directly  from  the  alimentary  tract  into  the  lacteals. 
The  physiological  act  of  vomiting  is  easier  in  an  infant  than  in  the  adult, 
doubtless  from  the  anatomical  peculiarities  of  the  stomach,  its  long  axis 
being  almost  in  a  direct  line  with  that  of  the  gullet. 

The  liver  of  the  new-born  infant  is  relatively  large  and  very  rich  in 
blood ;  it  is  larger  than  both  lungs  put  together,  and  this  proportion,  as 
Beneke  showed,  is  not  reversed  till  puberty.  The  increased  size  is  probably 
in  harmony  with  the  great  nutritive  and  metabolic  activities  required  for 
the  processes  of  growth  and  development,  especially  of  the  neuro-muscular. 
apparatus. 

The  bile  of  children,  recently  investigated  by  Jacubowitsch,  is  distin- 
guished by  its  poverty  in  inorganic  salts,  with  the  exception,  however,  of 
iron  salts,  its  poverty  in  cholesterin,  lecithin,  and  fat,  and  particularly  its 
smaller  percentage  of  the  special  bile  acids,  and  the  glycocholic  is  in  com- 
paratively less  amount  than  the  taurocholic  acid.  It  is  supposed  that  this 
.smaller  percentage  of  bile  acids  is  a  favorable  fact,  on  the  ground  that  the 
bile  acids  hinder  the  peptic  and  pancreatic  digestion,  the  active  ferments  of 
which  processes  are  supposed  to  possess  feebler  powers  than  in  the  adult. 
On  the  other  hand,  the  poorness  in  bile  salts  is  considered  to  be  a  reason  for 
the  alleged  incomplete  assimilation  of  fat  by  the  infantile  alimentary  juices 
and  agencies,  since  the  bile  acids  emulsify  the  fat  in  the  intestines,  glycerin 
and  fatty  acids  resulting.  Some  believe  that  the  indigestibility  of  fatty 
human  milk  and  of  cow's  milk  may  be  ascribed  to  the  above-mentioned 
peculiarities  of  the  bile.  It  must  be  obvious,  however,  that  much  more  has 
to  be  learned  before  pjiysiology  and  clinical  medicine  can  be  brought  into 
harmony  with  each  other. 

Escherich  has  carefully  studied  the  digestion  of  milk  in  infants.  The 
fseces  of  infants  fed  purely  on  milk  have  a  golden  tint,  a  soft  lard-like  con- 
sistence, a  feebly  acid  reaction,  and  contain  from  eighty-four  to  eighty-six 


THE    PHYSIOLOGY    OF    INFANCY.  69 

per  cent,  of  water.  The  digestion  and  absorption  of  proteids  in  the  aliment- 
ary canal  are  so  efficient  that  but  little  passes  on  in  the  faeces.  In  fact,  the 
whitish  flakes  and  clots  nearly  always  seen  in  the  faeces  are  composed  almost 
entirely  of  fat,  fatty  and  lactic  acids  in  combination  with  lime,  whilst  choles- 
terin  and  traces  of  bilirubin,  intestinal  epithelia,  and  mucus  may  also  be 
detected.  In  addition,  large  quantities  of  bacteria  are  always  present, — a 
fine  slender  bacillus,  named  by  Escherich  the  bacterium  lactis  aerogenes, 
and  the  polymorphic  bacterium  coli  commune,  which  often  takes  the  form 
of  cocci,  being  the  two  chief  kinds.  Of  other  varieties  of  bacteria,  as  of 
the  proteolytic  cocci  which  fluidify  gelatin,  torulse,  and  mycelial  fungi, 
there  are  almost  none  in  the  normal  milk-faeces.  But  these  varieties  may  be 
discovered  in  pathological  conditions,  as  also  when  the  diet  is  a  mixed  one 
or  contains  much  meat.  The  simplicity  of  the  micro-organisms  found  in  the 
milk-fgeces  is  doubtless  in  correspondence  with  the  absence  of  the  products 
of  albuminous  decomposition,  such  as  tyrosin,  indol,  phenol,  and  skatol ;  in 
the  milk-faeces,  however,  milk  acids  are  always  present,  and  to  their  presence 
should  be  attributed  the  acid  reaction.  Fermentation  of  milk-sugar  leads 
to  the  development  of  carbonic  acid  and  hydrogen,  which  are  the  principal 
gases  in  the  intestinal  tract  of  healthy  infants  fed  purely  on  milk,  foul- 
smelling  gases  being  conspicuous  by  their  absence. 

Though  the  quantity  of  faeces  varies  much  in  sucklings,  yet  three 
grammes  for  every  hundred  grammes  of  milk  ingested  may  be  given  as 
the  average  proportion. 

Certain  peculiarities  exist  in  the  stools  of  the  new-born,  the  so-called 
meconium  being  odorless,  tenacious,  and  viscous,  of  greenish  color  and  weak 
acid  reaction.  It  contains  constituents — epidermic  cells  and  hairs — derived 
by  swallowing  from  the  liquor  amnii,  also  cholesterin  and  intestinal  epithe- 
lium. Normal  meconium  is  free  from  products  of  putrefaction,  phenol  and 
acids  of  the  benzoic  series  being  absent.  Moreover,  immediately  after  birth 
it  does  not  contain  bacteria,  but  in  a  short  time  numerous  and  various  micro- 
organisms make  their  appearance.  Probably  some  entered  by  the  anus ; 
and  some  may  have  gained  entrance  by  the  mouth  and  respiratory  passages. 
An  investigation  on  the  new-born  might  throw  some  light  on  the  vexed 
question  whether  healthy  blood  and  tissues  do  contain  micro-organisms. 
According  to  Escherich,  even  these  bacteria  disappear,  or  are  replaced  by 
the  two  varieties  above  mentioned,  when  a  pure  milk  diet  is  commenced. 

DENTITION. 

The  eruption  of  the  teeth  is  undoubtedly  influenced  by  the  constitution 
and  the  nutrition  of  the  infant,  for  in  the  well-nourished  children  of  licalthy 
parents  the  teeth  are  cut  earlier  and  more  regularly  than  in  others.  The  first 
lower  middle  incisors  may  be  cut  between  the  third  and  the  tenth  month, 
the  average  time  being  the  seventh  ;  the  corresponding  uppers  may  be  cut  a 
month  or  so  later ;  the  lateral  incisors  may  appear  about  tlie  same  time,  or  a 
month  later:  then  the  first  molars  should  be  cut  at  about  twelve  mouths  or 


70  THE    PHYSIOLOGY    OF    INFANCY. 

SO,  the  canines  about  the  eighteenth,  and  the  four  remaining  molars  at  about 
two  years.  Exceedingly  variable  in  their  date  of  appearance,  much  allow- 
ance must  be  made  for  individual  and  racial  peculiarities.  This  diiference 
may  be  noted,  however,  between  the  eruption  of  rachitic  and  healthy,  both 
that  the  former,  besides  being  delayed  in  their  coming,  also  come  irregularly 
and  out  of  the  ordinary  series,  whilst  in  the  healthy  the  number  of  teeth  cut 
is  usually  even,  two  of  a  like  sort  being  cut  nearly  simultaneously,  and  the 
proper  order  of  the  series — viz.,  middle,  lateral  incisors,  premolars,  canines, 
second  molars — is  maintained.  As  a  general  rule,  the  lower  teeth  are  cut 
before  the  upper.  The  permanent  teeth  begin  to  appear  about  the  seventh 
year,  the  first  to  come  being  the  first  molars ;  then  follow  the  central  incisors 
at  eight,  the  lateral  incisors  at  nine,  the  first  and  second  bicuspids  at  ten  and 
eleven  respectively,  the  canines  at  twelve,  the  second  molars  at  fourteen,  and 
the  wisdom  teeth  in  adult  life ;  for  twenty  milk  there  are  substituted  thirty- 
two  permanent  teeth. 

THE   UEINE. 

Relatively  large  at  birth,  the  kidneys  do  not  increase  so  much  in  size 
during  childhood  as  do  the  heart  and  the  lungs, — the  adult  lungs  being 
from  twenty  to  twenty-five  times  as  large  as  at  birth,  whilst  the  kidneys 
only  grow  till  they  become  twelve  times  heavier  than  at  birth.  The  func- 
tional activity  of  the  kidneys  reaches  its  height  even  at  birth,  and  in  the 
pyramidal  portions  of  the  kidney  of  the  new-born  it  is  quite  common  to  see 
reddish  or  yellowish  deposits,  or  even  brownish  streaks,  which  microscopical 
examination  shows  to  be  uric  acid  crystals  blocking  the  straight  urinary 
tubules :  so  common  are  these  uric-acid  infarcts  (Virchow)  that  they  must 
be  considered  to  be  of  no  pathological  significance. 

The  quantity  of  urine  increases  rapidly  during  the  first  ten  days  of 
life,  but  during  the  next  week  more  slowly.  Cruse  has  estimated  the  daily 
quantity  to  be  about  130  to  417  cubic  centimetres,  but  there  is  no  doubt 
that  it  varies  within  very  wide  limits  :  its  rapid  increase  must  be  attributed 
chiefly  to  increased  ingestion.  During  the  second  year  of  life  the  daily 
quantity  discharged  is  estimated  at  500  to  600  cubic  centimetres,  and  twice 
as  much  is  said  to  be  passed  in  one  day  during  the  fourth  year. 

The  specific  gravity  of  the  urine  increases  rapidly  from  the  fifth  to  the 
tenth  day  of  life,  then  diminishes ;  but,  according  to  Cruse,  the  phosphoric 
acid  increases.     The  average  density  is  given  as  1005  to  1010. 

During  the  first  days  of  life  the  urine  is  generally  turbid,  dark,  and 
acid,  but  later  becomes  clear,  straw-yellow,  and  generally  neutral.  The 
kind  and  quantity  of  food  influence  its  characters  and  composition  very 
materially.  The  first  act  of  micturition  may  often  be  delayed  for  twenty- 
four  hours  or  more,  and  this  is  probably  the  reason  for  the  urine  being 
dark,  turbid,  and  acid,  it  having  undergone  concentration  in  the  bladder 
owing  to  absorption  of  water.  If  the  urine  is  passed  immediately  after 
birth,  it  is  clear,  nearh^  neutral,  and  very  pale.  These  facts  prove  that 
the  kidneys  have  been  at  work  during  iutra-uterine  life,  and  they  also  seem 


THE    PHYSIOLOGY    OF    INFANCY.  71 

to  show  that  the  uerv'ous  functions  of  micturition  chiefl}'^  dependent  on  the 
lumbar  enlargement  of  the  spinal  cord  are  in  a  fair  state  of  perfection. 

According  to  some,  the  discharge  of  nitrogen  in  the  urine  of  infants  is 
relatively  smaller  than  in  the  adult ;  and  the  same  has  been  stated  of  the 
discharge  of  phosphoric  acid  and  chloride  of  sodium ;  and  to  account  for 
this  it  is  supposed  that  more  of  the  ingested  nitrogenous  stuff  is  retained 
for  building-purposes.  Others,  probably  Avith  more  truth,  assert  that,  the 
metabolism  of  foods  and  tissues  being  in  greater  excess,  the  urea-discharge 
is  also  in  excess  in  children  as  compared  with  adults. 

During  the  first  days  of  life  the  normal  urine  is  maintained  by  some  to 
contain  a  trace  of  albumen,  which,  however,  soon  disappears,  and  according 
to  others  albuminuria  is  not  normal  even  at  any  time. 

THE    TEMPEKATUKE. 

Always  a  subject  of  much  interest,  the  temperature  of  the  body  before, 
during,  and  after  birth  has  been  much  investigated.  A  recent  monograph  by 
Raudnitz  gives  a  good  resum6  of  our  information  on  this  subject.  Im- 
mediately after  birth  the  temperature  falls  as  much  as  1.7°  C,  the  average 
minimum  temperature  being,  according  to  Eross,  35.84°,  whilst  the  average 
normal  temperature  of  the  new-born  is  given  as  37.6°  C.  After  this  pre- 
liminary fall  a  slow  rise  to  the  normal  occurs,  and  a  temperature  of  37.8° 
to  38°  C.  on  the  fourth  or  fifth  day  is,  according  to  Eross,  a  sign  of 
abnormality. 

The  temperature  of  young  children  undergoes  many  fluctuations  at  the 
dictation  of  slight  influences  which  should  be  ascribed  to  the  instability  of 
the  heat-regulating  centres,  just  as  we  witness  the  same  irregularity,  irrita- 
bility, and  variability  in  the  respiratory  and  circulatory  centres.  Demme 
has  noted  a  fall  in  the  temperature  of  children  experimentally  kept  in  dark 
rooms.  Increased  ingestion  of  food,  and  much  crying  or  struggling,  raise  the 
temperature,  whilst  inactivity  and  sleep  lower  it.  A  high  temperature,  like 
a  high  pulse  or  a  high  rate  of  breathing,  has  more  significance  if  observed 
during  the  sleeping  state  of  an  infant. 

Many  observers  attest  the  influence  of  the  law  of  temperature  being 
manifested  even  in  infants,  for  they  have  observed  the  normal  daily  varia- 
tion. As  a  rule,  the  temperature  begins  to  rise  in  the  morning,  reaches  its 
highest  point  in  the  evening  about  six,  and  then  slowly  sinks  to  its  lowest 
point  in  the  first  hours  of  the  morning.  It  is  noteworthy  that  new-born 
infants  may  under  the  excitement  of  inflammatory  affection  yield  a  tempera- 
ture as  high  as  41°  C.  =  105.5°  F.  In  fever  the  differences  between  the 
morning  and  the  evening  temperature  are  greater  than  in  adults,  and  the 
influence  of  antipyretics  on  the  fever-heat  is  more  considerable  in  them  than 
in  the  grown-up. 

THE   SKIN. 

Coated  with  a  layer  of  sebum,  shed  epithelium,  and  hairs,  called  the 
vernix  caseosa,  the  skin  of  the  healthy  new-born  infant  after  being  cleansed 


72  THE   PHYSIOLOGY   OF   INFANCY. 

is  found  to  be  much  redder  and  more  tender  than  in  later  life,  and  is  covered 
with  fine  down  called  lanugo.  In  the  first  few  weeks  of  life  a  fair  amount 
.of  desquamation  occurs,  and  the  fine  hairs  also  fall  out.  During  this 
period  the  sweat-glands  do  not  make  much  perspiration,  but  the  sebaceous 
glands  are  much  more  active^  especially  on  the  scalp,  where  flakes  of  fatty- 
matter  may  accumulate  and  be  shed  with  hairs  stuck  thereto. 

SUMMAKY. 

It  will  be  seen  that  the  subject  of  the  physiology  of  infancy  is  a  com- 
paratively unworked  field,  but  a  most  interesting  one  nevertheless. 

As  anatomy  and  histology  form  the  basis  from  which  are  to  be  studied 
developmental  and  pathological  diiferences,  so  physiology  is  the  standard 
by  which  the  clinician  judges  of  the  value  of  the  symptoms  resulting  from 
functional  disturbances. 


DIAGNOSIS. 

By  JAMES   FINLAYSON,  M.D. 


A  SPECIAL  chapter  on  the  Diagnosis  of  the  Diseases  of  Children  might 
be  regarded  as  very  important  if  the  subject  could  possibly  be  dealt  witli  in 
this  way ;  but  diagnosis  is  coextensive  with  the  whole  range  of  this  work, 
and  in  point  of  fact  it  will  consume  a  very  large  proportion  of  its  various 
sections  and  different  volumes.  Why,  then,  it  may  be  asked,  have  such  a 
chapter  at  all?  Are  not  the  diseases  of  children,  apart  from  malforma- 
tions and  perhaps  one  or  two  comparatively  rare  affections,  essentially  the 
same  diseases  that  affect  adults?  Are  not  the  facts  of  disease  the  same 
whatever  the  age  ?  Are  not  the  principles  and  methods  of  physical  diag- 
nosis practically  identical  for  all  periods  of  life  ?  The  diseases  are  essen- 
tially the  same ;  the  methods  are  in  no  sense  very  different ;  and  the  reader 
of  this  chapter  will  be  supposed  to  bring  to  his  aid  a  moderately  extensive 
knowledge  of  disease  as  it  exists  in  adults,  and  likewise  a  certain  familiarity 
with  the  methods  of  diagnosis  and  with  the  signs  of  disease  as  observed 
there.  What  more,  then,  is  ^^^anted  ?  Why  have  such  a  chapter  ?  Nay, 
more,  why  have  special  treatises  on  the  diseases  of  childhood  at  all  ? 

A  student  confronted  with  a  sick  child  may  be  moderately  well  acquainted 
with  diagnosis  as  practised  in  our  general  hospitals,  but  may  feel  as  if  all  his 
knowledge  and  all  his  methods  had  suddenly  failed  him  :  he  may  experience 
the  same  sense  of  helplessness  which  a  traveller  will  have  when  suddenly 
cast  adrift  in  a  strange  land,  of  whose  customs  he  is  ignorant  and  Avhose 
language  he  has  not  yet  learned  -^  in  proportion  as  he  is  intelligent,  and 
practised  in  travelling  at  home,  will  he  experience  the  vexation  of  seeing 
the  same  kind  of  things — the  means  of  locomotion,  the  places  of  rest,  the 
various  forms  of  food — and  yet  be  unable  to  understand  how  to  avail  him- 
self of  them  all ;  or,  perhaps,  misguided  by  some  spurious  resemblance,  or 
misled  by  some  opposite  custom,  he  may  find  himself  injured  by  the  very 
knowledge  which  would  otherwise  be  useful. 

We  usually  begin  by  asking  our  adult  patient  how  he  feels,  or  where 
he  has  pain,  if  any  be  present ;  but  our  little  patients  may  be  too  young 

^  See  Dr.  West's  Lectures  on  the  Diseases  of  Infancy  and  Childhood,  7th  edition,  Lon- 
don, 1884,  p.  3. 

73 


74  DIAGNOSIS. 

to  speak,  or,  if  they  do  speak,  the  pains  and  discomforts  may  be  referred 
to  in  a  misleading  manner :  thus,  it  is  common  for  a  child  with  a  pain 
originating  in  the  chest  to  refer  it  to  the  stomach  or  belly,  and  this  not 
merely  in  words,  but  actually  by  direct  signs.  All  the  information  we 
are  in  the  habit  of  getting  from  the  patient's  description  of  his  discomfort 
may  thus  utterly  fail  us ;  the  distress  may  be  as  great,  or  even  greater,  but 
the  "  infant  crying  in  the  night/'  however  definite,  however  obscure,  how- 
ever complex,  or  however  varied  the  nature  of  his  misery  may  be,  has  "  no 
language  but  a  cry." 

Baffled  in  this  direction,  the  student  bethinks  himself  of  the  well-known 
physical  signs  of  disease,  for  here  at  least  we  are  independent  of  articulate 
signs,  and  "  there  is  no  speech  nor  language  where  their  voice  is  not  heard." 
He  tries  the  pulse,  but  his  approach  and  the  excitement  of  crying  have  sent 
it  up  to  a  preternatural  height,  with  numbers  uncountable  or  at  least  with 
no  meaning.  He  tries  the  temperature,  but  the  child  resents  having  a  ther- 
mometer put  into  the  axilla ;  or  in  other  cases  the  arm  is  so  thin  and  scraggy 
and  the  covering  of  soft  parts  so  imperfect  and  so  difficult  to  keep  in  appo- 
sition that,  even  if  feverish,  the  readings  may  come  out  as  normal  or  sub- 
normal, and  so  mislead  instead  of  helping  us.  He  now  contents  himself 
with  feeling  the  skin  with  his  hand,  well  knowing  how  fallacious  this  is 
even  in  adults,  and  proceeds,  after  allowing  the  child  to  settle  a  little,  to  the 
examination  of  the  chest,  beginning,  as  is  common,  with  percussion  under 
the  clavicles ;  of  all  things,  this  is  one  which  a  young  child  objects  to,  on 
account  of  the  pain  so  apt  to  be  caused,  and  on  account  of  the  soiu-ce  of 
new  terror  in  each  successive  stroke  being  so  visible;  the  infant  again 
begins  to  cry  or  scream,  drowning  the  relative  percussion-sounds  sought 
for,  or  allowing  only  of  some  "  chinking"  or  "  cracked  metal"  percussion- 
note  being  caught  amidst  the  din,  and  so  giving  rise  to  all  sorts  of  erroneous 
visions  of  cavities  in  the  apex.  Auscultation  fares  no  better ;  the  child  ob- 
jects, in  its  own  language,  to  a  hard  stethoscope  pressed  with  a  heavy  head 
on  its  tender  ribs,  and  sees  new  dangers  in  the  close  proximity  of  the  ob- 
server's head.  But  even  if  more  successful,  the  student  is  accustomed  to 
rely  on  the  patient's  taking  long  breaths,  when  asked  to  do  so,  in  order  to 
educe  the  crepitant  rales  or  other  abnormal  sounds ;  or  to  hold  the  breath, 
to  get  clear  of  this  complication  in  auscultating  the  heart;  but  it  is  often, 
if  not  usually,  utterly  vain  to  expect  any  such  assistance  from  a  child  of 
tender  years,  while  the  hope  of  assistance  from  vocal  resonance  and  fremitus 
has  to  be  equally  abandoned. 

At  any  rate,  the  student  hopes  he  may  find  evidence  of  chest-disease  in 
the  cough  or  expectoration ;  but  he  learns  with  astonishment,  although  the 
cough  may  be  very  severe,  that  there  is  no  expectoration  at  all ;  and  by  and 
by  he  finds  that  the  study  of  expectoration  in  the  lung-diseases  of  childhood 
is  not  of  the  same  importance  as  in  adults,  for  the  good  reason  that  there  is 
usually  none  brought  up ;  on  consulting  his  books  he  finds  that  even  in  a 
pronounced  pneumonia  rusty  sputa  are  almost  unknown,  and  that  the  child 


DIAGNOSIS.  75 

may  cough  but  little,  or  may  only  begin  to  have  any  noticeable  cough  when 
the  worst  of  the  disease  seems  over. 

Defeated  in  the  region  of  the  chest,  the  abdomen  is  not  likely  to  give 
more  chance  of  success :  the  muscles  are  on  the  strain  from  pain,  or  from 
fright,  or  from  crying ;  and  of  course  palpation  and  percussion  require  the 
most  favorable  conditions  of  the  abdominal  walls  to  afford  any  information. 
Or  he  may  find  what  he  thinks  is  an  enlarged  liver  or  spleen  from  mere 
displacement  of  these  organs  in  the  lax  abdomen  of  the  child,  and  the 
enlarged  and  displaced  spleen  of  rickets  may  never  have  been  heard  of, 
although  he  may  have  visions  of  enlarged  spleen  from  typhoid  fever,  ague, 
or  leucocytheemia. 

The  examination  of  the  urine,  at  least,  might  be  supposed  to  be  a  matter 
familiar  enough  to  a  well-trained  student,  affording  some  information  or  at 
least  negative  data.  But  very  likely  the  urine  cannot  be  saved,  being 
passed,  of  course,  by  young  children  without  warning  even  when  well,  and 
very  often  passed  in  this  way  during  an  illness  by  those  who  are  old 
enough  to  give  notice  at  other  times.  But  the  mother  or  nurse  may  have 
information  to  give  about  its  appearance,  or  a  stray  and  scanty  specimen 
may  be  shown  confirming  their  description  of  its  being  "  as  white  as  milk" 
when  passed, — a  characteristic  usually  pointing  in  an  adult  to  the  admix- 
ture of  pus,  and  so  constituting  a  grave  symptom  of  urinary  disorder,  but, 
as  a  rule,  dependent  in  the  child  on  the  presence  of  white  urates  or  some 
other  trifling  peculiarity. 

If  the  beginner  now  turns  to  the  history  of  the  illness,  he  may  be 
equally  perplexed.  The  rigors  which  form  so  leading  a  feature  in  the 
initial  stages  of  acute  inflammations  and  fevers  in  the  adult  are  almost  in- 
variably absent  in  the  young.  The  symptoms  often  come  on  either  with 
such  suddenness  as  to  leave  no  chance  of  tracing  their  progress,  or  so  in- 
sidiously and  indefinitely  that  often  even  a  careful  mother  can  only  tell  us 
that  the  child  "  is  not  well,"  or  that  he  is  cross  and  fretful,  or  pining,  or 
wasting,  without  definite  indications  of  the  reason  why  such  conditions 
exist. 

The  family  histoiy  is  frequently  rendered  vague  and  indefinite  on  ac- 
count of  the  youthful  age  of  the  patient,  for  the  evidence  of  the  inheritance 
of  disease  on  which  we  rely  most  confidently  is  furnished  by  the  life-  or 
health-history  of  the  brothers  and  sisters  of  our  adult  patients ;  but  these 
brothers  and  sisters  of  our  infantile  patients  are  not,  very  likely,  as  yet 
born,  or  at  least  may  not  have  had  time  to  show  their  morbid  tendencies ; 
the  parents  also,  even  if  they  actually  die  young,  may  not,  at  the  time  of 
the  inquiry,  have  developed  the  evidences  of  their  fatal  diseases. 

DIAGNOSIS   MADE   EASY— TEETHING. 

Such  are  some  of  the  difficulties  which  beset  the  study  of  children's  ail- 
ments, even  by  those  who  are,  so  far,  familiar  with  the  diagnosis  of  disease. 
The  difficulties  arc  no  doubt  great, — often,  indeed,  insuperable, — and  we  have 


76  DIAGNOSIS. 

frequently  to  be  content  with  vague  results.  But  at  this  point  an  insidious 
temptation  is  presented  to  the  beginner,  decked  out,  it  may  be,  in  the  alluring 
apparel  of  speculative  science  falsely  so  called.  The  illnesses  of  young  chil- 
dren are  cleverly  described  as  being  largely  connected  with,  and  essentially 
due  to,  the  process  of  dentition.  The  gradual  evolution  of  the  first  teeth 
constitutes  a  striking  and  most  important  feature  of  early  life.  The  process 
goes  on  in  all  young  children,  and  so  is  available  as  a  universal  explanation ; 
a  few  exceptional  cases  usually  present  sufficient  evidences  of  disease  to 
show  that  the  absence  of  dentition  is  also  potent  as  a  cause  of  bad  health. 
With  the  growth  of  the  theory  of  reflex  action  and  irritation,  in  the  early 
part  of  this  century,  the  newest  views  of  the  nervous  system  were  used  to 
clothe  afresh  this  old  and  specious  doctrine,  so  that  Avhat  might  have  died 
out  as  an  old-world  superstition  was  made  to  appear  as  the  most  advanced 
scientific  doctrine  and  the  most  modem  practical  application  of  a  recent 
brilliant  discovery.  This  convenient  theory  of  the  dependence  of  infantile 
disease  on  the  process  of  dentition  is,  of  course,  now  exploded,  and  it 
might  be  supposed  that  it  needed  no  notice  in  a  work  like  this.  But 
superstitions  are  difficult  to  kill ;  although  exploded  in  one  country,  or  in 
one  time,  they  linger  on  to  haunt  the  members  of  each  new  generation ; 
and  temptations  rejected  as  unworthy  by  the  common  good  sense  of  a 
community  remain  to  allure  each  set  of  new  individuals  as  they  grow  up. 
So  it  is  with  teething.  Every  young  practitioner,  often  baffled  by  the  intri- 
cacies and  difficulties  of  infantile  disorders,  is  led,  as  it  were,  to  some  high 
mountain  and  made  to  survey  the  wide  realm  of  infantile  disease,  with  all 
the  manifold  forms  and  degrees  of  suffering  or  illness  to  which  the  young 
are  subject,  and  he  is  made  to  feel  that  all  this  dominion  can  at  once  be 
made  over  to  him  if  he  will  but  fall  dow^n  and  worship  this  fetich  called 
"Teething."  It  matters  nothing  that  at  the  moment  no  teeth  may  be 
coming  through ;  they  are  coming ;  the  "  breeding"  of  the  teeth  is  even 
more  serious  (because  deeper  and  more  unseen)  than  the  mere  piercing 
of  the  gum.  It  matters  not  that  the  symptoms  persist  after  the  gum  is 
pierced;  others  have  yet  to  come.  It  matters  not  that  the  coming  tooth 
(really  retarded  by  the  illness)  shows  no  signs  of  coming  through  to  confirm 
the  diagnosis,  for  it  is  ingeniously  contended  that  it  is  this  very  delay  in 
reaching  the  surface  which  accounts  for  the  prolonged  and  serious  illness. 
Even  after  the  whole  of  the  milk-teeth  have  appeared,  we  can  easily  specu- 
late that  the  "  breeding"  of  their  larger  successors  must  give  rise  to  even 
more  serious  perils  than  those  which  the  child  has  just  come  through. 

The  diversities  of  age  and  the  diversities  in  the  period  of  development 
of  the  teeth  are  thus  easily  bridged  over,  but  the  diversities  in  the  mani- 
festations of  disorder  are  no  less  ingeniously  met.  The  varied  forms  of 
nervous  disturbance — pain,  restlessness,  convulsions,  tremors,  twitchings, 
and  spasms — are  conveniently  ascribed  to  the  irritation  of  the  fifth  nerve  :  is 
not  this  an  aiferent  and  sensory  nerve?  are  there  not  reflex  actions?  What 
can  be  plainer !     Young  children  are  aifected  with  a  form  of  paralysis  so 


DIAGNOSIS.  77 

peculiar  to  them  that  it  has  been  termed  "  infantile  paralysis ;"  but  the 
process  of  teething  is  also  peculiar  to  them  :  has  not  "  reflex  paralysis"  been 
described  ?  Why,  then,  refuse  to  assent  to  the  name  of  "  dental  paralysis"  ? 
Teething  children  have  their  mouths  dribbling  with  saliva.  If  their  bowels 
are  confined  and  the  motions  hard  and  diy,  who  can  doubt  that  dentition, 
by  draining  away  the  fluids  to  the  mouth,  gives  rise  to  this  disagreeable 
symptom?  Of  course,  equally,  if  the  bowels  are  loose,  this  same  saliva 
will  naturally  explain  the  diarrhoea  of  infants  from  its  being  swallowed. 
Violent  choleraic  attacks,  convulsive  seizures,  or  any  terrible  disaster  may 
be  easily  traced  to  a  poisoned  state  of  the  saliva :  who  has  not  heard  of  the 
poisonous  saliva  of  a  mad  dog?  But  the  irritation  of  teething  may  equally 
disturb  the  bronchial  mucous  membrane  :  is  it  not  continuous  with  that  of 
the  mouth  ?  Bronchitis  and  catarrh  can  thus  be  ascribed  to  teething  with- 
out supposing  any  exposure  to  chills  or  any  error  in  clothing.  If  the 
mucous  membranes  suffer,  why  not  the  skin?  A  "tooth-rash"  is  a  splendid 
safety-valve ;  and  when  it  resists  our  best  efforts  at  treatment,  we  can  ex- 
plain how  dangerous  it  is  to  cure  a  rash  in  a  teething  child,  in  case  of  its 
driving  in  the  disease  to  some  internal  organ !  The  affections  of  the  eyes 
and  ears  are  too  obvious  to  require  explanation :  do  we  not  speak  of  the 
"•  eye-teeth"  ?  and  who  has  not  felt  pain  in  his  ears  from  a  bad  molar  ? 

The  popularity  of  this  doctrine  depends  partly  on  its  saving  a  world 
of  trouble  to  the  doctor,  but  also  on  its  meeting  the  views  of  the  parents. 
We  all  like  to  have  things  made  clear ;  and  if  "  the  doctor  explained"  the  in- 
teresting connections  referred  to  above,  we  can  easily  understand  how  much 
cleverer  both  doctor  and  parents  would  appear  in  the  eyes  of  the  latter. 

But  there  is  a  subtler  explanation  of  this  popularity  of  teething  Avith 
parents  and  nurses.  The  human  mind  resents  the  idea  of  our  transmitting 
anything  but  good  qualities  to  our  children,  or,  indeed,  of  anything  bad 
having  been  transmitted  in  our  especial  families.  A  mother's  death  from 
consumption  and  a  sister's  illness  from  the  same  cause  can  be  explained 
away  to  the  physician  so  as  to  lead  to  the  well-known  summary  of  the 
whole  matter,  that  there  is  "  nothing  like  hereditary  consumption  in  the 
family."  How  much  more  natural  to  try  to  explain  away  hereditary- 
scrofulous  disease,  for  example,  transmitted  to  our  own  children,  and  to 
account  for  swollen  glands  in  the  neck,  or  the  results  of  a  similar  mass  in 
the  abdomen,  by  the  natural  effects  of  the  process  of  teething ! 

But,  if  we  desire  to  minimize  the  bad  effects  of  an  inherited  taint  thus 
transmitted  to  a  new  generation,  it  is  even  more  likely  that  parents  and 
nurses  should  try  to  minimize  the  evil  results  of  want  of  care,  or  of  errors 
in  diet,  clothing,  and  hygiene,  as  regards  the  young  children  under  their 
charge.  A  diarrhoea  due  to  a  wrong  style  of  feeding  is  a  slur  on  their 
character  and  discretion  ;  a  diarrhoea  from  teethino;  is  what  mig-ht  be  called 
(as  in  the  marine  insurance  policies)  "  the  act  of  God."  A  wasting  due  to 
prolonged  starvation  of  the  child  (it  may  be  in  the  midst  of  plenty)  is  a 
serious  matter  to  be  faced  by  the  attendants;  a  pining  away  from  a  pro- 


78  DIAGNOSIS. 

longed  and  troublesonie  dentition  is  sad,  but  not  blameworthy.  A  convul- 
sion due  to  the  cutting  of  a  tooth  is  alarming  and  frightsome,  but  not  with- 
out its  pleasurable  excitement  when  combated  promptly  and  successfully  by 
the  domestic  remedy  of  the  warm  bath  and  tlie  timely  scarification  of  the 
gums  by  the  doctor ;  but  to  ascribe  the  convulsion  less  to  the  teething  than 
to  the  state  we  call  "  rickets/'  raises  the  awkward  subject  of  what  rickets 
depends  on ;  and  questions  of  proper  feeding,  of  good  air,  and  of  whole- 
some bedding,  when  raised  by  the  doctor,  disturb  the  entente  cordiale  fostered 
by  the  other  view. 

If  the  practitioner  wishes  to  avoid  trouble  in  the  diagnosis  and  trouble 
with  the  attendants,  the  comfortable  diagnosis  of  teething  is  most  attrac- 
tive. Indeed,  if  it  were  only  a  matter  of  speculative  or  pathological  in- 
terest, perhaps  it  might  be  legitimate  to  allow  the  mothers  thus  to  soothe 
their  minds,  amidst  the  distresses  of  their  children,  without  raising  any 
unpleasant  doubts.  But  here,  as  everywhere  in  medicine,  diagnosis  lies  at 
the  root  of  intelligent  practice.  The  process  of  teething  is  inevitable  and 
universal,  and  is  but  little  under  medical  control  of  any  kind  ;  on  the  other 
hand,  the  processes  leading  up  to  rickets,  for  example,  are  largely  under 
control,  even  in  the  case  of  those  who  are  comparatively  poor.  The  diag- 
nosis of  teething  diverts  the  mind  of  every  one  concerned  from  the  vital 
points  of  food,  air,  and  hygiene.  Many  a  teething  child  has  been  allowed 
to  go  on  indefinitely,  to  a  hopeless  extent,  with  a  diarrhosa  which,  far  from 
being  attended  to,  was  regarded  with  complacency  as  a  beneficial  outlet  for 
the  dangers  of  dentition,  the  stopping  of  it  being  looked  upon  as  little  less 
than  deadly ;  for  the  constipation  so  often  associated  with  tubercular  menin- 
gitis, and  the  convulsions  attending  it,  were  regarded  as  more  dangerous 
complications  of  teething, — diarrhoea  on  the  one  hand,  and  constipation  and 
convulsions  on  the  other,  being  both  erroneously  ascribed  to  this  process, 
instead  of  putting  the  diarrhoea  down  to  bad  and  indiscriminate  feeding, 
and  the  meningitis,  with  its  attendant  constipation  and  convulsions,  to  an 
inherited  tubercular  constitution. 

It  is  this  practical  consideration — ^the  intelligent  and  prompt  treatment 
of  sick  children — which  makes  one  protest  against  the  doctrine  of  dentition 
as  a  cause  of  disease.  It  may  still  be  a  moot  point  how  far  a  child  is  made 
ill  by  teething ;  but  if  the  beginner  is  ever  to  make  any  progress  in  the 
diagnosis  and  treatment  of  the  diseases  of  infancy  he  must  take  up  the 
attitude  of  refusing  to  believe  that  any  child  is  ever  seriously  ill  from 
teething :  a  restless  night,  a  little  disturbance  of  the  stomach  and  bowels, 
may  occur,  but  whenever  a  real  illness  appears,  whenever  a  prolonged  dis- 
turbance of  the  digestive  or  other  system  has  declared  itself,  then  we  may 
be  sure  there  is  something  else  at  work,  some  fault  to  be  corrected,  or  some 
more  grave  disorder  impending.  If  the  beginner  resolutely  determines  to 
find  out  what  this  fault  or  this  disorder  really  is,  he  will,  with  increasing 
experience,  fall  back  on  teething  less  and  less,  even  for  trifling  ailments, 
and  so  by  his  counsels  may  prevent  the  development  of  more  serious  mis- 


DIAGNOSIS.  79 

chief.  If  for  "teething"  we  read  "stomacli  and  feeding,"  and  if  we  always 
consider  whether  these  are  at  fault,  we  might,  although  proving  disagreeable 
and  troublesome  at  times  to  the  mothers  and  nurses,  do  more  good  service 
to  the  suffering  infants.^ 

METHOD   OF   EXAMINING  SICK   CHILDKEN. 

The  method  of  examining  any  sick  person  must  be  determined  by  the 
actual  condition  at  the  time,  Avhatever  plan  may  be  in  the  mind  of  the  physi- 
cian, or  whatever  may  be  the  views  of  doctrinaires.  In  the  case  of  a  sick 
child  this  is  pre-eminently  true.  Urgent  symptoms,  like  fits  of  any  kind, 
or  obvious  features,  like  the  appearance  of  an  eruption,  demand,  of  course, 
direct  attention  without  much  preliminary  inquiry.  In  ordinary  cases  it  is 
well,  as  a  rule,  to  hear  from  those  in  immediate  charge  of  the  child  a  full 
and  connected  account  of  the  illness  and  its  supposed  cause,  taking  special 
note  of  the  exact  dates  on  which  the  various  events  occurred,  as  this  pre- 
cision as  to  time  often  leads  the  narrator  to  correct  or  modify  or  expand  the 
original  statement.  Sometimes  this  preliminary  narrative  is  best  obtained 
in  the  sick-room ;  the  physician  can  then  sit  down  without  attracting  the 
child's  attention  to  the  visit's  having  any  direct  reference  to  him ;  or  the 
child  may,  at  times,  go  to  sleep  during  the  narrative,  and  so  afford  a  chance 
for  seeino;  the  effect  of  this  state.  More  often  it  is  best  to  get  all  this  ac- 
count  in  another  room,  out  of  the  hearing  of  the  child,  unless  very  young ; 
but  in  any  case  it  is  important  that  the  examination  should  not  be  begun 
until  after  the  physician  has  a  pretty  clear  view  of  what  jDoints  may  come 
up  for  his  investigation. 

It  is  usually  desirable  to  ascertain  by  definite  and  categorical  questions 
whether  the  illness,  as  now  existing,  appeared  to  come  on  in  the  midst  of 
perfect  health ;  and,  if  not,  to  ascertain  with  precision  up  to  what  time  the 
child  miglit  be  regarded  as  perfectly  healthy.  Unless  this  is  put  to  the 
mother  as  a  definite  question,  much  confusion  is  liable  to  creep  into  the  nar- 
rative. In  very  young  children  it  is  usually  best  to  hear  the  whole  medical 
history  of  the  infant,  with  dates  of  weaning,  teething,  walking,  etc.,  con- 
necting thus  the  past  history  of  the  child  with  his  present  illness.  Any 
previous  illnesses  of  the  child  should  also  be  fully  considered,  as  they  oflcn 
have  a  direct  bearing  on  the  case,  even  when  the  previous  illnesses  may 
seem  of  an  accidental  character,  like  measles  or  whooping-cough  ;  and  this 
is  all  the  more  important  when  the  illness  investigated  is  chronic,  and  per- 
haps of  an  obscure  and  indefinite  character.  The  obtaining  of  a  connected 
account  of  the  child's  illness  is  a  matter  of  no  small  difficulty,  confused  as 
it  is  apt  to  be  by  different  persons  being  in  charge,  and  by  the  minds  of  the 
attendants  and  their  ideas  of  time  being  rather  muddled  from  natural  anxiety 

^  This  subject  is  more  fully  discussed  by  the  writer,  from  the  historical  point  of  view, 
in  a  series  of  papers  "On  the  Dangers  of  Dentition,"  in  the  Obstetrical  Journal  of  Oreat 
Britain  a)id  Ireland,  October,  1873,  to  February,  1874 ;  or,  in  a  shorter  form,  in  the  British 
Medical  Journal,  September  19,  1874. 


80  DIAGNOSIS. 

and  want  of  rest.  The  greatest  patience  and  forbearance  must  be  shown  to 
women  worn  out  in  thus  watching  the  young.  It  is  usually  much  the  best 
way  to  let  them  tell  their  story  in  their  own  way,  as  this  satisfies  their  minds, 
and  supplementary  information  can  be  gained  by  questioning  :  if  the  ten- 
dency is  to  prolixity  and  irrelevancy,  the  narrator  can  be  guided  and  kept 
to  the  point  by  sticking  to  the  dates,  day  after  day  being  taken  up,  and 
the  rambling  thus  materially  lessened. 

The  beginner  will  do  well  to  listen  with  respectful  attention  to  the 
accounts  of  an  illness  given  by  the  mother  or  by  a  faithful  nurse.  Their 
familiarity  with  the  ways  of  the  child  may  make  them  feel  that  there  is 
something  wrong,  although  their  pov/ers  of  observation  and  description  may 
not  enable  them  to  carry  conviction  to  the  minds  of  others ;  their  constant 
handling  of  the  child  enables  them  to  detect  a  diminution  in  the  firmness 
of  the  child's  flesh,  or  a  failure  in  his  strength,  which  may  readily  escape 
the  attention  of  any  one  else.  When  a  woman  of  sense  in  attendance  on  a 
child  alleges  that  he  is  ill,  or  that  he  is  worse,  the  chances  are  that  she  is 
right,  even  although  the  proofs  she  may  adduce  may  seem  trivial  or  erro- 
neous. It  is  in  their  interpretations  and  theoretical  ideas  that  mothers  are 
so  apt  to  be  wrong,  and  their  wild  speculations  on  the  "  liver,"  the  "  hives," 
and  the  "  nerves"  tend  to  bring  their  opinions  generally  into  unmerited  con- 
tempt. Of  course  some  women  have  the  power  of  arguing  clearly  enough, 
up  to  the  level  of  their  knowledge ;  and  the  writer  can  recall  a  case  of 
intussusception  in  an  infant,  where  the  mother  urged  that  there  must  be 
"  some  obstruction  between  the  stomach  and  the  outlet  of  the  bowel," 
although  the  doctor  in  attendance  had  evidently  never  thought  of  the  case 
in  this  light. 

Men  much  versed  in  the  treatment  of  diseases  of  children  are  always 
chary  of  setting  aside  the  opinions  of  the  mothers  and  nurses  when  they 
differ  from  their  own  as  to  the  relative  state  of  the  infant's  actual  condition, 
unless  these  opinions  are  clearly  found  to  be  based  on  some  erroneous  inter- 
pretation of  the  symptoms  present.  While  estimating  lightly  all  their  theo- 
retical views,  we  should  weigh  seriously  all  their  statements  and  opinions  as 
to  the  actual  facts  of  the  illness,  and  especially  as  to  the  general  condition. 

For  the  personal  examination  of  the  child,  there  should  be  the  greatest 
flexibility  of  plan,  and  a  ready  promptitude  in  taking  advantage  of  every 
chance  which  may  arise,  and  in  deciding  at  once  which  points  are  of  the 
greatest  immediate  importance  in  the  case.  Thus,  if  the  child  be  asleep, 
advantage  may  be  taken  of  this  to  get  the  pulse  and  respirations  counted, 
the  general  character  of  the  breathing  observed,  and  the  color  of  the  face 
noticed ;  even  auscultation  may  to  some  extent  be  possible.  On  the  other 
hand,  if  the  case  seems  to  be  one  of  abdominal  disease,  this  same  state  may 
afford  a  golden  opportunity  for  examining  the  belly,  slipping  the  warm  hand 
under  the  clothes  of  the  sleeping  child,  and  ascertaining  the  condition  of 
the  walls  and  of  the  internal  organs,  before  crying,  or  fright,  or  pain,  may 
render  the  parts  so  tense  as  to  baffle  the  observer.     At  times,  by  sitting 


DIAGNOSIS.  81 

down  and  taking  the  temperature  in  the  axilla,  holding  the  arm  to  the  side, 
or  getting  the  nurse  or  mother  to  do  so,  we  may  allow  time  for  the  agitation 
and  fright  at  the  sight  of  a  stranger  to  subside,  and  the  child  may  even  go 
to  sleep  in  the  process,  allowing  some  part  of  the  examination  to  be  made 
in  this  state.  Or  the  delay  in  taking  the  temperature  may  sometimes  be 
utilized  for  hearing  the  history,  if  this  has  not  been  fully  gone  into,  or  for 
filling  in  details  or  clearing  up  confusion  in  the  narrative.^ 

In  proceeding  with  the  examination,  the  guiding  principle  is  to  avoid 
sudden  or  abrupt  methods ;  preliminary  manoeuvres,  and  even  a  little  play- 
fulness, often  help  to  establish  friendly  relationships  which  facilitate  the 
work ;  but  no  definite  rules  can  be  given.  The  patience  and  good  temper 
of  the  physician  must  be  inexhaustible,  and  when  these  are  combined  with 
a  genuine  desire  to  benefit  the  child,  and  a  bona  fide  love  of  little  children, 
there  are  no  limits  to  what  may  be  done.    Here,  as  in  many  other  things,— 

"  It  is  the  heart,  and  not  the  brain, 
That  to  the  highest  doth  attain. ' ' 

It  is  idle  to  deny,  however,  that  at  times  the  greatest  patience  and  tact  seem 
alike  thrown  away,  and  the  examination  must  remain  very  incomplete ;  or 
perhaps  special  parts  of  it,  if  of  extreme  importance,  may  have  to  be  car- 
ried through  by  main  force.  Usually  this  depends  less  on  the  nature  of  the 
illness  than  on  the  habitually  bad  moral  training  of  the  child  on  the  part 
of  the  parents ;  or  it  may  depend  on  the  medical  examination  or  treatment 
in  this  or  in  some  previous  illness  having  been  of  a  harsh  or  at  least  dis- 
agreeable character.  One  part  of  the  examination  has  often  to  be  conducted, 
so  far,  by  main  force,  viz.,  the  examination  of  the  throat,  and  for  this  reason 
it  is  usually  kept  to  the  last.  Some  young  children  occasionally  give  us 
every  facility,  and,  by  getting  them  to  open  their  mouths  widely  and  to 
draw  a  deep  breath,  we  may  see  the  fauces  well  enough ;  or  we  may  require 
to  aid  the  view  by  a  gentle  depression  of  the  tongue  with  the  tip  of  the 
finger  or  the  end  of  a  spoon.  When  such  methods  are  not  available,  or  fail 
to  suffice,  the  best  way  is  make  every  preparation  for  securing  proper  light 
from  windows,  lamps,  candles,  or  tapers,  and  to  have  adequate  assistance  for 
holding  the  child  firmly  during  the  examination,  and  for  controlling  the 
arms,  which  are  often  best  kept  out  of  the  way  by  a  blanket  or  sheet  held 
tightly  round  the  front  of  the  chest  so  as  to  include  them.  When  all  is 
ready,  the  mouth  may  have  to  be  opened  by  main  force,  and  even  the  nos- 
trils held  in  separating  the  lips  and  teeth,  and  then,  with  the  handle  of  a 
teaspoon,  a  bone  spoon,  a  spatula,  or  a  tongue-depressor,  we  hold  down  the 


1  Of  late  years  some  mothers  take  the  temperature  of  their  sick  children  before  sending 
for  medical  advice,  and  can  tell  with  accuracy  the  degree  of  fever  present:  indeed,  they  are 
sometimes  guided  in  sending  for  the  medical  attendant  by  these  observations.  In  such  cases 
there  is  none  of  the  delay  referred  to,  and  the  temperature  found  comes  in  as  part  of  the 
history  narrated. 
Vol.  I.— 6 


82  DIAGNOSIS. 

tongue  and  turn  the  head  so  as  to  see  both  sides  of  the  fauces  in  a  good 
light :  we  are  often  aided  in  this  view  by  the  gasping  breathing  of  the  child, 
or  even  by  the  efforts  at  vomiting.  From  want  of  proper  arrangement 
before  beginning,  the  hands  of  the  child  may  tear  away  the  spatula  or  the 
candle,  and  all  the  annoyance  has  to  be  gone  over  again,  under  worse  con- 
ditions than  at  first. 

Young  children  (under  five  or  six  years)  are  usually  examined  best  on 
their  mother's  knee ;  if  in  bed,  they  can  be  lifted  out  with  one  of  their 
blankets,  this  change  often  helping  to  pacify  them  if  fretful.  Soft  shawls, 
or  thin  blankets,  previously  warmed,  are  very  useful  in  covering  up  the  child 
while  successive  portions  of  the  body  are  being  exposed  for  examination : 
thus,  the  shawl  may  be  tucked  round  the  loins  while  the  back  of  the  chest 
is  being  examined ;  or  over  the  shoulders,  or  over  the  abdomen,  as  the  case 
may  be.  Exposure  of  a  small  part  of  the  surface  of  the  body  for  a  short 
time,  with  the  adjoining  parts  covered  over  with  warm  shawls,  has  seldom 
any  injurious  influence  :  a  large  surface  uncovered  is,  however,  a  very  differ- 
ent matter,  and  with  the  lower  part  of  the  back  uncovered  we  are  apt  to 
have  the  cold  air  extending  also  round  to  the  abdomen  and  even  to  the 
lower  part  of  the  chest  in  front, — a  most  undesirable  occurrence,  particu- 
larly if  the  examination  happens  to  be  a  little  protracted  and  the  skin  wet 
from  sweating  or  from  the  application  of  poultices;  when  thus  covered 
with  moisture  the  skin  should  first  be  dried  with  warm  towels. 

With  some  tact  on  the  part  of  the  nurse,  the  back  of  the  child,  when 
thus  seated  on  her  knee,  may  often  be  pretty  well  examined  before  the  child 
realizes  that  anything  except  rearranging  the  clothes  is  being  attempted. 
For  the  observer  keeps  literally  as  well  as  figuratively  in  the  background, 
and  some  one  may  perhaps  divert  the  child's  attention  in  front  by  showing 
some  bright  object,  as  a  lighted  taper,  trying,  of  course,  to  avoid  as  much  as 
possible  any  distracting  sounds  in  carrying  out  this  diversion.  In  very  young 
children,  and  even  in  some  others,  the  back  of  the  chest  can  often  be  best 
examined  by  laying  the  child  on  his  abdomen  on  the  nurse's  knees  and  then 
uncovering  the  back ;  the  child  is  often  pacified,  for  a  time,  by  this  change 
of  position,  to  which,  of  course,  he  is  accustomed  during  the  process  of 
dressing  and  renewing  the  napkins.  A  similar  benefit  is  often  obtained  by 
getting  the  nurse  to  hold  the  young  child  close  to  her  breast,  with  the  face 
of  the  infant  towards  either  shoulder,  as  if  looking  over  it,  and  when  the 
child's  vision  is  thus  directed  away  from  the  physician  the  back  may  be  in 
part  uncovered  for  the  purpose  of  examination. 

The  examination  of  the  chest  is  usually  best  begun  in  one  of  these  ways, 
for  the  hack  of  the  chest  is  usually  the  most  important,  as  the  signs  of  bron- 
chitis and  pneumonia  are  often  most  marked  there ;  moreover,  this  part  of 
the  examination  is  sometimes  all  that  the  child  will  permit.  Auscultation 
is  first  practised,  because  it  is  less  disagreeable  to  the  child  and  requires 
greater  quietness,  and  on  the  whole  it  is  more  important  than  percussion. 
It  is  best  done,  as  a  rule,  by  listening  directly  with  the  ear  to  the  chest-M-all, 


DIAGNOSIS.  83 

as  this  is  less  irritating  than  applying  a  stethoscope  :  moreover,  the  head  of 
the  observer,  closely  applied,  follows  more  readily  any  wriggling  movements 
of  the  child.  Circumstances  will  determine  whether  the  skin  should  be  com- 
pletely bared  or  whether  some  thin  garment  may  be  left ;  of  course  nothing 
thick  should  intervene.  A  thin  towel  or  napkin  or  handkerchief,  previously 
heated,  may  be  interposed  between  the  ear  of  the  physician  and  the  skin,  for 
the  head  of  the  observer  is  often  much  colder  than  the  child's  skin,  and  so 
is  apt  to  irritate ;  in  any  case  we  prefer  to  have  only  one  ply  between  the 
ear  and  the  skin  ;  at  times  we  can  listen  with  advantage  with  the  ear  on  the 
naked  chest.  After  auscultation  of  the  back  of  the  chest  is  completed,  and 
any  observations  made  on  this  part  by  eye  or  hand,  it  is  usually  well  to 
practise  percussion.  Of  course  we  generally  prefer  the  finger  as  a  plex- 
imeter  to  judge  of  the  resistance  as  well  as  the  sound.  The  strokes  are 
made  lightly  and  rapidly,  and  it  is  often  well  to  make  a  mental  estimate  of 
the  average  or  mean  sound  educed  by  the  series  of  strokes  obtained  in  varying 
states  of  inspiration  and  expiration,  as  the  breathing  is  often  so  rapid  that 
no  other  basis  of  comparison  can  be  obtained.  Having  in  this  way  made 
observations  on  the  percussion-sounds,  on  the  two  sides  at  various  levels, 
from  top  to  bottom,  we  can  then  lay  the  child  down  or  turn  him  over  on  his 
back,  having  finished  our  examination  of  this  region.  When  the  child  is 
laid  flat,  the  front  of  the  chest  may  be  examined ;  this  is  generally  the  best 
position  for  young  children ;  older  ones  may  often  sit  up  with  advantage, 
having  the  back  supported  by  the  mother's  arms.  Auscultation  of  the  front 
of  the  chest  is  usually  best  accomplished  by  means  of  a  stethoscope,  although 
the  direct  method  also  can  often  be  practised  with  advantage  in  this  situation, 
and  sometimes  we  are  glad  to  try  both  methods  if  we  fail  at  first.  In  using 
the  stethoscope  it  is  well  to  put  it  in  position  first,  or  even  to  allow  the  child 
to  play  for  a  little  with  the  "  trumpet,"  so  that  he  may  feel  that  it  is  nothing 
terrible,  before  bringing  down  one's  head  with  what  is  apt  to  be,  even  with 
care,  somewhat  uncomfortable  pressure.  By  short  successive  applications 
and  giving  plenty  of  time,  the  use  of  the  stethoscope  may  often  be  practised 
successfully ;  whereas  if  stethoscope  and  head  are  abruptly  applied  simul- 
taneously, even  apart  from  the  tender  chest  being  hurt  by  the  hard  instru- 
ment, the  child  is  apt  to  be  greatly  terrified.  While  auscultating  we  lie 
in  wait,  as  it  were,  for  the  occasional  deep  or  even  sighing  respirations,  so 
common  in  childhood,  to  reveal  the  rales  developed  only  under  such  circum- 
stances. Great  patience  and  yet  promptitude  are  required,  as  the  child  often 
holds  the  breath  almost  entirely,  and  then  has  a  series  of  quick  sliallovv 
respirations  ;  but  usually  we  can  also  catch  an  occasional  deep  breath. 
When  the  child  is  old  enough,  and  an  estimation  of  the  resonance  and 
fremitus  of  the  voice  seems  important,  it  is  often  possible  to  get  the  child 
to  answer  some  question  put  by  the  mother  during  the  examination. 

The  examination  of  the  abdomen  may  often  with  advantage  be  taken 
before  proceeding  to  the  front  of  the  chest:  the 'relative  importance  of  the 
two  parts  of  the  examination  as  judged  from  the  history  of  the  illness  must 


84  DIAGNOSIS. 

guide  us.  If  the  child  is  lying  quietly,  we  may  be  able  to  palpate  the 
abdomen  and  determine  the  position  of  the  organs,  or  the  presence  of 
glandular  or  other  swellings,  before  attempting  the  examination  of  the 
chest ;  for  this,  of  course,  however  carefully  performed,  may  lead  to  a  fit 
of  crying.  Particularly  is  this  apt  to  occur  with  percussion  in  front,  even 
when  gently  done,  so  that  we  often  leave  this  to  the  very  last  when  any  dis- 
turbance from  crying  will  be  less  vexatious,  even  if  it  occurs.  The  per- 
cussion of  the  front  of  the  chest  is  almost  always  best  done  with  the  finger 
as  a  pleximeter.  Care  must  be  taken  to  put  the  finger  in  exactly  similar 
relative  positions  on  the  two  sides ;  and,  as  before,  we  often  aim  at  getting 
an  average  sound  out  of  successive  strokes.  The  lateral  regions  are  often 
of  great  importance  in  cases  of  pulmonary  collapse.  The  percussion  under 
the  left  clavicle  seems  often  a  little  duller  than  the  right,  in  young  infants, 
apart  from  any  disease,  probably  owing  to  the  proximity  of  the  heart  im- 
pairing the  sound.  A  slight  relative  dulness  at  the  light  apex  counts, 
therefore,  for  more  than  a  similar  dulness  at  the  left  in  very  young  chil- 
dren. 

The  exploration  of  the  abdomen  is  often  most  important,  but  not  seldom 
the  difficulties  are  extreme.  For  this  reason  it  has  been  suggested  above 
that,  where  this  part  of  the  case  seems  of  primary  importance,  no  chance 
should  be  missed  of  examining  it  during  a  quiet  period,  perhaps  while  the 
child  is  asleep,  perhaps  before  risking  an  upset  from  the  examination  of  the 
chest,  perhaps  in  the  midst  of  this  part  of  the  process.  On  the  other  hand, 
we  may  with  equal  propriety  postpone  the  examination  of  the  abdomen  to 
the  last,  if  the  child  is  cross,  in  hope  of  a  better  chance  arising.  Too  often 
in  young  children  we  are  confronted  with  the  difficulty  of  extreme  tension 
of  the  abdominal  walls,  with  resistance  and  screaming  and  kicking,  making 
palpation  or  percussion  equally  useless.  Sometimes  by  keeping  the  hand 
lightly  applied  under  the  clothes  till  the  child  is  settled,  we  may  be  able, 
without  arousing  his  fears,  to  feel  the  state  of  matters  as  regards  laxity, 
tenderness,  or  tumor. 

In  palpation,  we  mast  see  that  the  hand  is  warm,  and  that  it  is  applied, 
in  the  first  instance,  gently  and  lightly,  carefully  avoiding  any  sudden  jerks 
with  the  fingers,  but  feeling  with  the  whole  hand  so  as  to  avoid  exciting  the 
muscles  to  resistance.  For  similar  reasons  ^ve,  of  course,  begin  with  light 
palpation,  before  risking  the  irritation  of  deep  palpation  or  of  percussion, 
and  the  results  of  palpation  frequently  guide  the  exploration  by  percussion. 
The  presence  or  absence  of  tension  of  the  walls  is  important ;  we  often  find 
them  tense  in  inflammatory  affections  of  the  bowels  and  of  the  peritoneum, 
even  apart  from  effiisions ;  and  if  Ave  can  press  down  a  lax  abdominal  wall 
without  eliciting  signs  of  pain,  we  may  almost  presume  that  there  is  no 
peritonitis.  The  mere  inability  to  do  this  counts  for  little,  unless  circum- 
stances favor  the  examination,  as  the  least  fright  may  render  the  abdominal 
muscles  extremely  tense,  and  pressure  then  readily  causes  pain  and  further 
resistance. 


DIAGNOSIS.  85 

The  next  point  is  to  determine  the  position  of  the  organs  and  the 
presence  of  any  solid  tumor.  The  liver  can  usually  be  felt,  but  it  is  often 
erroneously  supposed  to  be  enlarged  when  but  little  changed  in  size.  It 
must  be  remembered  that  the  liver  is  relatively  large  in  young  children,  and 
that  it  is  also  relatively  prominent  in  them  below  the  ribs.  Moreover,  in 
rickets  and  other  distortions  of  the  chest  the  liver  is  displaced  so  as  to 
simulate  a  great  enlargement.  Indeed,  the  whole  belly  is  often  very  promi- 
nent and  distended  in  rickets,  and  the  inexperienced  finding  an  apparent 
enlargement  of  the  liver  may  erroneously  suspect  the  presence  of  dropsy ; 
even  the  percussion-note,  pei-haps  from  great  tension  of  the  gas  in  the  bowel, 
or  from  other  causes,  may  seem  to  be  duller  than  a  tympanites  could  give ; 
in  such  cases  also  the  air-filled  bowels  often  give  a  spurious  kind  of  fluctu- 
ation, which  may  confirm  the  deception,  and  so  Ave  occasionally  see  futile 
attempts  at  removing  fluid  from  the  abdomen  by  tapping  in  cases  where 
none  could  possibly  be  obtained,  because  there  is  none  present.  The  spleen 
may  also  be  found  very  readily  at  times  in  rickety  children,  partly  from 
enlargement,  partly  from  displacement.  By  inserting  one  hand  behind  the 
left  false  ribs,  and  pressing  with  the  other  in  front,  we  can  often  feel  the 
spleen ;  when  felt  veiy  distinctly  we  are  seldom  wrong  in  presuming  that  it 
is  more  or  less  enlarged.  In  marked  enlargement  its  notch  can  be  easily 
felt,  and  sometimes  it  extends  away  down  to  the  pubic  bones,  and  even 
turns  there  towards  the  right  of  the  middle  line.  The  spleen  is  often  en- 
larged in  rickets,  usually  only  to  a  moderate  extent ;  it  may  be  found  en- 
larged in  scrofulous  children,  with,  it  may  be,  albuminuria  or  other  signs 
of  amyloid  disease  :  occasionally  the  enlargement  is  associated  with  leukaemia : 
ague  must  also  be  inquired  for  :  concurrent  disease  of  the  liver  may  suggest 
the  cause  of  splenic  enlargement :  embolism  has  also  been  known  by  the 
writer  to  produce  very  palpable  increase  in  the  size  of  a  boy's  spleen.  Oc- 
casionally, however,  no  satisfactory  explanation  can  be  found  of  the  tumor, 
which  may  disappear  as  unaccountably  as  it  grew. 

For  enlargement  of  the  kidney  and  for  other  abdominal  tumors  the  reader 
is  referred  to  special  sections  of  this  book. 

There  is  often  great  importance  to  be  attached  to  finding  little  tumors  or 
lumps  in  the  abdomen  in  cases  of  suspected  tubercular  peritonitis  and  tabes 
mesenterica.  In  searching  for  these,  the  full  breadth  of  the  hand  should  be 
applied  at  first  to  the  wall,  and  if  the  child  is  quiet  this  is  worked  about  in 
various  ways  and  pressed  down,  at  first  gently,  and  then,  as  the  child  gets 
accustomed  to  the  manipulation,  more  deeply,  in  search  of  the  hard  masses : 
at  this  stage  the  fingers  have  to  be  made  to  dip  down,  and  we  often  feel 
more  security  in  the  diagnosis  when  the  lump  can  be  caught  between  the 
finger  and  thumb  or  between  the  two  fingers.  It  is  always  well  to  go  back 
upon  a  suspected  tumor,  after  it  is  found,  so  as  to  feel  sure  that  the  sensation 
is  not  due  to  any  accidental  cause. 

During  this  part  of  the  examination  the  hand  may  experience  a  distinct 
sensation  of  rubbing  or  friction  in  the  abdomen :  this  may  be  made  out 


86  DIAGNOSIS. 

more  plainly,  at  times,  by  wriggling  movements  of  the  hand,  or  by  trying 
to  rub  the  abdominal  wall  against  deeper  parts ;  or  we  may  bring  it  out  by 
making  the  patient  breathe  deeply  while  we  feel  carefully  in  different  parts, 
as  this  makes  some  of  the  abdominal  organs  move  with  the  diaphragm. 

Any  pain  or  tenderness  elicited  during  such  manipulations  should  of 
course  be  noted :  the  beginner  must,  however,  be  constantly  on  his  guard 
against  being  misled  by  the  absence  of  tenderness  into  supposing  that  there 
is  no  peritonitis,  as  erroneous  ideas  on  this  subject  have  been  too  often 
gathered  from  systematic  lectures  or  from  descriptions  of  "typical  cases." 
The  fact  is  that  in  a  verj^  large  number  of  cases  of  tubercular  peritonitis  in 
children  there  is  no  tenderness  on  pressure  at  all,  and  even  in  some  cases  of 
acute  peritonitis  of  a  fatal  nature  it  may  seem  to  be  absent  or  to  be  merged 
in  a  general  uneasiness  on  handling  the  abdomen. 

The  prominent  belly,  contrasting  strongly  with  the  wasted  state  of  the 
chest  and  of  the  thighs,  is  a  familiar  appearance  in  tubercular  disease  of 
the  abdominal  organs,  even  in  cases  where  there  may  be  little  or  no  fluid 
present ;  and  an  even  more  striking  degree  of  the  same  thing  may  be  found 
in  cases  of  malignant  tumors  of  the  abdomen.  In  both  of  these  conditions 
we  may  see  more  or  less  distention  of  the  superficial  veins,  and  at  times 
they  may  be  enlarged  to  an  enormous  extent.  The  uniform  distention  of 
the  abdomen  from  fluid  in  the  peritoneum  often  contrasts  with  more  local- 
ized swellings  from  tumors  there ;  the  discrimination  must  be  made  by  per- 
cussion and  palpation,  as  in  the  case  of  adults.  Fluid  in  the  abdomen  is, 
as  already  stated,  often  due  to  tubercular  disease,  although  of  course  it  may 
also  be  due  to  the  existence  of  dropsy  from  disease  of  the  heart  and  kidney, 
but  in  such  cases  we  have  almost  invariably  more  or  less  dropsy  elsewhere. 
A  suddenly-developed  dropsy,  localized  in  the  abdomen,  may  depend,  as  in 
the  adult,  on  disease  of  the  liver, — not  usually  on  cirrhosis  of  the  liver, 
although  this  is  not  entirely  unknown,  but  perhaps  due  to  thrombosis  of 
the  portal'  vein  :  in  such  cases  we  tiy  to  make  out  an  enlarged  spleen,  and 
we  inquire  for  hemorrhages  from  the  stomach  or  bowels ;  we  also,  of  course, 
examine  for  jaundice  or. other  signs  of  hepatic  disorder;  but  the  diagnosis 
must  usually  remain  very  doubtful  during  life,  unless  the  fluid  quickly 
disappears.  In  bad  peritoneal  dropsy  from  any  cause  we  may  see  hernial 
protrusions,  with  fluid  in  them  communicating  with  the  general  abdominal 
effusion. 

The  chest  is,  of  course,  best  surveyed  when  both  chest  and  abdomen 
are  completely  uncovered ;  but  the  actual  state  of  the  child  must  determine 
whether  it  is  wise  to  have  it  so.  The  appearance  of  marked  wasting  with 
great  distinctness  of  the  ribs ;  the  existence  of  any  of  the  forms  of  "  pigeon- 
breast"  with  prominence  of  the  sternum  and  an  accentuated  transverse 
groove  above  the  liver ;  the  presence  of  the  so-called  "  beading  of  the  ribs" 
(or  the  "  rachitic  rosary,"  as  it  is  sometimes  termed),  consisting  in  visible 
and  pal2:)able  swellings  at  the  ends  of  the  ribs  where  they  join  the  carti- 
lages ;  various  bad  conformations  of  the  chest,  whether  with  depression  of 


DIAGNOSIS.  87 

the  lower  end  of  the  sternum  or  with  unilateral  distortions  interfering  with 
the  symmetry  of  the  chest ;  bulging  forward  of  the  sternum,  with  a  ten- 
dency to  the  circular  form  of  chest,  indicative  of  emphysema  in  older  chil- 
dren, as  in  adults ; — all  these  structural  peculiarities  can  often  be  sufficiently 
appreciated  at  a  glance. 

But  we  must  likewise  notice  the  chest  in  action.  The  awful  dyspnoea 
of  croupy  attacks,  with  powerful  action  of  the  muscles  of  the  neck  and 
sudden  elevation  of  the  upper  part  of  the  sternum  and  ribs,  almost  in  a 
mass,  coupled  with  recession  of  the  ribs  in  the  lateral  region  and  sucking  in 
of  the  lower  part  of  the  flexible  sternum,  tells  at  once  of  the  urgent  need 
for  air  experienced  by  the  child,  and  of  the  mechanical  interference  with  its 
entry  into  the  lungs.  An  excited  action  of  the  accessory  muscles  of  respi- 
ration, with  panting  and  heaving  of  the  chest,  but  without  the  recession 
movements  just  described,  characterizes  the  attacks  of  spasmodic  action  in 
the  child,  as  in  the  adult ;  for,  although  not  very  common  under  twelve  or 
fifteen  years,  genuine  spasmodic  asthma  in  children  is  not  so  very  infrequent 
as  is  often  supposed.  Marked  unilateral  respiration,  with  one  side  heaving 
rapidly  and  the  other  motionless,  is  very  suggestive  of  a  large  pleuritic  effu- 
sion, and  this  is  rendered  almost  certain  if  we  detect,  on  getting  a  fair  view 
of  the  chest,  that  the  motionless  side  is  larger  and  fuller  than  the  other, 
wdth'  obliteration  of  the  intercostal  spaces :  some  rearrangement  of  the 
position  of  the  child  may  be  required  to  ascertain  this,  as  the  decubitus  is 
invariably  in  such  cases  on  the  affected  side.  Marked  unilateral  retraction 
and  immobility  at  once  suggest,  in  a  child,  the  results  of  an  old  pleurisy  or 
empyema,  although  of  course  it  may  occasionally  depend  on  long-standing 
pulmonary  excavation  or  on  the  contraction  of  a  fibroid  phthisis.  Moderate 
flattening  and  retraction  under  the  clavicle,  or  impaired  movements  there, 
fulness  over  the  pericardial  area  from  effusion,  general  bulging  of  the  tissues 
of  the  chest  and  neck,  with  crackling  on  touching  it,  due  to  subcutaneous 
emphysema, — all  require  detailed  examination,  and  cannot  be  •  recognized 
the  moment  the  chest  is  seen,  as  in  many  of  the  conditions  already  men- 
tioned. 

STATE   OF   GENEKAL   DEVELOPMENT. 
Weight — Dentition — Walking. 

While  the  child  is  being  uncovered,  for  the  purpose  of  having  the  chest 
and  abdomen  examined,  an  opportunity  is  afforded  of  judging  of  the  gen- 
eral development,  and  this  survey  must  be  supplemented  by  an  examination 
of  the  limbs  and  of  the  head.  The  large  head,  ])rominent  belly,  and  dis- 
torted cliest  may  at  once  fix  in  our  minds  the  idea  of  rickets,  even  apart 
from  any  deformity  in  the  limbs ;  but  usually,  even  in  children  who  have 
never  walked,  we  may  see  evidences  of  rickets  in  the  great  prominence  of 
the  curvatures  of  the  clavicles, — aj^pcaring  as  if  they  had  undergone  repair 
from  fracture, — and  in  the  curved  arm  and  forearm  resulting  from  rest- 
ing the  weight  of  the  body  on  the  upper  limbs  while  sitting  up  in  bed ; 


88  DIAGNOSIS. 

enlarged  wrists  and  ankles,  and  open  or  soft  fontanels,  come  to  our  aid  as 
confirmations.  The  wasted  appearance  of  the  chest  and  limbs,  contrasting 
with  a  great  prominence  of  the  abdomen  (with  or  without  the  presence  of 
fluid),  has  already  been  referred  to  as  strongly  suggestive  of  tubercular 
disease  in  the  peritoneum  or  mesenteric  glands,  constituting  an  affection  of 
special  importance  in  childhood,  as  it  is  relatively  frequent  at  this  period  of 
life.  It  is  best  spoken  of  as  "  abdominal  phthisis,"  owing  to  the  frequently 
uncertain  and  mixed  character  of  the  pathological  conditions  actually  present. 
The  general  aspect  of  the  child  with  such  disease  is  only  referred  to  here,  as 
it  will  require  very  special  consideration  in  other  sections  of  this  work. 

Of  course  in  phthisical  disease,  whether  in  the  chest  or  the  abdomen,  we 
may  have  a  wasting  which  involves  the  belly  also  in  the  general  atrophy, 
the  whole  child  presenting  a  uniformly  shrunken  appearance.  But,  quite 
apart  from  affections  of  this  kind,  the  whole  body  may  be  pretty  equally 
atrophied  in  a  multitude  of  cases  of  wasting  disease  arising  from  malnu- 
trition, due  to  improper  feeding  or  diarrhoea,  even  apart  from  any  tubercu- 
lar tendencies.  The  patient's  face  is  small,  and  assumes  the  appearance,  in 
many  ways,  of  that  of  an  old  man.  A  good  place  to  judge  of  the  extent  of 
the  wasting  in  a  child  is  in  the  upper  part  of  the  thigh  in  the  region  of  the 
great  adductor  muscles.  We  often  see  this  part  hollow  and  with  the  skin 
lying  in  loose  folds.  We  may  test  with  advantage  the  tone  of  the  tissues 
by  pinching  up  the  skin  here,  the  raised  fold  thus  made  taking  a  long  time 
to  efface  itself  in  cases  of  wasting  and  debility  ;  even  the  skin  pinched  up 
on  the  abdomen  may  linger  as  a  visible  fold  to  a  striking  extent. 

Along  with  signs  of  general  wasting  we  have  often  badly-formed  nails, 
with  longitudinal  marks  amounting  almost  to  cracks ;  or  we  may  find  the 
curving  and  clubbing  familiar  to  us  in  phthisical  adults.  Frequently  along 
the  spine,  and  extending  towards  the  scapulae,  we  see  long  soft  hairs  in  weakly 
children ;  but  the  importance  of  this  sign  must  not  be  exaggerated,  as  it 
may  be  found  sometimes  in  those  who  are  fairly  strong. 

A  most  important  point  in  the  estimation  of  the  development  and  actual 
condition  of  children  consists  in  weighing  them.  Unfortunately,  accurate 
details  as  to  what  may  be  regarded  as  normal  weights  for  the  various  ages 
and  heights,  in  both  sexes,  are  not  yet  ascertained  on  a  sufficiently  extensive 
scale  to  guide  us  in  estimating  the  value  of  one  individual  weighing,  although 
numerous  observations  are  to  be  found  compiled  by  Quetelet,  Roberts,  Bow- 
ditch,  and  Vierordt.  It  must  be  remembered  that  the  normal  weight  varies 
relatively  for  the  sexes  at  different  periods  of  life ;  that  in  both  sexes  it 
varies,  of  course,  with  the  height ;  and  that  with  the  same  sex  and  the  same 
height  it  will  vary  with  the  age  of  the  child.  Probably  also  the  nationality 
leads  to  variation  in  weiglit,  as  between,  for  example,  American  and  British 
children.  The  social  position  of  the  children  weighed  for  the  purpose  of 
ascertaining:  avera2;es  likewise  determines  a  2;reater  weiirht  for  the  "  most 
favored  classes"  of  society.     In  the  case  of  very  young  children,  the  influ- 


DIAGNOSIS. 


89 


ence  of  nourishment  by  breast-milk  determines  for  the  more  favored  class 
in  this  respect  an  increased  growth  and  weight  in  the  early  part  of  life ; 
and  it  can  even  be  traced  as  exerting  an  influence  for  some  years  after  birth. 
This  difference  as  to  children  nursed  at  the  breast  and  those  brought  up  arti- 
ficially applies  chiefly,  if  not  exclusively,  to  the  poorer  grades  of  the  com- 
munity ;  at  least  the  evidence,  so  far  as  statistical  data  are  concerned,  ap- 
plies to  these  classes  only,  as  the  others  scarcely  come  within  the  chance  of 
such  observ^ations  being;  made  on  a  large  scale,^ 


1  MEAN   HEIGHT   AND   WEIGHT   OF   10,904   GIRLS   IN  THE   UNITED   STATES   OF   AMERICA. 

(Including  3681  American,  3623  Irish,  585  German,  and  1397  Mixed  English,  Irish,  and  American 

Parentage.)    Dr.  Bowditch. 

Abstract  from  Roberts's  ^'■AntJn^ojJotnetry." 


Age  Last  Birthday. 

Height,  without 
Shoes. 

Weight,  including 
Clothes. 

5  years. 

41.0  inches. 

40  lbs. 

6      " 

43.5      " 

44   " 

7      " 

45.5      " 

48   " 

8      " 

47.5      " 

52   " 

9      " 

49.5      " 

56    " 

10      " 

51.5      " 

60   " 

11      " 

53.5      " 

66    " 

12      " 

56.0      " 

76   " 

13      " 

58.0      " 

88   " 

14      » 

60.0      " 

96   " 

15      " 

61.0      " 

104   " 

16      " 

61.5      " 

110   " 

17      " 

62.0      " 

112    " 

18      " 

62.0      " 

114   " 

MEAN  HEIGHT  AND  WEIGHT  OF  BOYS  AND  MEN 

Between  4  and  50  Years.    English  Artisan  Class.    (13,931  Observations.) 

Abstract  from  Roberts's  '■^Anthropometry." 


Age  Last  Birthday. 

Height,  without 
Shoes. 

Weight,  including 
Clothes  =  7  and  10  Lbs. 

4   years. 

38.50  inches. 

44  lbs. 

5 

41.00      " 

50   " 

6       " 

43.00      » 

54   " 

7       " 

45.00      " 

57    " 

8       " 

47.00      " 

59   " 

9       " 

49.00      " 

62   " 

10       " 

50.50      " 

66    " 

11 

51.50      " 

70   " 

12       " 

53.50      " 

74   " 

13        " 

55.50      " 

78   " 

14       " 

58.00      " 

84   " 

15       " 

60.50      " 

94    " 

16       " 

63.00      " 

106   " 

17       " 

64.50      " 

116    " 

18       " 

65.50      " 

122   " 

19       " 

66.00      " 

128   " 

20       " 

66.25      " 

132   " 

21 

22       " 

66.50      " 

136    " 

23-30  " 

66.50      " 

138    " 

23-50" 

66.50      " 

140   " 

90 


DIAGNOSIS. 


But,  whatever  difficulties  beset  the  estimate  of  a  child's  weight  as  com- 
pared with  any  absolute  standard,  the  relative  weight  of  the  child  from  time 


HEIGHT  AND  WEIGHT  OF  BOYS  BETWEEN  13  AND  20  YEARS. 

(3695  Boys  in  Telegraph  Service  in  England.) 

Abstract  from  Robe7'ts's  "A}ithropometjy." 

Average  Weight  in  Lbs.,  without  Coat,  Hat,  and  Shoes. 


Age  at 

Last  Birthday 

Height. 

Average  in 
Lbs. 

Height  in 
Inches. 

13 

14 

15 

16 

17 

18 

19 

lbs. 

lbs. 

lbs. 

lbs. 

lbs. 

lbs. 

lbs. 

. 

4  ft.  3 

62 



62.0 

51 

"    4 

73 

70 

67 

70.0 

52 

"     5 

72 

69 

70.5 

53 

"    6 

74 

74 

74 

67 

72.2 

54 

"    7 

75 

76 

77 

76 

76 

76.0 

55 

"    8 

78 

80 

78 

87 

81 

80.8 

56 

"     9 

82 

83 

83 

86 

83.5 

57 

"  10 

86 

86 

87 

88 

94 

88.2 

58 

"  11 

87 

89 

91 

93 

93 

91 

90.7 

59 

5  ft. 

90 

93 

92 

96 

101 

109 

97.0 

60 

"     1 

96 

98 

99 

101 

106 

102 

119 

103.0 

61 

"    2 

96 

101 

104 

106 

109 

111 

113 

105.7 

62 

"     3 

103 

108 

108 

110 

115 

117 

117 

111.1 

63 

"    4 

111 

112 

115 

115 

116 

115 

120 

115.0 

64 

"     5 

107 

117 

115 

120 

127 

121 

118.0 

65 

"     6 

119 

117 

122 

126 

126 

130 

123.3 

66 

"     7 

123 

120 

125 

132 

129 

138 

128.0 

67 

"    8 

131 

126 

131 

142 

144 

134.8 

68 

"     9 

129 

142 

182 

188 

144 

140 

139.4 

69 

"  10 

136 

144 

147 

151 

137 

143.0 

70 

"  11 

149 

129 

150 

142.6 

71 

This  table  shows  not.  only  the  average  weight  and  average  height  of  boys,  but  also  the 
variation  of  weight  in  boys  of  the  same  height,  according  to  age.  For  example,  there  is  a 
steady  progression  with  age  at  the  height  of  5  ft.  2,  boys  of  13  being  only  96  lbs.  and  those 
of  19  beino-  113, — a  range  of  8  or  9  lbs.  above  and  below  the  mean  of  105.7. 

Althouo-h  applying  to  those  somewhat  older  than  "children,"  the  inter-relationship  of 
height,  weight,  and  age  is  well  shown,  and  no  similar  data  for  earlier  ages  are  known  to  the 
writer. 

WEIGHT  AND  LENGTH  OF  INFANTS   ACCORDING  TO  THEIR  AGE  AND  THE  CHARACTER 

OF  THEIR  NOURISHMENT. 

(Russow  :  from  Gephardt's  ".Handbuch  der  Kinderkrankheiten.") 


Class  I. — Children  of  Average  "Weight  and  Upwards. 

Nourishment. 

Weight  in  Grammes. 

Length  in  Centi- 
metres. 

15  Days. 

3Mos. 

6  Mos. 

9  Mos. 

12  Mos. 

15  Days. 

6  Mos. 

12  Mos. 

Breast-milk       

Breast-milk,  with  some  cow's 
milk  and  starchy  food     .    . 

3594 
3525 

5701 
5310 

7072 
6317 

8401 
7916 

9930 
8480 

51 
49 

67 
64 

73 

69 

1 

DIAGNOSIS. 


91 


to  time  is  a  more  definite  matter.  The  weight  of  a  child  is  so  small  that 
great  care  is  required  in  regard  to  the  estimate  of  the  clothing.  The  best 
way  in  routine  practice  seems  to  be  to  take  the  weight  in  the  clothes  the 
child  wears  while  iu-doors,  as  this  leaves  the  variation  from  time  to  time 
but  trifling,  although  heavier  underclothing  and  heavier  shoes  make  a  little 
difference.  A  system  of  frequent  weighing  (two  or  three  times  a  day)  has 
lately  been  advocated,  and  has  been  alleged  to  bring  out  some  curious  re- 
sults, showing  more  definitely  the  somewhat  fitful  manner  in  which  increase 
of  weight  occurs  at  different  parts  of  the  year,  and  its  relationship  to  in- 
crease in  height.  Such  a  system  of  regular  weighings  of  school-children, 
even  if  recorded  only  once  a  Aveek,  might  give  useful  warnings  to  parents 
and  teachers.  Of  course  the  conditions  would  require  to  be  the  same  as 
regards  the  time  of  day  Avheu  weighed  and  the  clothing  worn.  We  might 
then  learn  whether  the  strain  of  education  or  the  influence  of  some  latent 
disease  was  telling  on  the  general  nutrition  before  the  deterioration  had 
advanced  too  far. 

In  actual  practice,  however,  we  have  seldom  much  assistance  given  ub 
in  diagnosis  by  the  records  of  previous  weights  in  children,  although  in  the 
course  of  treatment  we  often  avail  ourselves  of  the  balance  to  judge  of  the 
results  in  this  respect  and  to  guide  the  prognosis.  It  is  in  such  matters  as 
estimating  a  general  falling  off  in  the  nutrition  and  weight  that  the  opinion 
of  careful  mothers  and  nurses  is  so  valuable,  particularly  in  young  children  : 
even  when  the  weight  might  show  but  little  change,  their  estimate  of  the 
softness  of  their  muscles,  or,  on  the  other  hand,  of  their  increasing  firmness, 
indicates  with  considerable  certainty  the  tendency  of  the  case  in  either  direc- 
tion. The  importance  of  a  gradual  falling  off  for  weeks  or  months  before 
the  onset  of  dubious  cerebral  symptoms  is  well  known  in  the  diagnosis  of 
tubercular  meningitis,  although  in  not  a  few  cases  this  dreadful  disease  may 


Class  II. — Children  under  the  Average  "Weight. 

Nourishment. 

Weight  in  Grammes. 

Length  in  Centi- 
metres. 

15  Days. 

3Mos. 

6  Mos. 

9  Mos. 

12  Mos. 

15  Days. 

6  Mos. 

11  Mos. 

Breast-milk 

Breast-milk,  with  cow's  milk 
and  starchy  food 

3027 

2928 

4225 
4143 
4089 

5775 
5598 
4744 

6490 
5932 
5254 

7910 

0823"! 
6128J 

49 
43 

59 
55 

09 

1 
63 

Cow's  milk  and  starchy  food 
exclusively 

2900 

The  original  figures  are  here  given  as  indicating  the  relative  variations  very  clearly. 
For  those  not  quite  familiar  with  the  Metric  System  the  following  figures  will  serve  as  a 
guide  :  1000  grammes,  or  1  kilogramme,  =  2.2  lbs.  avoirdupois  (nearly) ;  and  10  lbs.  =  4536 
grammes:  1  centimetre  =0.3937  inch  ;  50  centimetres  =  19.685  inches.  The  artificial  feed- 
ing here  referred  to  concerned  the  poorer  classes  of  society.  lielatively  better  results  miglit 
be  obtained  from  more  careful  and  scientific  substitutes. 


92  DIAGNOSIS. 

seem  to  surprise  the  child  before  any  falling  off  had  occurred.  Likewise 
in  other  obscure  affections  of  a  tubercular  or  scrofulous  nature,  whether  in 
lungs,  bronchial  glands,  abdomen,  or  brain,  this  preliminary  deterioration 
before  pronounced  symptoms  had  appeared  often  constitutes  a  point  of 
capital  importance  in  the  diagnosis. 

A  valuable  means  of  estimating  the  development  of  children  is  afforded 
by  the  state  of  their  dentition,  and  the  age  at  which  they  may  have  begun 
to  walk,  for  these  are  points  on  which  the  mothers  can  usually  supply 
information. 

Particulars  as  to  the  order  and  date  of  the  eruption  of  the  milk-teeth 
will  be  given  in  other  chapters,  so  far  as  these  can  be  reduced  to  a  rule. 
Speaking  generally,  we  may  say  that  in  rickets,  and  all  forms  of  bad  and 
retarded  development,  the  dentition  is  later  in  being  completed ;  but  it 
happens  not  infrequently  that  in  such  cases  there  may  be  an  early  start, — 
perhaps  an  unusually  early  start, — followed  by  a  prolonged  pause  after  the 
first  few  teeth  appear.  In  not  a  few  cases  of  bad  rickets  or  of  syphilis  there 
may,  indeed,  be  a  complete  absence  of  the  teeth  even  when  the  child  is  of  an 
age  when  all  the  milk-teeth  should  have  appeared.  A  backward  state  of  the 
teething,  so  that  the  rickety  child  at  two  years  may  have  only  as  many  teeth 
as  a  healthy  child  at  ten  or  twelve  months,  is  a  common  and  very  suggestive 
fact.  Very  suggestive  also  is  the  arrest  in  the  natural  progress  of  dentition 
often  brought  about  by  some  intercurrent  illness  even  in  those  who  have  been 
healthy.  Occasionally,  no  doubt,  the  appearance  of  new  teeth  in  the  very 
midst  of  some  serious  illness  is  observed ;  but  this  is  entirely  exceptional. 

The  date  of  walking  varies  much  in  perfectly  healthy  children.  Any 
precocity  in  this  respect  is  in  no  way  desirable,  and  no  anxiety  should  be 
expressed  with  regard  to  it  if  the  child  seems  otherwise  quite  strong  and 
healthy,  unless  the  period  goes  beyond  the  fourteenth  or  fifteenth  month, 
although  children  in  good  condition  usually  walk  a  month  or  two  earlier. 
When,  however,  we  find  a  child  unable  to  walk  at  eighteen  months,  the 
chance  of  this  delay  being  due  to  rickets  is  very  great,  if  there  are  no 
obvious  localized  defects  in  the  limbs  from  paralysis,  joint-mischief,  etc. 
Occasionally,  indeed,  the  inability  to  walk  depends  on  a  general  deficiency 
of  the  development  of  the  whole  nervous  system,  including  a  mental  defect, 
to  which  even  when  very  notable  the  mother  is  apt  to  be  singularly,  or  per- 
haps wilfully,  blind,  enlarging,  it  may  be,  on  the  remarkable  acuteness  of 
her  offspring. 

As  in  the  case  of  dentition,  the  child's  progress  in  standing  and  walking 
is  often  arrested,  after  a  fair  start  had  been  made,  by  the  supervention  of 
rickets.  The  child  is  then  said  "  to  have  been  taken  off  his  feet,"  a  report 
which  must  always  suggest  the  idea  of  rickets  to  the  physician.  Of  course 
any  acute  illness  may  operate  in  the  same  way,  so  that  after  recovery  from 
measles,  a  bad  bronchitis,  or  a  diarrhoea,  for  example,  the  child  may  be 
found  to  have  lost  the  power  of  walking,  only  to  be  regained  slowly,  so 


DIAGNOSLS.  93 

that  he  may  appear  to  be  several  months  behind  others  of  his  own  age  in 
this  respect. 

In  cases  of  inability  to  walk,  when  brought  for  advice,  we  must  ascer- 
tain by  a  local  examination  whether  there  is  pain,  or  dislocation,  or  any 
mechanical  defect  interfering  with  the  process ;  we  also  examine  for  atrophy, 
coldness,  spasm,  and  other  signs  of  paralysis  in  the  limb,  ascertaining  if 
the  child  when  sitting  or  lying  can  move  the  legs  freely ;  we  must  also 
examine  the  back  for  curvatures  or  other  deformities ;  we  likewise  search, 
as  already  stated,  for  any  signs  of  rickets  or  for  indications  of  mental 
defect.  The  case  is  often  made  clearer  if  we  can  ascertain  that  the  child 
has  ever  ^^'alked,  even  for  a  month  or  two,  or  if  any  acute  attack  of  illness 
was  followed  immediately  by  the  loss  of  power  complained  of. 

Precocious  development  of  the  sexual  organs,  or  signs  of  premature 
puberty,  are  occasionally  seen  in  children,  in  both  sexes.  When  such  are 
noticed,  we  must  inquire  for  any  unnatural  excitation  of  the  parts  by  the 
patient  or  the  nurse,  or  for  any  evidences  of  masturbation,  which  of  course 
at  that  age  may  assume  very  unusual  forms  if  present.  In  young  girls  the 
premature  signs  of  puberty  may  depend  on  some  ovarian  tumor.  The 
writer  had  recently  a  child  of  three  and  one-half  years  under  his  care, 
with  an  abdominal  swelling,  where  the  well-developed  mammae,  the  pres- 
ence of  hairs  on  the  labia  pudendi,  which  were  unduly  full,  and  the  occa- 
sional discharge  of  a  material  like  butter  from  the  vulva,  enabled  the  diag- 
nosis of  an  ovarian  tumor  to  be  made  Avith  a  considerable  deo-ree  of 
certainty.  The  tumor  proved  to  be  a  very  large  solid  ovarian  tumor ;  but 
the  shock  of  the  very  serious  operation  demanded  for  the  removal  of  such 
a  large  solid  mass  was  too  much  for  the  child. 

examinatiojst  of  the  head. 

The  development  of  the  child  as  regards  the  bony  system  has  been 
alluded  to  incidentally  in  connection  with  the  distortions  of  rickets ;  but 
special  attention  must  often  be  directed  in  various  cases  to  the  state  of  the 
head.  The  size  of  the  head  varies  enormously,  and  it  is  not  possible  to 
give  absolute  measurements  of  any  great  diagnostic  value.  We  can  often 
judge  of  it  best  by  a  comparison,  by  means  of  the  eye,  with  other  portions 
of  the  body,  particularly  with  the  chest  and  abdomen ;  sometimes  we  can 
with  advantage  take  measurements  of  the  circumference  of  these  three  parts, 
particularly  in  watching  their  relative  growth,  in  young  children,  over  a 
period  of  months.  The  circumference  of  the  head  taken  at  the  occipital 
protuberance  and  the  prominent  part  of  the  brow  is  greater  at  birth  than 
the  circumference  of  the  chest,  which  is  best  measured  a  little  below  the 
nipples  to  escape  the  angles  of  the  scapulre.  This  diiference  is  maintained 
for  some  months  after  birth,  but  in  well-developed  children  the  measure- 
ments, as  taken  above,  become  nearly  equal  between  the  ages  of  one  and 
two  years,  and  after  four  years  the  chest  rapidly  increases  as  compared  with 


94 


DIAGNOSIS. 


the  skull.^  In  badly-developed  children  the  chest  is  much  longer  in  assert- 
ing its  equal  or  superior  size,  this  being  delayed  in  many  such  cases  till  the 
age  of  five  years. 

The  size  of  the  head  depends,  of  course,  ver}-  much  on  the  parentage  of 
the  child ;  but  it  is  often  too  large  and  sometimes  unduly  small  in  disease. 
In  rickets  the  head  looks  large  and  the  face  small ;  the  top  of  the  head  is 
usually  rather  flat,  and  sometimes  gives  the  idea  of  a  square  shape.  The 
fontanels  are  often  much  wider  than  usual  for  the  age,  and  may  indeed 
remain  unclosed,  or  only  covered  by  a  soft  membrane,  for  a  year  or  tAvo 
after  thev  should  be  closed  :  the  measurement  of  the  fontanels,  particularly 
the  anterior,  can  often  be  made  with  advantage  in  inches  (both  antero-pos- 
teriorly  and  transversely)  from  time  to  time  in  watching  a  case,  so  as  to 
judge  of  its  progress  towards  closure.  The  sutures  in  rickets  can  often  be 
felt  with  undue  facility,  but  they  are  seldom  actually  separated  and  bulging 
as  in  hydrocephalus ;  the  thickened  edges  of  the  bones  can  often  be  felt  at 
the  sutures,  which  assume  in  this  way  an  undue  prominence.  Here  and 
there  at  the  sides,  and  in  the  occipital  region  particularly,  the  point  of  the 
finger  mav  feel  the  soft  spots  of  cranio-tabes.  Whenever  such  characters 
are  found  in  the  skull  we  search  for  other  signs  of  rickets :  in  the  chest  for 
the  characteristic  distortion  and  the  so-called  "  beading"  of  the  ribs ;  for 
curves  in  the  long  bones  of  both  the  upper  and  the  lower  extremities ;  more- 
over, the  actual  state  and  history  of  dentition,  the  date  of  walking  or  of 
giving  over  walking,  if  the  child  is  sufficiently  old  for  this  to  come  up,  and 
the  presence  or  histoiy  of  tenderness  in  the  bones  on  handling  the  child,  all 
come  in  to  help  the  diagnosis.  Rickets  has  such  wide-reaching  effects,  and 
has,  in  particular,  so  important  an  influence  on  nervous  disorders,  that  the 
large  head  may  readily  lead  the  inexperienced  to  ascribe  laryngeal  spasms 
and  general  con\Tilsions  to  some  grave  disease  of  the  brain,  while  really  the 
case  is  essentially  due  to  rickets  and  perhaps  readily  curable. 

In  examining  the  skull  we  may  find  thickened  masses  or  bosses  around 
the  fontanel  especially,  or,  on  the  other  hand,  thinned  portions  of  bone,  soft 


1  vSee  "  Third  Eeport  of  the  Clinical  Hospital,  Manchester,"  by  Dr.  James  Whitehead, 
London,  1859.  The  following  table  may  be  useful  for  reference,  relating  to  children  of  good 
development. 


Head. 

Chest, 

Difference  between  Head  and 

No.  OF  Cases. 

Age. 

I>XHES. 

Inches. 

Chest. 

100 

One  day. 

13.75 

12.94 

Head  more  than  chest  0.81 

66 

6  to  12  weeks. 

15.25 

14.25 

'i              "             "     1.00 

75 

6  to    8  months. 

16.68 

15.58 

"             "     1.10 

71 

11  to  13 

17.80 

17.20 

"              "             "     0.60 

67 

21  to  24       " 

18.38 

17.85 

"     0.53 

50 

34  to  36        " 

18.70 

18.61 

^-     0.09 

60 

4  to    4V  years. 

19.20 

19.72 

Chest  more  than  head  0.50 

46 

6  to    6.V      " 

19.51 

20.76 

"              "             "     1.25 

40 

9  to  10 

19.56 

21.31 

"              u             u     1.75 

31 

11  to  12        " 

20.00 

23.46 

■    "              "             "     3.46 

DIAGNOSIS.  95 

or  almost  approaching  to  the  character  of  holes  (cranio-tabes).  Both  con- 
ditions have  been  described  by  Parrot  as  occurring  in  rickets ;  but,  as  he 
considers  this  disease  as  a  manifestation  of  syphilis,  we  require  to  remember 
this  in  connection  with  the  detection  of  similar  conditions  in  cong-enital 
syphilis. 

The  enlarged  head  of  hydrocephalus  usually  differs  from  that  of  rickets 
so  clearly  that  mistakes  do  not  often  arise  after  a  careful  examination.  The 
upper  part  of  the  head  is  not  flat,  but  often  arched  or  vaulted.  The  fontanel 
is  not  merely  wide  or  unclosed,  but  often  prominent  and  tense ;  the  sutures 
issuing  from  it  are  frequently  wide,  with  a  protrusion  between  the  edges  of 
the  bone.  The  face  looks  small  in  comparison  with  the  head,  and  there  is 
a  peculiar  downward  look  of  the  eyeballs,  with  an  unduly  large  part  of  the 
white  sclerotic  visible  in  the  upper  segment,  from  the  same  cause.  The 
enlarged  head  sometimes  remains  as  a  permanent  record  of  the  occurrence 
of  hydrocejahalus  in  the  past,  the  illness  having  run  its  course,  the  sutures 
and  fontanels  being  all  firmly  closed.  In  such  cases  the  intellect  may  be 
defective,  presenting  the  form  of  idiocy  called  macrocephalic ;  but  enlarge- 
ment of  the  head  in  this  way  by  no  means  involves  mental  deficiency  as  a 
necessar}'  consequenc-e. 

It  was  hoped  at  one  time  that  auscultation  of  the  head  would  supply  im 
portant  diagnostic  or  differential  data  in  doubtful  forms  of  enlargement ;  but 
this  hope  has  scarcely  been  realized.  No  doubt,  on  listening  over  the  unclosed 
fontanel  of  hydrocephalus  we  may  frequently  hear  a  "svhiffing  sound  syn- 
chronous with  the  pulse ;  but  similar  sounds  may  at  times  be  heard  in  cases 
of  rickets  also,  so  that  probably  the  open  fontanel  has  more  to  do  with  the 
phenomenon  than  any  changes  within  the  skull.  Auscultation  may  be 
practised  either  with  a  stethoscope  held  lightly  over  the  fontanel,  or,  better 
perhaps,  by  direct  application  of  the  ear  to  the  infant's  head,  with  the  inter 
position  of  a  thin  napkin  or  handlvcrchief  if  desired.  During  the  auscul- 
tation very  loud  and  at  first  unintelligible  rushing  sounds  are  heard,  com- 
plicating any  whiff  or  murmur  which  may  be  present :  these  are  due  to 
breath-sounds  resonated  in  the  nasal  passages  and  cavities ;  they  have,  of 
course,  no  significance,  and  may  be  heard  in  healthy  children  also,  but,  as 
we  seldom  auscultate  the  head  except  when  it  is  under  suspicion  of  disease, 
they  are  apt  to  puzzle  the  beginner. 

Percussion  of  the  skull  has  been  practised  of  late  years  in  children,  as 
in  adults,  in  connection  with  eliciting  localized  tenderness  due  to  superficial 
lesions  in  tlie  brain  or  its  membranes.  Various  parts  of  the  skull  are  struck 
with  the  point  of  the  finger ;  by  questioning  the  patient,  or  by  watching  the 
expression  of  his  face,  we  judge  if  any  one  spot  seems  specially  tender. 
We  must,  of  course,  compare  corresponding  parts  on  the  two  sides  of  the 
skull,  and  if  we  detect  a  seemingly  tender  spot  we  come  back  upon  it  once 
or  twice,  to  see  that  the  difference  did  not  arise  from  any  mere  accidental 
variation  in  the  strength  of  stroke  or  the  irritability  of  the  child.  Of 
course,  if  tenderness  is  made  out,  wc  must  sec  that  no  mere  abrasion  or 


96  DIAGNOSIS. 

similar  state  of  the  scalp  is  responsible  for  the  diiference.  When  clearly 
marked,  the  results  of  this  method  may  have  a  certain  value  in  fixing 
the  position  of  a  lesion  indicated  otherwise  by  localized  convulsions  or 
paralysis. 

A  further  application  of  percussion  to  the  skull  consists  in  a  study  of 
the  sounds  thus  educed.  Although  promulgated  more  than  thirty  years 
ago/  this  method  has  not  been  much  practised.  Of  late  a  colleague  of  the 
writer's  (Dr.  William  MacEwen)  has  called  his  attention  to  a  peculiar 
change  in  the  percussion-sound  found  in  the  case  of  children  aiFected  with 
accumulations  of  fluid  of  various  kinds  within  the  skull :  the  change  of 
percussion-sound  is  difficult  of  expression,  but  it  is  in  the  direction  of 
undue  resonance  or  of  a  tympanitic  quality.  Dr.  MacEwen  thinks  that 
the  sound  may  even  vary  on  the  two  sides  of  the  skull  according  to  the 
position  of  the  fluid.  Certainly  a  peculiar  quality  of  the  percussion-sound 
has  been  demonstrated  by  Dr.  MacEwen  in  various  cases,  and  has  been 
verified  by  the  writer  in  certain  children  w4th  cerebral  tumors  and  effusion 
into  the  ventricles  of  the  brain ;  but  as  yet  it  seems  scarcely  possible  to 
formulate  the  conditions  which  give  rise  to  this  change.  In  addition  to  the' 
diiference  between  dull  and  clear  or  iympanitic  sounds^  we  occasionally 
obtain  a  curious  cracked  sound  on  percussion  over  the  parietal  regions, 
suggesting  the  idea  of  the  sutures  shaking  against  each  other,  although  this 
may  be  found  not  only  in  young  infants  with  unclosed  fontanels,  but  also  in 
those  with  firmly-united  sutures.  In  the  further  study  of  this  matter  the 
following  points  are  suggested  as  worthy  of  careful  consideration.  1.  The 
physical  surroundings  of  the  head  of  the  child :  thus,  the  percussion-sound 
may  be  found  very  different  according  as  the  head  is  allowed  to  lie  on  a 
pillow  or  is  supported  on  the  lap  of  the  nurse,  and  equally  according  as  the 
child  lies  or  sits  up.  What  may  seem  a  highly  tympanitic  note  while  the 
head  rests  on  pillows  may  lose  all  this  quality  on  a  change  of  position. 
2.  The  state  of  the  fontanels  and  sutures,  as  to  closure,  must  be  kept  in 
view  as  probably  influencing  the  sounds.  3.  Variations  in  the  state  of  the 
bones  as  regards  thinness  or  thickness  over  the  closed  fontanels  or  around 
them,  and  in  the  region  of  the  squamous  portion  of  the  temporal  bone, 
are  probably  very  potent  in  affecting  the  sound  produced  by  percussion. 
4.  The  position  of  the  head  as  held  erect,  or  to  one  side  or  the  other,  or 
directed  downward,  or  lying  flat  with  the  face  upward  or  downward, 
should  also  be  kept  in  view,  in  connection  with  the  idea  that  the  presence 
of  fluid  and  its  varying  levels  within  the  skull  may  determine  a  change 
of  note. 

Smallness  of  the  head  is  no  less  serious  a  sign  than  enlargement,  and 
when  extreme  it  is  often  associated  with  idiocy  (the  "  microcephalic"  form 
of  some  writers).     Moderate  degrees  of  smallness  must  not  be  judged  of 


^  Betz,  Ueber  Perkussion,  insbesondere  iiber  Perkussion  des  Schiidels,  Schmidt's  JaJw- 
biicher,  Bd.  Ixxxvi.,  1855. 


DIAGNOSIS.  97 

rashly,  for,  if  the  development  and  shape  are  otherwise  good,  this  may 
result  from  family  peculiarities  of  little  import.  With  the  microcephalic 
idiots  we  often  find  obvious  deviations  from  the  ordinary  contour,  sometimes 
giving  a  peculiar  bird-like  aspect  to  the  head. 

Occasionally  unilateral  alterations  in  the  skull  are  detected  as  connected 
with  obvious  or  obscure  disease  in  the  central  nervous  system ;  while  uni- 
lateral atrophy,  or  more  rarely  unilateral  hypertrophy,^  may  lead  to  a  want 
of  symmetry  dating,  it  may  be,  from  birth.  Another  form  of  want  of 
development  of  the  side  of  the  head  and  face  arises  in  connection  with  long- 
standing wry-neck  in  early  life,  and  a  slighter  form  has  been  ascribed  to 
injurious  modes  of  carrying  the  infant,  so  as  to  hinder  free  movements  in 
all  directions. 

The  occurrence  of  the  "  blood-tumor"  called  cephalhsematoma,  appearing 
soon  after  birth  in  the  scalp  of  the  infant,  can  usually  be  easily  distinguished 
from  the  much  more  serious  disorder  due  to  defect  in  the  bones  of  the  skull, 
with  protrusion  of  the  brain  substance  or  membranes,  to  which  the  name 
encephalocele  is  applied.  These  important  subjects  will  be  discussed  in 
other  sections  of  this  work ;  but  it  may  be  worth  while  to  mention  the 
occurrence  of  another  form  of  "  blood-tumor"  or  hgematoma  in  the  peri- 
cranium, which  may  give  rise  to  discoloration  of  the  eyelids  (as  in  cases  of 
hemorrhage  there  from  fracture  of  the  skull) :  the  writer  has  seen  such  an 
accumulation  of  blood  in  this  situation,  so  extensive  and  so  uniformly  dif- 
fused as  to  simulate,  at  the  first  glance,  a  case  of  hydrocephalus.  On  exam- 
ining with  the  hand  for  the  sutures,  however,  the  whole  surface  of  the  scalp 
was  soft  and  fluctuating,  and  the  bones  of  the  skull  could  be  felt  only  on 
dipping  the  fingers  down  suddenly  through  the  fluid. 

EXAMINATION   OF   THE   BACK. 

An  examination  of  the  spine  of  children  reveals  at  times  the  two  well- 
known  forms  of  curvature  with  which  we  are  familiar  in  the  adult.  Acute 
or  angular  curvature,  described  by  Pott,  occurs  indeed  with  special  frequency 
in  early  life,  and  its  appearance  is  so  characteristic  as  to  require  little  notice 
here. 

The  lateral  curvature  is,  of  course,  much  less  common  in  children  than 
in  girls  at  or  a  little  beyond  the  age  of  puberty ;  but  a  typical  lateral  curva- 
ture may  occur  even  in  young  babies,  and  in  such  cases  we  must  see  whether 
there  is  any  error  in  habitually  carrying  the  child  so  as  to  look  in  one 
direction  only.  Very  often  the  lateral  curvatures  in  children  are  merely 
secondary  results  of  serious  antecedent  disorders.  A  pleurisy  followed  by 
retraction  of  the  side,  an  infantile  ]iaralysis,  grave  hi]-»-joint  disease,  frac- 
tures or  dislocations  in  the  leg  or  thigh,  and  indeed  anything  which  shortens 


1  See  on  Atrophy  a  very  good  article  in  Pepper's  "System  of  Practical  Medicine,"  vol. 
v.,  by  Dr.  Charles  K.  Mills.     For  Unilateral  Hypertrophy,  hihliographical  references  will 
be  found  in  a  paper  by  the  writer  in  the  Glasgow  Medical  Journal^  November,  1884. 
Vol.  I.— 7 


98  DIAGXOSLS. 

one  of  the  lower  limbs  as  compared  with  the  other, — all  these  give  rise  to 
lateral  curvatures. 

A  very  common  curvature  found  in  3'oung  children  may  mislead  the 
beginner  by  suggesting  the  presence  of  caries  with  Pott's  curvature,  when 
all  that  exists  is  simple  softness  of  the  bones  and  muscular  weakness,  such 
as  occur  so  frequently  in  rickets.  In  these  cases  the  back  in  the  lower  dorsal 
and  lumbar  regions  is  found  to  bulge  or  cur\^e  backward  when  the  child  is 
made  to  sit ;  there  is  no  true  angular  projection,  and  on  taking  the  weight 
off  the  spine  by  the  recumbent  posture  the  curvature  disappears. 

An  opposite  curvature  of  the  lower  part  of  the  column,  with  a  hollow 
instead  of  a  projection,  gives  the  spine  a  "  saddle-back"  appearance  in  this 
situation ;  there  is  a  projection  backward  of  the  upper  part  of  the  spine 
about  the  scapulae,  and  the  name  "  lordosis"  has  been  applied  to  this  variety. 
The  deformity  is  due  to  paralysis  or  weakness  of  the  muscles  of  the  back, 
and  it  acquires  special  significance  in  the  diseases  of  childhood  from  this 
"  saddle-back"  constituting  one  of  the  most  striking  features  of  the  "  pseudo- 
hypertrophic muscular  paralysis,"  an  affection  v\diich  we  may  say  is  limited 
to  children.  The  same  condition  of  the  back,  however,  may  exist  in  chil- 
dren as  a  more  isolated  affection  and  entirely  independently  of  this  form  of 
paralysis. 

The  peculiar  fixity  of  the  head  and  neck  found  in  occipito-atlantoid 
disease  needs  only  to  be  noticed  in  a  word  :  it  occurs  with  relative  frequency 
in  childhood. 

The  congenital  malformation  termed  spina  bifida  requires  also  to  be 
mentioned  here  :  its  presence  may  account  for  paralysis  and  convulsions  in 
infancy.  The  gravity  of  the  condition  turns  in  part  on  the  level  at  which 
the  tumor  exists  in  the  spine,  and  in  part  on  the  nature  of  the  contents, — 
matters  which  are  fully  discussed  in  special  chapters. 

TEMPEKATUEE— THEEMOMETEY. 

In  all  acute  illnesses,  and  in  very  many  of  the  chronic  ailments,  of 
children,  the  determination  of  the  presence  or  absence  of  pyrexia,  and  an 
estimation  of  the  degree  and  persistence  of  this  pyrexia  if  present,  con- 
stitute points  of  capital  importance  in  the  diagnosis ;  very  often  the 
same  data  guide  the  prognosis  .and  treatment.  Formerly  this  was  deter- 
mined in  part  by  the  hand  applied  to  the  child's  skin,  say  over  the  abdomen, 
and  in  part  by  the  counting  of  the  pulse.  The  number  of  pulse-beats  in  a 
child,  particularly  if  very  young,  is  but  a  poor  guide  in  the  estimation  of 
fever.  The  pulse  is  made  to  run  up  by  so  many  causes  that  it  is  only  when 
we  feel  satisfied  that  v\'e  have  counted  it  in  a  period  of  quiescence,  as  during 
sleep,  that  the  numbers  have  any  great  meaning.  The  hand  applied  to  the 
skin  is  confessedly  a  rough  method,  but  when  the  sense  of  increased  heat  is 
veiy  notable,  one  of  experience  may  get  considerable  assistance  from  it.  It 
is  when  the  skin  feels  to  the  hand  little  if  at  all  hotter  than  normal  that  we 
mav  all  make  grave  mistakes  if  we  trust  to  such  a  method  :  a^rain  and  a^-ain 


DIAGNOSIS.  99 

even  those  of  experience  have  supposed  a  child  to  show  no  increase  of  heat, 
when  it  has  been  found  that  the  temperature  was  3°  or  4°  F.  higher  than 
normal,  or  perhajDS  even  more  than  this. 

The  introduction  of  the  thermometer  into  regular  clinical  work  has  been 
of  signal  service,  but  in  no  department  has  it  been  of  more  practical  value 
than  in  dealing  with  children.  In  using  a  thermometer  it  behooves  us  to 
know  clearly  what  we  are  aiming  at.  It  has  already  been  admitted  that 
the  application  of  the  hand  may  teach  us  much ;  and  if  all  we  desire  is  to 
record,  as  it  were,  in  figures  such  information  as  the  hand  might  give,  then 
almost  any  method  of  using  the  instrument,  however  faulty,  may  serve 
such  a  purpose.  But  in  dealing  with  instruments  of  precision,  such  as  good 
thermometers,  we  are  exposed  to  new  fallacies  if  we  do  not  use  them  properly. 
It  is  all  very  well,  and  perfectly  fair,  to  say  that  the  child  does  not  seem 
hot  as  judged  by  the  hand ;  we  know,  so  far,  the  value  of  such  a  rough 
sta,temeut ;  but  to  say  that  the  thermometer  shows  that  there  is  no  pyrexia 
implies  something  very  different ;  and  if  the  statement  is  founded  on  an 
error,  we  have  through  this  fallacy  not  only  lost  what  guidance  the  true 
temperature  might  have  given,  but  we  are  actually  liable  to  be  put  wrong 
much  further  than  if  no  observations  had  been  made  with  the  instru- 
ment at  all.  While,  therefore,  not  disparaging  the  practical  assistance 
which  rough  and  rapidly-taken  observations  may  yield,  we  must  see  that  we 
understand  their  real  value.  A  child  with  a  measly  or  a  scarlet  rash  may 
be  found  to  have,  on  some  rough  observation,  a  temperature  of  102°  F. ; 
this  may  be  enough  for  the  purposes  of  diagnosis,  showing  that  with  the 
rash  there  is  a  distinct  degree  of  fever ;  and  if  the  child  does  not  seem  very 
ill,  it  may  really  matter  but  little  whether  the  temperature  is  102°  F.  or 
whether,  if  properly  taken,  it  might  come  out  as  103°  F.  or  103^°  F. 
Of  course  a  very  great  elevation  (106°  F.  or  107°  F.)  miglit  mean  some- 
thing very  different;  but  in  such  a  case  the  obvious  state  of  the  child 
would  likewise  be  different. 

It  is  when,  perhaps,  with  a  low  surface-temperature  there  is  a  very  dis- 
tinct increase  of  the  internal  heat  that  errors  from  faulty  observations  become 
positively  misleading.  When,  for  example,  we  may  be  dealing  with  a  case 
of  enteric  fever  towards  the  end  of  the  first  week,  and  the  thermometer, 
badly  applied,  shows  a  maximum  of  only  100°  F.  instead  of  102°  F.,  we 
might  here  almost  infer  that  enteric  fever  was  excluded  by  such  an  obser- 
vation, if  we  trusted  to  the  "  instrument  of  precision."  Or  the  hectic  fever 
of  obscure  phthisis  may  be  present,  but  missed  by  faulty  use  of  the  instru- 
ment ;  and  so  we  might  be  led,  if  trusting  to  the  record,  to  set  aside  the 
diagnosis  of  phthisis  as  unlikely,  owing  to  the  supposed  absence  of  the  fever 
which  we  had  really  failed  to  discover.  Such  mistakes  are  constantly  being 
made,  and  the  educational  effect  on  those  who  make  them  is  towards  care- 
lessness, inaccuracy,  and  confusion. 

When  the  writer  had  to  take  charge  on  one  occasion  of  patients  in  a 
children's  hospital  newly  opened,  he  was  confronted  by  the  striking  fact 


100  DIAGNOSIS. 

that  nearly  every  child  in  the  ward  had  subnormal  temperatures,  some  of 
them  to  a  considerable  extent.  It  was  evident  at  once  to  him  that  the  fault 
lay  not  in  the  children's  temperatures,  but  in  the  taking  of  the  observations. 
He  explained  to  the  head-nurse  in  charge  that  the  temperatures  were  sub- 
normal because  they  were  badly  taken,  that  probably  not  one  of  the  children 
had  subnormal  temperatures,  and  that  very  likely  several  of  them  were 
more  or  less  feverish.  The  astonishment  of  the  nurse  was  mingled  with 
indignation,  for  she  had  just  taken  her  nurse's  certificate  with  distinction, 
and,  to  do  her  justice,  probably  could  take  temperatures  as  well  as  most 
practitioners  of  medicine.  First  by  taking  the  temperature  in  the  rectum 
it  was  shown  to  her  that  the  heat  of  the  child  was  not  subnormal  there,  and 
then  by  great  care  in  the  taking  of  the  axillary  temperature  it  was  shown 
that  there  also  the  mercury  rose  to  the  normal.  How,  then,  had  the  mistake 
arisen  ?  By  trusting  to  the  rules  given  for  inserting  the  thermometer  into 
the  axilla  and  leaving  it  for  a  stated  time,  regardless  of  the  progress  of  the 
mercury  upward,  and  reading  it  off  then. 

A  child's  axilla  is  often  a  very  small  affair,  and  especially  when  much 
wasted  there  is  scant  covering  even  for  so  small  a  thing  as  the  bulb  of  a 
thermometer ;  the  instrument  readily  slips  out  behind,  or  falls  down,  or  the 
arm  ceases  to  be  applied ;  the  regulation  number  of  minutes  allowed  finds 
the  mercury  indicating  the  temperature  of  the  night-dress  or  the  adjacent 
air,  but  in  no  sense  the  temperature  of  the  closed  axilla.  To  obtain  this, 
we  must  see  that  the  axilla  is  closed ;  and  in  young  children  this  usually 
means  that  the  observers  must  hold  the  arm  to  the  side  themselves.  But 
the  temperature  of  the  axilla,  as  open,  is  often  very  different  from  its  tem- 
perature after  it  is  closed ;  this,  indeed,  is  a  gradually  increasing  quantity, 
as, the  surfaces  of  the  skin  applied  to  each  other  recover  from  the  cooling 
influences  of  the  previously  interposed  air  when  separated.  All  these  points 
are  easily  learned  by  a  few  observations  with  thermometers  long  enough  to 
project,  so  as  to  be  easily  read  from  minute  to  minute,  and  without  any 
maximum-registering  index.  With  such  an  instrument,  we  often  see  that 
with  the  lapse  of  minutes  the  mercury  falls  instead  of  going  on  steadily 
rising ;  we  learn  at  once,  under  such  circumstances,  that  it  must  have  slipped 
out  in  some  way ;  if  properly  applied,  we  can  read  its  gradual  ascent,  from 
minute  to  minute,  till  it  attains  a  stationary  point ;  only  when  this  stationary 
level  is  maintained  for  four  or  five  minutes  do  we  feel  sure  that  the  maximum 
is  reached.  By  selecting  different  cases  we  may  see  the  greatest  diversity 
in  the  rapidity  of  the  rise  of  the  mercury ;  and  it  is  this  that  has  confused 
many.  At  times  the  maximum  is  reached  in  one  minute  or  so,  and  by  wait- 
ing four  minutes  longer  we  have  the  security  of  this  being  the  maximum, 
and  so  it  may  be  rashly  said  that  the  temperature  can  be  taken  with  absolute 
certainty  in  five  minutes ;  and  so  it  can,  under  such  circumstances.  Very 
likely  in  an  intense  scarlet  fever;  with  deep  injection  of  the  skin,  we  get  a 
rapidly-attained  maximum  in  the  axilla,  particularly  if  the  arm  happens  to 
have  been  close  to  the  side,  as  by  the  child's  lying  on  it ;  but  if  the  arm 


DIAGNOSIS.  101 

has  been  separated  from  the  side,  or  tossed  about  so  as  to  take  up  colder  air 
frequently  into  it, — if  the  child  is  wasted  to  "  skin  and  bone/' — if  with  the 
feverishness  there  is  a  certain  tendency  to  collapse, — then  we  have  to  wait 
till  the  influence  of  the  cooling  air  on  the  skin  is  neutralized  by  the  increased 
cutaneous  circulation,  favored  by  the  apposition  of  the  arm  to  the  side ;  in 
this  way  a  long  time  may  be  required  for  the  observation,  not  from  any 
want  of  sensitiveness  in  the  instrument,  but  because  the  tissues  of  the  arm- 
pit have  been  cooled  and  we  must  wait  till  the  axilla  itself  is  warmed  up  to 
its  maximum  heat,  for  it  is  only  then  that  it  is  in  any  sense  an  index  of  the 
heat  of  the  blood,  which  such  observations  really  aim  at  estimating.  Ex- 
perience teaches  us  that  when  the  thermometer  in  the  axilla  remains  stationary 
for  five  minutes  the  maximum  for  that  particular  time  of  the  day  is  attained 
with  practical  certainty.  Under  the  adverse  conditions  referred  to  above, 
we  often  have  to  wait  ten,  fifteen,  or  twenty  minutes  before  the  stationary 
point  is  maintained  for  the  requisite  period  of  five  minutes ;  hence  fifteen  to 
twenty-five  minutes  may  be  required  in  such  a  case,  instead  of  five  minutes 
as  in  the  other.  All  this  would  have  been  readily  learned  by  any  of  those 
really  interested  in  the  taking  of  temperatures,  if  the  introduction  of  short 
thermometers  had  not  made  readings  in  sita\ery  difficult,  and  if  maximum- 
registering  indexes  had  not  misled  the  observers  very  often ;  for  of  course 
the  index  remains  say  at  99°  F.  for  many  minutes,  or  indefinitely,  even 
although  the  mercury  has  really  fallen  to  95°  F.  owing  to  the  bulb  having 
slipped  out  behind  into  the  child's  night-dress ;  whereas  if  no  index  existed, 
this  fall  in  the  thermometer  from  such  an  accident  would  immediately  have 
arrested  attention  whenever  the  reading  was  next  made,  and  so  have  led 
to  a  correction  of  the  faulty  position  of  the  instrument. 

On  account  of  the  great  delay  often  inevitable  in  cases  of  wasted  chil- 
dren, and  of  the  uncertainty  as  to  the  results  unless  the  observation  is 
supervised  with  the  utmost  closeness,  axillary  observations,  especially  in 
infancy,  have  been  almost  discarded  by  some,  particularly  as  many  young 
children  resist  and  resent  the  introduction  of  a  thermometer  into  their 
axillae,  so  as  to  make  its  retention  there  for  ten  or  fifteen  minutes  almost 
impossible.  Temperature-observations  taken  in  the  rectum  can  be  made 
rapidly  and  with  great  precision  in  three  or  four  minutes  (for,  the  cavity 
being  always  dosed,  there  is  no  time  required  to  counteract  the  cooling  in- 
fluence of  the  air,  as  in  the  mouth  or  the  axilla);  young  children  often  object 
less  to  the  introduction  of  the  thermometer  there,  where  it  is  unseen,  than 
to  its  being  placed  in  the  axilla ;  and  even  if  there  is  a  little  resistance,  the 
period  is  so  much  shorter  that  with  care  this  can  usually  be  overcome. 
The  child  is  placed  on  the  left  side  in  bed,  or  on  the  nurse's  knee,  the  but- 
tocks can  be  loosely  covered  with  a  blanket  or  shawl,  and  the  thermometer 
allowed  to  project,  after  the  bulb,  properly  oiled,  has  been  introduced  into 
the  bowel,  for  a  couple  of  inches:  the  observer  should  hold  the  thermometer 
and  place  the  hand  on  the  pelvis,  to  guard  against  sudden  movements  dis- 
placing the  instrument.     The  mercury  rises  rapidly,  and  when  statiouaiy 


102  DIAGNOSIS. 

for  one  minute,  in  this  situation,  we  know  that  the  maximum  has  been 
reached ;  this  always  occurs  within  three  or  four  minutes.^  But  few  falla- 
cies beset  this  method,  the  introduction  of  the  bulb  within  a  mass  of  hard 
faeces  being  one  of  the  chief,  although  even  then  the  error  is  probably 
trifling.  Of  course  if  the  bulb  were  very  large  a  certain  time  would  be  re- 
quired to  allow  the  blood  to  warm  up  the  mucous  membrane  after  parting 
with  its  heat  to  the  mercury ;  but  the  bulbs  of  clinical  thermometers  are 
usually  so  small  as  to  reduce  this  loss  of  heat  to  insignificance,  in  view  of 
the  mucous  surface  being  richly  supplied  with  rapidly-circulating  blood. 

Another  source  of  serious  mistake,  in  connection  with  temperature- 
observations,  arises  from  judging  as  to  the  pyrexia  from  one  observation, 
and  particularly  in  concluding  as  to  its  absence  in  the  case  from  isolated 
records.  It  constantly  happens  that  a  child's  temperature  is  practically 
normal  during  the  early  part  of  the  day,  although  by  night  it  may  be  highly 
feverish.  We  must,  therefore,  consider  whether  the  time  of  day  has  been 
favorable  for  catching  the  evidence  of  pyrexia.  But  even  when  fever  is 
present  we  must  constantly  remember  that  in  the  feverish  child,  to  a  much 
more  marked  extent  than  in  the  healthy,"^  there  is  a  daily  curve  of  tempera- 
ture, and  that,  to  be  even  roughly  comparable,  the  hours  of  observation 
from  day  to  day  must  be  approximately  similar.  In  serious  cases,  or  in 
connection  with  therapeutic  measures,  we  may  wish  to  know  how  far  the 
high  temperature  is  continuous,  or  to  what  extent  remissions  occur  from 
hour  to  hour.  The  only  way  to  secure  a  fair  idea  of  the  character  and 
severity  of  the  pyrexia  is  by  reducing  frequent  observations  (say  every 
two  hours)  to  the  form  of  a  curve ;  othenvise  we  are  constantly  liable  to  be 
misled  by  having  our  observations  complicated  by  accidental  elevations  or 
depressions  of  the  temperature,  which  may  really  be  pursuing  a  practically 
unaltered  course. 

It  is  amusing  in  one  sense,  in  another  somewhat  painful,  to  hear  at 
times  certain  practitioners  sjDeaking  complacently  of  their  remedies— per- 
haps a  little  digitalis  or  aconite,  or  a  grain  or  two  of  quinine — "  bringing 
down  the  temperature"  to  the  extent  of  a  degree  Fahr.  or  perhaps  something- 
less,  when  we  know  that  no  special  care  has  been  taken  to  have  the  tempera- 
ture accurately  taken  at  either  observation,  and  that  the  difference  they  pride 
themselves  on  is  probably  the  balance  of  errors, — that  even  if  the  obser- 

^  This  method  was  advocated  strongly  by  Ziemssen  ;  see  his  "  Pleuritis  und  Pneinnonia 
im  Kindesalter,"  Berlin,  1862.  It  is  referred  to  by  the  writer  in  his  paper  on  iSTormal  Tem- 
perature in  Children,  Glasgow  Medical  Journal,  February,  1869,  and  more  specially  in  his 
paper  on  the  Temperature  of  Children  in  Phthisis,  Glasgow  Medical  Journal,  November, 
1869. 

2  The  writer's  opinion  is  that  the  temperature  in  healthy  children  cannot  be  correctly 
spoken  of  as  either  higher  or  lower  than  in  adults ;  it  is  in  a  sense  both ;  the  daily  range  is 
greater,  amounting  to  about  2°  P.  or  even  3°  P.  The  minimum  in  health  is  attained  shortly 
after  midnight,  and  the  maximum  in  the  afternoon ;  the  temperature  falls  rapidly  in  the 
evening,  about  the  time  the  child  goes  to  sleep.  It  may  range  from  97°  F.  to  100°  F.  in  the 
rectum  in  healthy  children. 


DIAGNOSIS.  103 

vations  were  both  quite  accurate,  the  time  of  day  very  likely  accounts  for 
the  diminution,  for  these  remedies  are  often  given  at  night,  when  the  fever 
is  high,  and  the  improvement  is  found  in  the  morning,  when  the  pyrexia 
naturally  falls, — and  that,  even  if  an  attempt  has  been  made  to  compare 
similar  periods  of  the  day,  these  isolated  observations  may  give  a  misleading 
conception  of  the  course  of  the  pyrexia  in  the  intervals.  Even  more  extraor- 
dinary is  it  to  see  the  influence  of  iced  applications  to  the  bare  chest  and 
abdomen,  in  reducing  the  internal  temperature  in  fever  during  their  use, 
gravely  proved  by  reading  a  thermometer  put  into  the  axilla,  under  such 
circumstances,  five  minutes  after  its  introduction  !  The  writer  had  this  in- 
fluence demonstrated  to  him  at  a  well-known  hospital,  where  those  in  charge 
seemed  highly  pleased  with  their  scientific  methods  ! 

Of  course  the  physician  must  judge  which  cases  are  those  calling  for 
frequent  and  scrupulously  accurate  observations  on  the  temperature,  and  he 
must  judge  how  far  children  should  be  disturbed  in  this  way.  The  prac- 
tice of  medicine  is  an  art,  not  a  science,  and  we  must  often  be  content  with 
approximate  and  roughly  accurate  methods ;  but  let  us  understand  clearly 
when  we  are  scientifically  accurate  and  when  roughly  practical :  we  are 
bound  to  be  more  rigidly  exact  in  our  proofs  when  we  are  vaunting  the  suc- 
cess of  some  troublesome,  disagreeable,  or  dangerous  method  of  treatment. 

The  various  degrees  of  temperature  may  be  regarded,  so  far,  as  having 
the  same  significance  as  in  adults ;  but  in  the  child  the  temperature  is  more 
mobile,  and  trivial  disturbances  of  the  digestive  system  may  make  the  ther- 
mometer run  up  veiy  quickly  to  a  great  height.  In  the  interpretation  of 
the  records  we  require  to  be  guided  by  the  results  of  actual  experience  in 
clinical  thermometry,  and  we  must  not  conclude  as  to  their  significance  from 
a  priori  reasoning.  The  following  table,  given  by  the  writer  in  his  "  Clinical 
Manual,"  may  be  found  useful  as  a  guide  : 

-D  1  r  35°    Cent.  =   95°     Falir. )   ,^       ,  n  .  ^ 

JtJelow    <  >  V  ery  low  or  collapse  temperatures. 

1 36°    Cent.  =   96.8°  Fahr.  i  ^  ^  ^ 

About       36^°  Cent.  =   97.7°  Falir.      Subnormal  temperatures. 

Normal,    37°    Cent.  =   98.6°  Fahr.      Normal  temperatures. 

r37i°Cent.  =   99.5°  Fahr.-.   q,.  ,,i      ,  ,  v  ^  i,  -i 

^  I   bhghtly  above  normal,  or  sub-febrile 

About    \  38°    Cent.  =:  100.4°  Fahr.  \      ^  , 

I       temperatures. 
1 38  i°  Cent.  =  101.3°  Fahr.  J  ^ 

. ,      ,     f  39°    Cent.  =  102.2°  Fahr.  1   ,r   i      *  i     ^  i    -i    ^ 
About    <  }  Moderately  febrile  temperatures. 

I  39.]°  Cent.  =  103.1°  Fahr.  J  '  ^ 

A-u     ,     r40°    Cent.  =  104°     Fahr.  1   tt-  ,  i     ^  i    ■,    ^ 
About    <  V  Hiirhlv  febrile  temperatures. 

1 40i°  Cent.  =  104.9°  Fahr.  /       ^    -  ^ 

Above       41°    Cent.  =  105.8°  Fahr.      Hyperpyretic  temperatures. 

Very  high  temperatures  (106°  F.  or  more)  and  veiy  low  temperatures 
(under  9(5°  F.)  are  necessarily  frauglit  witli  danger;  but  a  sudden  rise  of 
temperature  (to  104°  or  105°  F.)  may  sometimes  give  ground  for  hoping 
that  we  are  dealing  with  a  trifling  febricula ;  on  the  other  hand,  a  moderate 
temperature  (102°  to  103°  F.)  with  cerebral  symptoms  may,  just  because 
of  its  moderation,  give  rise  to  the  most  grave  apprehensions  of  a  deadly 


104  DIAGNOSIS. 

meningitis,  whereas  with  a  higher  temperature  (say  105°  or  105|^°  F.)  we 

might  hope  that  the  cerebral    symptoms  were  dependent  on  an  incipient 

pneumonia  or  some  less  fatal  disorder.     The  figures  must  be  interpreted  not 

only  in  view  of  the  other  symptoms,  but  also  in  view  of  the  known  facts  of 

medical  thermometry. 

PULSE. 

The  pulse  in  childhood  has  ceased  to  be  regarded  as  any  great  criterion 
of  the  degree  of  fever,  having  been  superseded  to  a  great  extent  by  the  use 
of  the  thermometer ;  but  its  value  in  many  other  ways  is  still  very  great. 
The  strength  of  the  pulse  in  childhood  affords,  as  in  the  adult,  one  of  our 
best  guides  in  estimating  the  general  strength  of  the  patient,  although  at 
both  ages  we  are  liable  to  many  mistakes  and  surprises  in  relying  unduly 
on  this  sign.  The  correlation  of  the  pulse  and  temperature  is  often  very 
suggestive.  At  the  beginning  of  enteric  fever  we  may  have  a  pretty  high 
degree  of  pyrexia  (say  102°  or  103°  P.)  with  almost  no  elevation  of  the 
pulse-rate,  a  combination  always  suggestive,  when  ascertained ;  very  often, 
however,  the  low  pulse  and  the  apparently  cool  state  of  the  skin  may  lead 
the  physician  to  omit  taking  the  temperature  at  all.  Towards  the  end  of 
such  a  fever  the  pulse  may  be  higher  in  proportion  than  the  temperature, 
and  it  may  continue,  probably  through  weakness,  to  be  very  high  even  after 
the  defervescence  is  complete, 

A  slowness  in  the  pulse  has  often  great  significance  in  the  diagnosis  of 
cerebral  aifections,  and  especially  of  meningitis.  At  the  beginning  of  the 
illness,  with  distinct  elevation  of  the  temperature,  we  may  find  the  pulse 
rapid,  but  with  the  advance  of  the  disease  the  temperature  may  fall  to  some 
extent,  and  with  more  or  less  drowsiness  the  pulse  usually  falls,  and  may 
even  become  extremely  slow  (say  about  sixty  beats  per  minute) :  this  is 
always  of  evil  omen  and  aids  the  diagnosis  of  this  disastrous  disease.  With 
the  advance  of  the  disease,  after  the  temperature  has  become  almost  normal, 
we  may  find  the  pulse  running  up  to  an  almost  uncountable  height  a  day 
or  two  before  death. 

Closely  allied  to  slowness  is  irregularity  and  intermission  in  the  pulse. 
This  also,  occurring  with  headache,  sickness,  moderate  fever,  or  other  signs 
of  meningitis,  is  always  of  grave  import.  The  irregularity  is  of  two  kinds, 
and  both  are  found  in  meningitis.  We  may  have  the  pulse  pretty  regular 
as  to  rate,  but  with  a  succession  of  a  few  beats  now  and  then  having  dis- 
tinctly less  strength ;  or  we  may  have  the  irregularity  in  the  rate  of  a  few 
beats,  quite  irrespective  of  any  influence  of  the  respiration-movements, 
which  we  must  remember  have  some  effect  on  the  pulse-rate  even  in  health. 
Or  again,  with  or  perhaps  without  much  irregularity,  we  may  have  inter- 
mission in  the  pulse,  a  beat  being  lost  every  five  or  ten  or  twenty  beats. 
This  also  occurs  in  brain-disease  of  various  kinds. 

Irregularity  and  intermission  of  the  pulse  occur  in  other  than  bj'ain-dis- 
orders,  notably  in  cases  of  pericarditis  in  its  early  stage,  and  also  in  acute 
endocarditis :  probably  on  this  account  we  have  irregularity  in  the  pulse, 


DIAGNOSIS.  105 

not  uncommonly,  in  chorea.  Of  course  it  is  often  present,  as  in  the  adult, 
in  valvular  disease  of  the  heart.  In  the  extreme  stage  of  feverish  illness, 
flickering  or  irregular  or  intermittent  pulse  indicates  the  grave  condition  of 
the  patient,  but  in  such  cases  the  diagnosis  is  already  made,  as  a  rule. 

Much  unnecessary  alarm  has  sometimes  been  caused  by  detecting  an 
intermission  in  the  pulse-beats  in  the  case  of  children  not  obviously  ill,  to 
any  serious  extent  at  least,  particularly  during  sleep,  or  it  may  be  in  the 
evening  before  going  to  bed.  With  medical  parents  this  discovery  is  apt  to 
excite  alarming  ideas  of  incipient  meningitis ;  but  it  is  to  be  construed  only 
as  an  indication  of  a  certain  amount  of  weakness,  perhaps  of  a  merely 
temporary  character.  It  is  similar  in  kind  to  the  intermission  in  the  pulse 
often  found  in  children  after  their  recovery  from  enteric  fever,  during  their 
sleep  at  nights :  if  the  general  indications  are  favorable,  no  stress  should  be 
placed  on  these  intermissions. 

The  "  pulsus  bigeminus,"  the  "  pulse  of  high  tension"  in  renal  disease, 
the  "  aortic  regurgitant  pulse,"  the  "  dicrotic  pulse,"  and  other  peculiarities 
best  brought  out  by  the  sphygmograph,  all  occur  in  childhood ;  but  their 
significance  is  similar  to  that  in  the  adult,  and  need  not  detain  us  here. 

PHYSIOGNOMY. 

The  idea  of  defining  special  temperaments  and  diatheses  from  the 
general  aspect  of  the  patient  is  now  abandoned  by  most :  at  present  it  is 
felt  that  the  necessary  precision  is  unattainable  for  any  useful  classification 
of  temperaments.^  And  yet,  every  one  of  exjjerience  can  recognize  certain 
peculiarities  at  a  glance,  bearing  vitally  on  the  diagnosis ;  not  always  so 
much  of  a  build  and  complexion  indicative  in  themselves  of  danger,  as 
of  evidences  of  past  or  present  disorders  \^^hich  from  their  constitutional 
character  may  throw  light  on  the  future.  Such  are  the  evidences  of  glan- 
dular enlargements  in  the  neck  or  old  scars  there  or  elsewhere  from  scrofu- 
lous disease ;  the  evidences  of  old  ulcerations  of  the  cornea ;  the  sunken  nose 
and  notched  teeth  of  syphilis  or  the  mucous  patches  or  eruptions  at  the 
child's  lips  or  anus  dependent  on  the  same  disease.  At  times,  also,  the 
peculiar  complexion,  with  much  ruddy  color,  may  suggest  the  inheritance 
of  a  scrofulous  tendency,  although  this  may  appear,  at  the  time  of  the 
observation,  in  any  overt  manner  at  least,  only  in  other  members  of  the 
family.  The  delicate  build,  with  fine  eager  features  and  look  of  premature 
beauty,  may  suggest  fears  of  tubercular  tendencies  in  one ;  while  coarse 
features  with  thick  lips  and  reddish  hair  may  give  rise  to  forebodings  of  a 
similar  kind  in  another.  These  very  diiferent  types  of  two  classes  fre- 
quently affected  with  pulmonary  consumption  have  been  made  the  subject 
of  experimental  researches  by  means  of  composite  photography;^  and  it  is 
possible  that  the   growing   application   of   photography   in  the  study  of 

1  .Jonathan  Hutchinson,  The  Peclic;rcc  of  Disease,  London,  1884. 
''■  Mahomed  and  Galton,  Guy's  Hospital  Reports  for  1881. 


106  DIAGNOSIS. 

children's  diseases  may  lead  in  the  future  to  some  more  clear  apprehension 
of  the  rather  indefinable,  but  still  very  important,  impressions  gathered 
from  the  aspect  of  a  child  by  one  of  experience. 

Coming  to  pallor  of  the  complexion,  we  are  in  presence  of  something 
more  definite.  Its  significance  as  a  sign  of  anaemia  is  recognized,  as  in  the 
adult,  by  a  comparison  of  the  color  of  the  mucous  membranes,  or,  if  need 
be,  by  actual  testing  of  the  blood-color,  and  by  ascertaining  if  the  general 
symptoms  of  anaemia,  such  as  breathlessness,  giddiness,  etc.,  are  present,  or 
by  a  physical  examination  of  the  veins  and  heart  for  anaemic  murmurs. 

Occasionally,  although  very  rarely  in  childhood,  we  have  the  combina- 
tion of  anaemia  with  the  bronzing  of  Addison's  disease.  The  presence  of 
freckles  in  abundance  on  the  face,  and  of  pigmentation  about  the  cheek- 
bones and  brow,  is  sometimes,  apparently,  connected  with  the  existence  of 
pulmonary  consumption.^ 

The  presence  of  jaundice  in  children  is  recognized  as  in  the  adult,  and 
special  sections  of  this  work  deal  with  several  peculiar  forms  found  in  early 
life  and  with  the  spurious  jaundice  of  new-born  children. 

But,  apart  from  obvious  jaundice,  we  sometimes  see  a  dark  complexion, 
somewhat  allied  to  it,  leading  one  to  feel  that  those  with  this  "  bilious 
temperament,"  as  it  is  often  called,  are  specially  liable  to  digestive  dis- 
orders, with  a  tendency  to  great  feverishness  and  headache  in  such  attacks ; 
while  with  a  blond  or  florid  complexion  we  often  see  that  children  are 
specially  liable  to  great  cerebral  excitement  and  delirium  from  ver}^  trivial 
ailments. 

The  appearance  of  flushing  in  feverish  illnesses  of  all  kinds ;  the  flushed 
cheek  or  cheeks  in  the  early  stages  of  cerebral  inflammations ;  the  combi- 
nation of  flushing  and  duskiness  in  many  pulmonary  inflammations ;  the 
more  pure  duskiness  of  suffocative  bronchitis,  advancing  through  various 
degrees  to  alarming  lividity  ;  the  combination  of  duskiness  and  pallor  in 
the  face  with  coldness  of  the  surface ;  the  successive  redness,  blueness,  and 
blackness  perceptible  in  bad  paroxysms  of  whooping-cough ;  the  extraordi- 
nary blueness,  aggravated  by  crying,  seen  in  the  "  morbus  caeruleus"  of  chil- 
dren aflected  with  congenital  malformations  of  the  heart, — all  these  are 
jDhysiognomic  features  of  the  utmost  value. 

Sweating  is  a  common  feature  in  certain  stages  of  febrile  diseases, 
whether  in  children  or  adults,  and  the  cold  sweats  of  exhaustion  also  occur 
in  childhood.  But  in  rickety  children  very  profuse  sweating  of  the  head 
and  neck,  especially  when  the  child  goes  to  sleep,  may  occur  in  the  most 
extreme  form  without  any  fever  whatever. 

Distention  of  the  veins  of  the  face  and  neck  may  occur  to  a  notable 
extent  in  all  forms  of  dyspnoea,  and  in  cases  of  croup  the  outstanding  veins 
in  the  neck  often  form  serious  impediments  in  the  performance  of  trache- 
otomy.    In  some  chronic  affections,  and  in  weakly  children,  the  veins  are 

1  Jeanin,  Des  Pigmentations  cutanees  dans  la  Phthisie  pulmonairc,  Paris,  1869. 


DIAGXOSIS.  107 

often  unduly  visible,  and  the  blueness  of  prominent  nasal  veins,  and  of 
prominent  jugulars,  is  often  very  noticeable  in  rickety  children. 

The  appearance  of  the  child  lying  asleep  with  eyes  half  open  has  since 
the  time  of  Hippocrates  been  regarded  as  of  bad  omen  and  indicative  of 
grave  brain-disease.  Taken  roughly,  there  is  of  course  much  truth  in  this 
widely  current  idea ;  but  it  is  a  mistake  to  attach  great  Aveight  to  this  state 
of  the  eyes,  especially  if  only  an  occasional  condition,  as  it  undoubtedly 
occurs  not  infrequently  apart  from  narcotics,  without  any  implication  of 
the  brain,  and  indeed  without  any  great  danger  of  any  kind. 

As  to  special  appearances  of  the  face  indicating  suifering  from  disease  in 
the  head,  or  in  the  abdomen  or  the  chest,  the  writer  cannot  give  directions ; 
for  personally  he  has  failed  to  recognize  any  really  distinctive  appearances. 
No  doubt  knitting  of  the  eyebrows  is  common  in  headaches,  and  so  in  the 
painful  paroxysms  of  brain-affections ;  and  a  certain  j)inched  aspect  of  the 
face,  bordering  on  or  passing  into  a  collapsed  appearance,  is  common  in  bad 
abdominal  cases ;  but  distinctive  features  are  often  absent.^ 

The  characteristic  appearances  of  the  various  febrile  rashes  and  eruptions 
and  of  the  numerous  cutaneous  affections  of  childhood  demand  such  careful 
and  detailed  study  that  it  is  better  to  leave  them  to  be  dealt  with  in  their 
special  sections. 

THE   CRY. 

The  cry  of  the  child  has  been  regarded  as  capable  of  affording,  along 
with  the  expression  of  the  face,  distinctive  indications  of  the  site  of  the 
disease,  whether  in  head,  chest,  or  abdomen.  Xo  doubt,  however,  this  has 
been  exa2;2:erated. 

It  has  been  pointed  out  by  certain  writers  that  the  cry  consists  of  two 
portions,  the  expiratory  and  the  inspiratory,  and  that  under  certain  con- 
ditions either  one  or  the  other  of  these  portions  may  be  modified.  When 
there  is  not  merely  an  expiratory  cry  or  moan,  but  a  loud  or  inspiratory 
portion  ("  reprise^')  as  well,  we  may  regard  the  presence  of  pulmonary  mis- 
chief as  unlikely ;  but  the  writer  has  seen  a  child  crying  so  vigorously  as  to 
make  it  appear  almost  unnecessary  to  strip  the  clothes  off  for  an  examina- 
tion of  the  chest,  and  yet  on  doing  so,  after  much  hesitation,  pulmonary 
consolidation  has  been  found.     The  cry  must,  therefore,  be  interpreted  with 

1  "  Jadelot's  lines"  are  thus  given  by  Dr.  Eustace  Smith  in  his  "  Practical  Treatise  on 
Diseases  in  Children,"  London,  1884,  p.  7: 

"  The  ocul/j-zyrjomatic  line  begins  at  the  inner  cantlius  of  the  eye,  passes  thence  down- 
wards and  outwards  beneath  the  lower  lid,  and  is  lost  on  the  cheeiv  a  little  below  the  pro- 
jection of  the  malar  bone.  This  line  points  to  disease  or  derangement  of  the  brain  and 
nervous  system. 

"  The  nasal  line  rises  at  the  upper  part  of  the  ala  of  the  nose  and  passes  downwards, 
curling  round  the  corner  of  the  mouth.  This  line  is  a  constant  feature  of  abdominal  mis- 
cliief,  and  is  never  absent  in  cases  of  gastro-intestinal  derangement. 

"  Tlic  Labial  line  begins  at  the  angle  of  the  mouth  and  runs  outwards,  to  be  lost  in  the 
lower  part  of  the  face.  This  is  more  shallow  than  the  preceding.  It  is  a  fairly  trustworthy 
sign  of  disease  in  the  lungs  and  air-passages." 


108  DIAGNOSIS. 

caution.  Crying  only,  or  chiefly,  immediately  after  coughing  suggests  the 
idea  of  pain  being  set  up  thereby,  as  in  pneumonia,  pleurisy,  and  some  forms 
of  bronchitis.  A  moaning  cry  is,  of  course,  a  clearer  indication  of  local 
suffering  or  general  distress  than  the  lusty  cry  of  mere  irritability,  sleepi- 
ness, or  bad  temper.  Crying  with  wriggling  movements  of  the  pelvis  and 
legs  has  been  regarded  as  a  sign  of  colicky  or  intestinal  pain.  Loud  crpng, 
with  somewhat  similar  movements  of  the  legs,  seems  at  times  to  be  due  to 
pain  in  the  kidneys  or  bladder  from  gravel.  The  loud  piercing  shriek,  as 
if  from  some  sudden  dart  of  pain,  has  been  so  frequently  noticed  in  cases  of 
cerebral  disease  as  to  have  received  the  name  of  the  "  hydrencephalic  cry  :" 
its  absence  counts  for  nothing,  and  its  presence  in  actual  cases  of  this  disease 
is  not  always  so  typical  as  to  count  for  much. 

Continuous  crying  or  screaming  is  so  often  found,  by  the  sequel,  to  be 
due  to  earache,  that  this  should  always  be  thought  of  in  obscure  cases ;  and 
the  result  of  an  examination  of  the  ears,  or  decided  relief  from  the  use  of 
hot  or  narcotic  applications,  may  clear  np  the  diagnosis ;  or  perhaps  the 
alarming  symptoms  simulating  meningitis  may  disappear  after  the  discharge 
of  matter  from  the  ears. 

In  croupy  affections  the  cry  may'  be  hoarse. 

Mothers  and  nurses  from  their  experience  of  healthy  infants  naturally 
think  of  crying  as  a  sign  of  hunger ;  but  in  the  presence  of  serious  illness 
hunger  is  less  likely  to  cause  crying  than  thirst,  especially  in  feverish  cases, 
or  where  copious  discharges  from  the  bowel  have  drained  away  much  fluid 
from  the  system. 

The  absence  of  crying  is  often  of  graver  import  than  its  presence.  The 
sick  child,  ill  and  exhausted  beyond  endurance,  may  only  wrinkle  up  the 
lips,  as  if  to  cry,  without  any  sound ;  or  in  bad  pulmonary  cases,  or  even  in 
rickets,  the  child  may  not  be  able  to  spare  the  breath  required  for  the  cry ; 
or  in  the  sopor  and  coma  of  brain-disease  the  child  is  only  too  quiet. 

The  absence  of  tears,  after  the  age  of  three  or  four  months,  during  the 
crying  of  the  child,  is  construed  as  a  bad  sign.  Something  of  the  same  kind 
is  often  seen  in  adults  :  "  the  dying  weep  not." 

DEOPSY. 

Dropsical  swellings  are  not  very  different  in  children  from  what  they 
are  in  adults.  General  anasarca  of  renal  origin  is  relatively  common  at  this 
age,  partly  on  account  of  the  frequency  of  scarlatinal  dropsy,  and  partly  be- 
cause parenchymatous  nephritis  specially  affects  young  subjects.  Whenever 
a  child  appears  with  suddenly-developed  anasarca  we  are  bound  to  think  of 
scarlet  fever ;  we  look  for  signs  of  desquamation  on  the  fingers  and  else- 
where, and  we  inquire  for  a  history  of  sore  throat,  red  rash,  etc.  Any 
mistake  in  missing  the  diagnosis  of  scarlet  fever  in  such  cases  may  be  dis- 
astrous as  regards  other  children.  Once  in  a  while  there  is  a  case  of  genuine 
renal  or  scarlatinal  dropsy  without  a  trace  of  albumen  in  the  urine. 

In  scarlatinal  dropsy,  and  indeed  in  other  forms  of  acute  or  subacute 


DIAGNOSIS.  109 

nephritis  in  children,  even  it  may  be  without  dropsy,  we  must  always  be  on 
our  guard  lest  the  supervention  of  acute  pleuritic  or  pericardial  effusion,  or 
the  occurrence  of  uremic  convulsions,  should  come  on  under  circumstances 
which  might  aggravate  the  condition  or  give  rise  to  painful  reflections  of 
these  being  caused  by  indiscretions. 

The  dropsy  of  heart-disease  docs  not  differ  in  the  young,  in  any  notable 
manner,  from  what  we  see  in  adults.  Hepatic  dropsy  and  tubercular  peri- 
tonitis have  been  already  mentioned  as  giving  rise  to  dropsies  limited  to  the 
abdomen. 

Qi^dema  of  the  feet  or  of  the  eyelids  in  young  children  is  not  uncommon 
as  a  result  of  anaemia  with  perhaps  feeble  circulation  but  without  renal  or 
cardiac  disease  :  it  may  occur  in  cases  of  diarrhoea  or  other  chronic  illnesses. 
We  see  a  more  peculiar  form  of  the  .same  thing  in  a  swollen  state  of  the 
hands  and  feet,  the  swelling  being  so  tense  as  not  to  pit  on  jjressure.  A 
somewhat  similar  condition,  with  hardness  and  swelling  more  extensively 
distributed,  has  been  described  in  newly-born  or  very  young  children,  under 
various  names  ("  induration  of  the  cellular  tissue,"  "  sclereme,"  "  hide- 
bound") :  it  may  be  complicated  by  a  low  temperature  and  by  great  debility, 
and  is  indeed  a  most  dangerous  condition. 

As  in  adults,  obstruction  to  the  circulation  in  the  chest  may  give  rise 
to  oedema  of  the  upper  part  of  the  body  and  arms :  in  children  tumors  in 
the  mediastinum,  giving  rise  to  such  symptoms,  are  usually  of  glandular 
nature. 

Subcutaneous  emphysema,  from  the  rupture  of  air- vesicles  in  whooping- 
cough  or  other  diseases,  may  seem  at  the  first  glance  to  resemble  oedema; 
but  the  crackling  sound  and  sensation  on  testing  the  parts  for  pitting,  and 
the  resonant  percussion,  prevent  mistakes. 

GENEEAL   PAINS,    AND   PAINS   IN   THE   LIMBS. 

Pains  in  the  head,  back,  chest,  or  abdomen,  when  they  can  be  localized 
by  the  child's  language  or  sigus,  serve,  of  course,  to  guide  our  examination. 
At  times  they  are  present  there,  but  undescribed,  and  the  only  indication  we 
get  is  from  the  expression  of  pain  in  the  face,  or  from  the  cry,  and  from 
the  apparent  aggravation  on  moving  or  pressing  certain  parts.  Elsewhere, 
persistent  crying  has  already  been  spoken  of  as  often  due  to  earache.. 

Sometimes  the  discomfort,  as  in  adults,  is  too  general  to  be  defined, 
although  extreme  enough.  In  rickety  cases  the  tenderness  is  in  tlie  bones 
and  muscles  and  is  developed  on  handling  the  child  or  disturl)iiig  his  ])()sition. 
In  cerebral  meningitis,  and  more  especially  in  ccrel)ro-spinal  meningitis, 
there  is  great  general  hypersesthesia,  with  special  pains  on  moving  the  neck 
and  limbs.  In  one  case  the  writer  made  an  erroneous  diagnosis  of  rheimia- 
tism  in  a  boy  with  incipient  cerebral  meningitis,  being  misled  by  the  pains 
in  the  limbs,  and  also  no  doubt  by  the  fact  that  this  child  had  previously 
suffered  from  rheumatism.  In  cercbro-spinal  meningitis  the  resemblance 
to  rheumatism  is  greater,  and  cases  of  this  alarming  disease  arc  sometimes 


110  DIAGNOSIS. 

put  down  as  rheumatic  ailments  of  no  great  severity,  owing  to  the  absence 
of  any  swelling  in  the  joints. 

Rheumatism  in  childhood  is  at  times  rather  difficult  of  recognition,  as 
the  articular  affection  is  only  slight,  and  perhaps  contemptuously  spoken  of 
as  "  growing  pains,"  although  such  trivial  attacks  are  often  associated  with 
endocarditis  leading  to  permanent  mischief  in  the  heart.  At  times  the  pains 
are  almost  limited  to  the  feet  or  heels,  with  some  stiffness  in  the  muscles. 
In  other  cases,  of  course,  acute  articular  rheumatism  may  be  plain  enough, 
but  in  children  under  six  or  seven  years  it  is  not  common  to  have  it  in  a 
glaring  form.  As  in  adults,  pains  more  or  less  distinctly  rheumatic  may 
concur  with  an  eruption  of  purpuric  spots. 

Another  disease  sometimes  erroneously  called  rheumatism  is  acute  peri- 
ostitis, or  "necrosial  fever."  This  affection  is  often  thought  of,  in  the 
early  stages,  as  typhoid  fever,  when  the  pains  in  the  limb  are  trifling,  and 
is  often  supposed  to  be  rheumatism  when  they  are  more  pronounced  :  the 
disease  frequently  advances  to  suppuration  before  it  is  recognized  as  peri- 
ostitis at  all.  The  tibia  is  the  commonest  bone  affected,  but  others  are  also 
attacked. 

Over  the  tibia  the  red  spots  of  erythema  nodosum  may  give  rise  to  much 
pain  with  feverishness  :  they  often  occur  in  rheumatic  subjects. 

The  pains  in  the  limbs  in  the  early  stage  of  infantile  paralysis  often  lead 
to  a  misconception  of  the  nature  of  the  attack,  and  affections  of  the  joints 
may  be  suspected,  and  especially  the  diagnosis  of  hip-joint  disease  is  some- 
times made,  with,  it  may  be,  disastrous  results  in  the  subsequent  treatment. 
But  joint-affections  also  occur  only  too  frequently  in  children,  with  pain 
and  swelling;  scrofulous  disease  in  particular  must  always  be  borne  in 
mind.  Although  it  is  a  rare  affection,  haemophilia,  or  the  hemorrhagic 
diathesis,  frequently  gives  rise  to  joint-affections  in  children,  with  uainful 
swellings,  due  probably  to  effused  blood. 

Glandular  swellings  are  also  sources  of  pain,  especially  in  the  groin  and 
in  the  neck ;  in  the  latter  situation  the  pains  arising  from  them  may  simvi- 
late  rheumatic  affections  of  the  muscles,  or  they  may  give  rise  to  distortions 
resembling  torticollis ;  from  the  violent  shooting  pains,  going  up  to  the 
head,  grave  cerebral  mischief  may  sometimes  be  apprehended.  The  glandular 
swellings  are  not  always  perfectly  easily  felt,  but  when  enlarged  and  tender 
glands  are  detected  the  explanation  of  the  pains  and  feverishness  may  be  at 
once  obtained  in  otherwise  very  alarming-looking  conditions. 

FAMILY   HISTORY— HEEEDITY. 

The  family  history  is  of  capital  importance  in  the  study  of  sick  chil- 
dren, for  it  is  often  by  the  known  tendencies  to  disease  in  the  individual 
and  in  the  family  tliat  we  interpret  the  meaning  of  existing  symptoms. 

The  best  way  is  to  ascertain  all  the  facts  known  to  our  informants  re- 
garding the  ages  of  the  parents  and  of  the  brothers  and  sisters,  if  they  are 
alive,  their  state  of  health,  and  their  liability,  past  or  present,  to  any  ail- 


DIAGNOSIS.  Ill 

ments.  If  there  are  deaths,  we  ascertain,  seriatim,  the  age  at  death  and  the 
cause  of  death ;  we  often  require  also  to  get  particulars  as  to  the  duration 
of  the  illness  and  the  leading  symptoms,  so  as  to  compare  these  with  the 
name  assigned  to  the  disease.  In  cases  of  suspected  syphilis  we  ma}-  have 
much  light  thrown  on  the  nature  of  the  illness  by  a  history  of  repeated 
abortions  in  the  early  months  of  pregnancy,  then  of  still-births  at  the  full 
time,  and  then  (as  the  intensity  of  the  disease  seems  to  lessen)  of  live  chil- 
dren born  with  signs  of  congenital  syphilis.  After  all  such  information  is 
obtained,  we  have  often  to  make  inquiry  as  to  other  relatives,  particularly 
the  grandparents  and  the  uncles  and  aunts  on  both  sides.  When  we  have 
definite  suspicions  as  to  the  nature  of  the  illness,  as  in  cases  of  tubercular 
disease,  rheinnatism,  cancer,  diabetes,  etc.,  we  inquire  specially  as  to  these, 
giving  a  variety  of  names,  so  as  to  help  our  informants,  and  asking  if  any 
such  cases  occurred  among  the  relatives  named.  At  other  times  we  gain 
our  point  best  by  asking  who  was  the  nearest  relative  affected  with  consump- 
tion, for  example :  if  none  are  alleged,  we  then  say  that  most  people  have 
had  some  relatives  thus  affected,  as  cousins,  for  instance ;  and  if  any  such 
are  admitted,  we  explore  the  history  of  the  relatives  again  on  the  side  under 
suspicion,  and  after  any  discovery  we  should  always  ask  if  there  were  any 
others  affected,  before  abandoning  the  quest.  A  knowledge  of  human 
nature  leads  us  to  inquire  for  such  weak  points  in  the  mother's  family 
history,  questioning,  not  herself,  but  rather  the  father  of  the  child,  or,  per- 
haps better  still,  some  of  his  sisters,  and  we  prefer  to  do  so  out  of  the  hear- 
ing of  the  mother  and  her  friends ;  or,  equally,  we  inquire  of  the  maternal 
relatives  of  the  child  for  weak  points  in  the  father's  family  history :  having 
got  a  clue,  we  may  then,  if  necessary,  push  our  inquiries  among  the  rela- 
tives concerned,  always,  of  course,  trying  to  avoid  words,  such  as  cancer 
or  scrofula,  which  are  likely  to  be  offensive,  but  speaking  of  "  decline  with 
lung-complaints,"  "swellings  in  joints,"  "tumors,"  etc.,  as  if  they  were  very 
commonplace  ailments.  In  this  way  we  can  often  gain  information  of 
much  value  for  a  due  estimate  of  the  case. 

Tubercular  tendencies  are  so  important  and  manifold  in  the  diseases  of 
children  that  we  have  to  make  special  search  for  them,  including  all  sorts 
and  forms  we  can  think  of,  under  various  popular  names.  Tlie  influence 
of  a  mother's  phthisis  seems  more  potent  than  a  father's  in  transmitting  such 
an  affection. 

In  the  case  of  cancer,  with  which  probably  other  malignant  tumors 
should  be  grouped  for  this  purpose,  we  must  remember  that,  althougli  affect- 
ing at  times  even  very  young  children,  cancer  is  notably  a  disease  of 
advanced  life,  and  that  children  may  inherit  the  tendency  from  parents  in 
whom,  or  in  whose  brothers  and  sisters,  it  may  not  yet  have  had  time  to 
appear,  although  it  may  do  so  when  they  become  older. 

The  remarkable  phenomenon  of  atavism  must  be  remembered  :  lai'gc 
numbers  of  a  family  may  be  swept  off  by  a  disease,  notably  by  tubercular 
disease,  although  no  cases  may  have  occurred  in  the  parents  or  in  their 


112  DIAGXOSIS. 

brothers  or  sisters ;  the  historv'  of  the  grandparents  and  of  grand-uncles 
and  grand-aunts  may  come  in  to  clear  up  the  mystery. 

Allied  to  atavism,  although  distinct  from  it,  is  the  peculiarity  found  in 
the  transmission  of  haemophilia  (or  the  hereditaiy  hemorrhagic  diathesis) 
by  the  mother  to  her  children,  although  not  only  she  but  all  the  female 
members  of  her  family  escape  the  disease  in  their  own  persons.  This  disease 
is  transmitted  always  in  the  female  line,  but  only  to  male  descendants. 
Peculiarities  of  this  kind  in  the  phenomena  of  heredity  probably  account 
for  some  of  the  anomalies  of  transmission  of  other  diseases,  although  they 
may  not  yet  have  been  worked  out  as  in  the  case  of  haemophilia,  which  is 
a  favorable  disease  for  the  purpose,  inasmuch  as  it  is  absolutely  rare  and 
yet  a  very  striking  affection. 

In  the  case  of  the  so-called  hereditary  ataxia  (Friedreich's  disease)  we 
have  the  same  nervous  affection  occurring  in  various  members  of  a  family, 
although  the  fact  of  actual  transmission  is  not  made  out.  It  is  very  doubt- 
ful, therefore,  if  the  word  "  hereditary''  should  be  used,  although  in  view 
of  the  facts  known  as  to  haemophilia  we  can  understand  that  a  disease  may 
occur  in  a  family  notwithstanding  that  it  is  necessarily  absent  both  in  the 
parents  and  in  the  grandparents. 

The  combination  of  the  constitutions  of  the  two  parents  may  determine 
peculiarities  unknown  to  either  of  them.  The  injurious  influence  of  con- 
sanguineous marriages  may  also  be  explained  in  some  such  way,  the  in- 
fluences for  evil  in  a  family  being  intensified,  instead  of  diluted,  by  the 
marriages  of  near  kin.  Further,  when  both  parents,  although  of  different 
families,  are  consumptive  or  rheumatic  or  neurotic,  the  danger  of  trans- 
mission is  no  doubt  much  greater,  if  for  no  other  reason  than  that  there  is 
thus  a  double  chance  of  transmission,  or  a  double  portion  of  the  same 
inheritance. 

In  rickets  the  disease  has  often  the  appearance  of  heredity,  from  several 
children  being  affected  in  the  same  family,  and  it  is  notable  that  the  later 
children  in  certain  families  seem  especially  prone  to  this  affection.  The 
explanation  is  probably  not  to  be  sought  in  heredity,  except  in  so  far  as  the 
mother  of  a  large  family  in  poor  circumstances  is  liable  to  have  had  her 
health  run  down  by  work,  anxiety,  and  child-bearing ;  but  the  children  in 
such  a  family  are  of  course  all  apt  to  be  exposed  to  similar  unhealthy  sur- 
roundings, and  with  the  increase  in  their  number  the  mother  is  less  likely 
to  be  able  to  take  them  out  in  the  open  air  or  to  attend  to  them  in  the  special 
manner  in  which  she  could  A^'hen  there  were  only  one  or  two  altogether  in 
the  family. 

Pseudo-hypertrophic  muscular  paralysis  is  notably  a  family  disease : 
although  not  traceable  in  the  parents  of  the  affected  children,  it  may  show 
itself,  at  times,  in  the  uncles  as  well  as  in  the  brothers  of  the  patients. 

The  tendency  to  transmission  of  a  disease  to  children  born  after  the 
parents  have  had  the  affection  themselves  seems  to  be  more  potent  than  in 
cases  where  the  children  were  born  before  the  parents  were  so  affected.     In 


DIAGNOSIS.  113 

the  case  of  syphilis  in  a  fatlier  we  can  see  at  a  glance  tliat  it  is  only  after 
the  parent  has  had  the  disease  that  snch  can  be  transmitted  :  all  the  earlier 
children  are  quite  unaffected.  We  can  even  understand  that  in  the  case  of 
a  mother  actually  affected  with  advanced  consumption  during  her  pregnancy 
the  child  thereafter  born  is  more  likely  to  be  affected  than  those  who  were 
born  before  the  mother's  health  had  broken  down.  But,  although  it  is 
not  so  intelligible,  it  would  seem  to  be  made  out  that  in  the  case  of  gout, 
of  rheumatism,  and  probably  some  other  affections,  the  parents,  although 
capable  of  transmitting  these  diseases  to  their  offspring  before  they  have 
had  overt  manifestations  of  them  in  their  own  persons,  are  more  likely  to 
transmit  these  diseases,  or  to  transmit  them  in  greater  intensity,  to  those 
born  after  they  themselves  had  been  affected. 

Transmission  of  disease  or  diseased  tendencies  under  different  forms 
is  a  suljject  of  great  importance,  but  as  yet  not  fully  worked  out.  We 
can  easily  understand  that  such  disease-manifestations  as  hip-joint  disease, 
tubercle  in  the  brain,  and  tabes  mesenterica  may  all  be  reduced  to  one  com- 
mon inheritance,  and  that  these  occurring  in  the  brothers  or  sisters  of  a 
patient,  or  in  his  uncles  or  aunts,  may  throw  light  on  cases  of  mischief  in 
the  pleura,  pericardium,  or  lung,  or  on  many  other  tubercular  or  scrofulous 
affections  in  other  members  of  the  same  family  stock. 

Rheumatism,  growing  pains,  chorea,  and  heart-disease  form  another 
group ;  one  child  may  have  all  four,  but  in  a  rheumatic  family  one  child 
may  have  but  one  of  these  forms,  and  a  second  may  have  another,  or  per- 
haps other  two,  out  of  the  list,  as  his  portion  of  the  common  morbid 
tendency. 

Some  would  remove  chorea  from  this  list  and  put  it  among  the  neurotic 
group  of  hereditary  ills,  classing  it  rather  with  hysteria,  epilepsy,  and  in- 
sanity. In  any  case,  there  is  such  a  neurotic  group,  and  probably  a  liability 
to  bad  or  generalized  neuralgia,  bad  headaches,  and  general  excitability 
should  be  included  as  the  result  of  the  inheritance  of  an  unstable  nervous 
system,  which,  however,  is  quite  compatible  with  great  quickness  of  intel- 
lect and  general  ability  ;  for 

"  Great  wits  are  sure  to  madness  near  allied, 
And  thin  partitions  do  their  bounds  divide." 

These  nervous  diseases  seem  to  replace  one  anotlier  in  the  history  of 
the  individual  at  different  periods  of  his  life  or  in  different  members  of  his 
family.  It  is  extremely  probable  that  the  inheritance  of  a  bad  nervous 
system  predisposes  not  merely  to  alcoholism  but  also  to  criminal  courses  of 
life,  and  that  cliildreu  of  drunkards  and  of  the  criminal  classes  come  into 
the  world  biassed  towards  evil  courses  whicli  may  take  tlie  place  in  them  of 
more  definitely  recognized  diseases. 

Rheumatism  has  been  already  referred  to,  but  it  has  also  other  affinities. 
TIic  rlieumatic  and  gouty  inheritance  may  show  itself  in  the  children  being 
liable  to  psoriasis  and  eczema;  to  uric  acid  gravel,  and,  it  may  be,  calculus; 
Vol.  I.— 8 


114  DIAGNOSIS. 

or  to  asthma  and  to  asthmatic  bronchitis.  Uric  acid  calculous  disease  is 
known  to  be  often  hereditary  without  perhaps  any  connection  with  other 
diseases  being  ascertained. 

Gout  is  practically  unknown  in  childhood  in  its  articular  form ;  but  we 
may  see  the  little  pearly  gouty  deposits  in  the  ears;  and  in  addition  to 
some  of  the  ailments  mentioned  in  the  last  paragraph  we  may  see  granular 
kidney  :  in  any  case,  this  granular  (or  so-called  gouty)  kidney  may  appear 
as  an  hereditary  disease  in  certain  families,  declaring  itself  even  in  early 
life. 

Saccharine  diabetes  in  children,  although  rare,  can  often  be  traced  as 
hereditary :  as  in  the  adult,  we  can  sometimes  trace  relationships  between 
diabetes  and  phthisis  pulmonalis  or  other  tubercular  disease. 

Malformations  of  all  kinds  can  often  be  traced  as  occurrino;  in  different 
generations  of  the  same  family,  and  even  trifling  deviations  from  the  normal 
formation  are  likewise  hereditary.  Equally  so,  as  is  matter  of  universal 
comment,  are  the  family  peculiarities  of  build  or  feature :  indeed,  it  is 
probably  in  extension  of  this  inherited  transmission  to  the  internal  organs 
and  the  minute  tissues  that  we  are  to  seek  the  explanation  of  a  liability  to 
many  of  the  inherited  diseases  with  which  we  are  acquainted. 

Intermediate  between  congenital  malformations  and  inlierited  diseases 
we  may  place  deaf-mutism  and  congenital  color-blindness,  although  the 
exact  structural  defect  may  evade  our  recognition.  It  would  be  something 
of  an  absurdity  to  speak  of  the  use  of  concave  or  convex  spectacles  being 
transmitted  in  certain  families,  but  the  errors  in  refraction  requiring  such 
corrections  are  undoubtedly  often  hereditary,  the  defect  in  vision  depending 
on  inherited  structural  peculiarities  in  the  eye. 

It  would  seem,  however,  as  if  not  only  structural  peculiarities  and  the 
tendencies  to,  or  the  beginning  of,  chronic  disease  were  transmitted  from 
generation  to  generation,  but  that  special  tendencies  to  acute  disorders  are 
also  inherited. 

It  might  be  disputed  whether  a  special  tendency  to  catarrh  should  be 
classed  under  this  heading,  or  whether  it  should  be  referred  to  structural 
peculiarities  in  the  mucous  membranes ;  but,  in  any  case,  catarrhal  tenden- 
cies are  undoubtedly  transmitted ;  these  may  lead  to  wheezing  conditions  in 
the  chest,  or  to  nasal  catarrhs  favoring,  for  example,  affections  of  the  tym- 
panum from  this  cause,  with  its  attendant  deafness,  so  often  found  to  run  in 
families. 

But,  further,  special  families  seem  specially  liable  to  attacks  of  the  acute 
specific  fevers,  and  when  they  do  appear  there  is  apt  to  be  a  special  severity 
in  the  disease.  We  may  thus  trace  a  severe  type  of  diphtheria  or  enteric 
fever,  with  perhaps  grave  intestinal  hemorrhages,  as  occurring  in  different 
members  or  generations  of  the  same  family,  at  such  intervals  of  time  or  of 
geographical  distance  as  to  preclude  the  idea  of  any  common  infection,  and 
yet  with  such  frequency  and  severity  as  to  make  the  idea  of  special  liability 
irresistible. 


DIAGNOSIS.  115 

PECULIAEITIES   IN   THE   DISOEDERS   OF   THE   VAEIOUS 
SYSTEMS   IN    CHILDHOOD. 

In  proceeding  now  to  make  remarks  on  some  diagnostic  points  in  the 
varions  systems,  as  an  aid  to  the  study  of  sick  children,  it  is  evident  that  in 
a  chapter  like  this  these  remarks  must  be  fragmentary,  and  any  attempt  at 
systematic  completeness  must  be  abandoned.  In  selecting  certain  subjects 
for  comment,  it  may  appear  to  many  readers  that  these  are  not  the  points 
specially  requiring  discussion,  and  that  they  have  been  selected  to  the  exclu- 
sion of  others  more  important.  The  writer  must  make  such  a  selection  as 
seems  to  him  likely  to  be  most  practically  useful  in  view  of  the  scope  of  the 
present  work  and  of  his  own  experience  of  what  it  has  been  important  for 
himself  to  learn  or  to  teach. 

In  proceeding  with  the  examination  of  a  sick  child  for  the  purposes  of 
diagnosis,  it  is  usually  well,  as  in  the  case  of  the  adult,  to  follow  the  various 
physiological  systems,  although,  as  already  explained,  there  must  be  a  great 
readiness  to  depart  from  any  fixed  method  according  to  the  exigencies  of  the 

case. 

NEKVOUS   SYSTEM. 

Among  the  disorders  of  the  nervous  system  we  have  paralysis  in  various 
forms,  but  some  varieties  common  in  the  adult  are  rare  at  early  ages.  Thus, 
hemiplegia  from  ordinary  hemorrhages  or  degenerations  such  as  occur  in 
advancing  years  is  scarcely  known.  But  hemiplegia  does  occur  and  is  some- 
times suspected  to  exist  when  the  disorder  is  really  due  to  something  else. 
Thus,  in  chorea,  really  a  convulsive  disorder,  we  usually  have  more  or  less 
loss  of  power,  and  when  the  affection  is  unilateral  the  loss  of  power  is  uni- 
lateral also ;  when  by  some  chance  the  twitchings  are  not  very  plain,  or 
when,  as  happens  rarely  but  still  occasionally,  the  loss  of  power  precedes 
the  twitchings,  and  the  child  is  brought  complaining  of  a  somewhat  sudden 
or  of  a  more  gradual  loss  of  power  in  one  arm  or  in  one  side,  we  may  by 
careful  examination  be  able  to  make  a  diagnosis  of  chorea,  and  so  remove 
much  of  the  anxiety  felt  at  such  an  occurrence. 

One-sided  paralysis  in  children  is  often  dependent  on  cerebral  tumors, 
usually  tubercular ;  but  the  presence  of  staggering  and  more  general  weak- 
ness often  takes  away  from  the  precision  of  the  hemiplegia.  In  children 
with  one-sided  paralysis  dating  from  birth,  we  must  always  think  of  the 
possibility  of  some  hemorrhage  or  other  lesion  from  injury  to  the  head  at 
parturition.  This  is  apt  to  be  followed  by  atrophy  of  the  brain  on  the  side 
affected,  and  by  a  spastic  state  of  the  paralyzed  side :  a  bilateral  lesion  may 
give  at  times  a  bilateral  hemiplegia,  if  such  a  term  may  be  used,  with  a  most 
remarkable  shuffling  gait.  Paralysis  of  one  arm  or  of  one  leg  (mono])lcgia) 
from  infantile  paralysis  may  occasionally  suggest  the  idea  of  hemiplegia, 
and  in  particular,  if  the  two  limbs  on  the  same  side  are  implicated  in  the 
attack,  the  idea  of  a  cerebral  lesion  may  be  suggested,  although  the  disease 
is  known  now  to  be  of  spinal  origin  :  all  the  more  likely  is  such  a  mistake 


116  DIAGNOSIS. 

to  arise  if  convulsions  have  ushered  in  the  attack.  Hemiplegia  from  throm- 
bosis or  j)erhaps  embolism  of  the  cerebral  vessels  occurs  at  times  in  con- 
nection with  the  specific  fevers  and  other  causes,  sometimes  with  unilateral 
convulsions,  and  occasionally  associated  with  aphasia.  Meningitis  and 
abscess  of  the  brain  occasionally  give  rise  to  one-sided  paralysis,  but  usually 
the  case  is  too  complicated  to  be  spoken  of  as  hemiplegia.  In  whooping- 
cough  we  may  have,  although  rarely,  small  hemorrhagic  lesions  in  the  brain, 
due  probably  to  the  paroxysmal  fits  of  coughing ;  with  these  also  we  may 
have  aphasia  as  well  as  hemiplegia.  Hemorrhage  on  the  surface  of  the 
brain  or  into  its  membranes  is  more  common  than  marked  hemorrhagic 
lesions  in  the  brain-substance  :  in  children  with  meningeal  hemorrhage,  who 
survive  the  shock,  there  may  be  paralysis  of  one  side,  and  the  post-mortem 
examination  may  show  the  presence  of  false  membranes. 

Paralysis  of  a  limb,  or  of  part  of  one  side,  is  not  very  uncommon  as  a 
sign  of  cortical  lesions  in  the  brain,  often  associated  with  convulsions  limited 
to  the  same  part. 

The  connection  of  chorea  and  hemiplegia  has  already  been  mentioned, 
but  after  genuine  hemiplegia  Ave  may  have  "  post-hemiplegic  chorea,"  as  it 
is  termed  (although  there  is  really  no  relationship  to  the  well-known  disease 
called  chorea),  with  very  curious  spasmodic  movements,  of  slow  evolution, 
resembling,  if  not  identical  with,  the  aifection  termed  "  athetosis."  In  the 
paralyzed  limbs  of  hemiplegic  children  there  is  often  a  tremulous  or  shaky 
state  especially  noticeable  when  the  arm  is  used  :  such  cases  are  often  due  to 
cerebral  tumor. 

Paraplegia  in  children  is  usually  dependent  on  caries  of  the  vertebrae, 
which  is  relatively  common  in  early  life :  its  features  are  not  specially  dif- 
ferent from  those  seen  in  the  adult.  Of  course  spina  bifida  may  give  rise 
to  a  form  of  paraplegia  special  to  children.  Diphtheritic  paralysis  is  rela- 
tively common  in  childhood  ;  although  usually  affecting  the  palate  and  the 
accommodation  of  the  eye  more  notably,  it  may  assume  the  paraplegic  type ; 
or  the  whole  muscular  system  of  the  body  may  seem  implicated.  Other 
specific  fevers  are  also  occasionally  followed  by  paraplegia.  Spinal  myelitis 
and  meningitis  may  affect  children,  as  well  as  adults,  from  obscure  causes, 
without  impressing  any  special  peculiarity  on  the  case  from  their  age. 

Epidemic  cerebro-spinal  meningitis  is  not  uncommon  in  children  when 
the  disease  is  present  in  a  community.  The  most  striking  features,  in  addi- 
tion to  headache,  vomiting,  and  fever,  are  the  severe  generalized  pains  in  the 
back  and  limbs,  with  great  suffering  on  handling  the  child,  the  presence  of 
retraction  of  the  head  and  neck,  which  is  often  extreme,  the  occurrence  of 
herpetic  or  purpuric  eruptions  on  the  body,  and  the  implication  of  the  eye 
and  ear.  The  pyrexia  is  more  intense  and  persistent  than  in  the  ordinary 
tubercular  cerebral  meningitis.  Recovery  may  take  place  from  a  condition 
which  seemed  quite  hopeless,  after  the  lapse  of  a  few  weeks ;  deafness  or 
some  other  remnant  of  the  disease  may  be  permanent. 

Infantile  paralysis,  with  its  pains,  feverishness,  sudden  loss  of  power, 


DIAGNOSIS.  117 

and  rapidly-developed  atrophy  and  coldness  of  the  limbs,  must  be  studied 
in  detail  elsewhere.  The  localization  of  the  paralysis,  when  not  absolute 
and  extreme,  is  different  in  the  upper  and  lower  limbs  :  in  the  arm  it  is 
usually  the  upper  part  which  is  badly  paralyzed,  the  muscles  of  the  forearm 
and  fingers  regaining  in  time  considerable  power;  in  the  leg  it  is  especially 
the  muscles  below  the  knee  which  are  weak  and  atrophied,  those  of  the 
thigh  being  often  pretty  sound.  As  is  well  known,  the  sensation  is  not 
affected  in  infantile  paralysis,  and  the  sphincters  almost  never.  Pain  in 
the  early  stage  of  this  affection  often  leads  to  erroneous  ideas  suggesting 
hip-joint  disease  and  various  other  painful  disorders ;  very  often  the  true 
diagnosis  is  not  suspected  till  the  paralysis  is  detected  when  the  child  is 
supposed  to  have  recovered  from  the  acute  disease. 

A  form  of  paralysis  limited  to  children,  or  at  least  always  beginning 
in  early  life,  is  the  pseudo-hypertrophic  muscular  paralysis  described  by 
Duchenne.  It  tends  to  occur  in  certain  families,  although  really  a  rare  dis- 
ease. The  child  begins  to  fall  easily,  and  his  companions  often  amuse  them- 
selves by  knocking  him  over,  as  the  process  of  rising  is  difficult  and  in  a 
sense  comical.  The  abdomen  stands  out,  from  the  presence  of  a  saddle- 
back curvature  in  the  spine,  and  the  child's  manner  of  lifting  the  feet  sug- 
gests a  resemblance  to  the  walking  of  a  turkey.  The  limbs,  instead  of 
being  wasted,  appear  as  if  hypertrophied,  in  the  earlier  stages  at  least,  and 
the  calves  of  the  legs  are  especially  prominent :  the  hypertrophy,  however, 
is  spurious,  and  the  limbs  are  really  weak. 

Aphasia  has  been  found  again  and  again  in  children  under  circumstances 
pointing  to  a  lesion  of  the  brain  in  the  usual  situation,  but  it  is  far  from 
being  so  common  as  in  adults.  At  times,  however,  it  has  also  been  seen 
with  left  instead  of  right  hemiplegia.  Occasionally  there  is  aphasia  of  a 
temporary  character  after  an  attack  of  enteric  fever. 

Affections  of  the  speech  and  other  symptoms  closely  resembling  those. 
found  in  bulbar  paralysis  usually  prove  to  be  due,  in  children,  to  tumors 
involving  the  floor  of  the  fourth  ventricle,  as  the  regular  progressive  labio- 
glosso-laryngeal  paralysis  does  not  occur  in  early  life. 

Paralysis  of  the  cranial  nerves  is  common  in  childhood.  The  portio 
dura  of  the  seventh  pair  is  often  involved  in  ear-disease  at  this  age.  In 
young  children  this  nerve  may  be  affected  from  acute  suppurative  inflam- 
mation in  the  middle  ear,  without  destruction  of  the  nerve,  as  proved  by 
the  subsequent  recovery.  The  other  causes  of  peripheral  facial  paralysis 
are  also  operative  in  childhood,  but  do  not  call  for  notice  liere :  facial 
jDaralysis  of  central  origin  occasionally  dates  from  an  obscure  affection  in 
early  infancy  pointing  to  cerebral  disorder ;  in  this  last  case  the  paralysis, 
although  of  old  date,  does  not  prevent  the  muscles  from  responding  to  the 
faradic  current  perfectly. 

Paralytic  affections  of  the  ocular  muscles,  with  squinting,  immobility 
of  the  eyeball,  lateral  deviation,  and  nystagmus,  are  very  common  in  child- 
hood in  connection  with  cerebral  tumors  :  these  affections  must  be  studied 


118  DIAGNOSIS. 

and  worked  out  iu  detail,  just  as  in  adults,  so  far  as  the  child's  condition 
and  intelligence  render  this  possible.  In  childhood  the  occurrence  of  squint- 
ing may  readily  be  brought  about  by  any  acute  illness,  so  as  to  occur  at  a 
particular  time,  although  from  errors  in  the  refraction  of  the  eye  its  appear- 
ance sooner  or  later  might  be  inevitable  :  in  such  cases,  of  course,  the  squint 
is  not  paralytic. 

Affections  of  the  optic  nerve  and  retina  are  likewise  of  frequent  occur- 
rence, and  the  diagnostic  points  in  connection  with  the  ophthalmoscopic 
examination  are  very  valuable ;  but  a  mere  passing  allusion  is  all  that  is 
here  required,  as  the  subject  requires  full  consideration  elsewhere. 

Marked  intolerance  of  light,  with  spasm  of  the  eyelids  and  lachryma- 
tion,  always  suggests  the  idea  of  keratitis ;  and  we  may  have  photophobia 
from  this  cause  without  the  lachrymation.  In  various  brain-aifections,  and 
specially  in  meningitis,  the  child  often  shuns  the  light,  without  any  local 
affection  of  the  eyes,  the  headache  being  apparently  intensified  by  any  bright 
light.  A  similar  objection  to  the  light  may  occur  in  headaches  from  other 
causes,  although  seldom  to  the  same  extent. 

The  state  of  the  pupil  has  often  to  be  carefully  examined  in  children. 
During  healthy  sleep  the  eyeball  is  drawn  upward  and  inward,  but  if  the 
lid  be  raised  the  pupil  is  found  contracted  :  if  the  child  awakes  during  this 
examination,  the  pupil  dilates  with  awakening,  but  contracts  immediately 
from  its  exposure  to  the  light.  Immobility  of  the  pupil  on  exposure  to 
light  may  be  taken  as  an  index  of  blindness  if  the  pupil  is  of  normal  size  : 
in  testing  critically,  the  eyes  should  be  exposed  separately  to  light  and  shade. 
If  the  pupil  happens  to  be  either  much  dilated  or  much  contracted,  or  under 
the  influence  of  atropine,  this  test  is  not  of  much  use ;  when  response  to 
light  is  obtained  it  shows  a  certain  sensitiveness  of  the  optic  nerve. 

Enlargement  of  both  pupils  is  common  in  cerebral  meningitis  with  effu- 
sion into  the  ventricles,  but,  as  in  the  adult,  some  of  the  most  grave  cerebral 
lesions  produce  contraction.  Inequality  of  the  pupils  is  also  common  in 
meningitis,  but  it  often  varies  much  as  to  its  degree  or  even  its  presence, 
and  also  as  to  the  side  on  which  the  dilatation  occurs  from  time  to  time 
Enlargement  of  one  pupil  is  common  in  paralysis  of  the  third  nerve,  usually 
with  other  signs  of  this  nerve's  implication.  Inequality  from  paralysis  of 
the  sympathetic  shows  itself  by  contraction  on  the  affected  side,  or  rather  by 
a  want  of  dilatation  on  shading  :  it  may  occur  in  spinal  caries  involving  the 
cervical  region,  or  from  other  implications  of  the  sympathetic  in  the  neck. 

Oscillation  of  the  pupil  under  the  stimulus  of  light,  so  that  it  contracts 
and  dilates  while  the  light  is  held  steadily  before  the  eye,  is  not  uncommon 
in  children  with  meningitis. 

Rhythmical  oscillation  of  the  pupil  has  been  noticed  in  the  deep  sterto- 
rous breathing  of  coma,  and  in  the  deep  breaths  of  Cheyne-Stokes  breathing, 
from  cerebral  lesion ;  the  pupil  dilates  with  inspiration  and  contracts  with 
expiration  ;  in  Cheyne-Stokes  breathing  the  pupil  contracts  during  the  period 
of  apnoea. 


DIAGNOSIS.  119 

Enlargement  of  the  pnpil  from  atropine  applied  locally  usually,  of 
course,  affects  only  one  side,  but  during  its  internal  administration,  if 
j3ushed,  both  pupils  are  enlarged  and  somewhat  imperfect  in  their  response 
to  light.  In  opium  narcosis  contraction  of  the  pupil  is  a  valuable  guide. 
The  pupils  in  children  are  usually  somewhat  larger  than  in  adults,  and  the 
extent  and  readiness  of  their  response  to  light  more  notable. 

Tubercular  meningitis  is  one  of  the  most  alarming  diseases  of  childhood, 
and  in  its  early  stage  one  of  the  most  difficult  for  diagnosis.  In  the  section 
on  digestive  disorders  reference  will  be  made  to  the  difficulty  often  experi- 
enced in  estimating  the  significance  of  persistent  vomiting.  In  the  remarks 
on  respiratory  disorders  a  short  reference  will  be  made  to  the  confusion  of 
this  disease  with  pneumonia.  Other  diseases,  and  especially  otitis,  may  also 
be  confused  with  it, — for  which  the  reader  must  refer  to  special  sections  of 
this  work.  But  in  this  place  some  allusion  may  be  made  to  the  frequent 
difficulty  experienced  in  deciding  whether  a  case  is  one  of  meningitis  or  of 
enteric  fever.  In  both  we  have  fever ;  in  both,  oppression  or  excitement 
or,  it  may  be,  coma ;  and  in  both  we  may  have  a  congested  state  of  the 
lungs.  The  points  which  aid  us  are  (1)  that  in  enteric  fever  sufficiently, 
severe  to  cause  cerebral  symptoms  the  temperature  is  usually  very  feverish, 
whereas  in  tubercular  meningitis,  after  it  produces  marked  cerebral  symp- 
toms, the  temperature  is  usually  moderate.  (2)  In  tubercular  meningitis 
the  child  has  usually  been  falling  off  in  condition  before  the  acute  symptoms 
come  on.  (3)  The  state  of  the  abdomen  and  bowels  may  guide  us,  not 
merely  as  to  looseness,  although  this  is  so  extremely  uncommon  in  menin- 
gitis as  to  count  for  much,  but  more  particularly  as  to  tumidity  of  the  abdo- 
men ;  this  is  rarely  absent  entirely  in  enteric  fever,  while  in  meningitis  the 
abdomen  is  seldom  full,  often  flat,  and  sometimes  retracted.  (4)  The  family 
history,  and  (5)  the  mode  of  onset,  may  also  help  us. 

Another  condition  sometimes  confused  with  meningitis  is  "  hydrencepha- 
loid  disease"  due  to  exhausting  illnesses,  and  especially  to  diarrhoea.  In 
both  diseases  the  child  may  lie  in  the  same  apathetic  condition,  with  little 
or  no  fever.  The  history  of  diarrhoea  with  the  vomiting  may  often  guide 
us ;  for,  as  already  said,  this  is  a  rare  complication  in  meningitis.  The 
collapsed  fontanel  in  young  children  may  also  often  guide  us,  for  it  is  in 
them  that  mistakes  are  most  likely  to  occur.  Occasionally  we  try  by  the 
effect  of  stimulants,  or  even  of  opium  in  small  doses,  to  obtain  confirma- 
tion of  our  diagnosis,  when  we  think  avc  are  dealing  with  the  less  serious 
disease. 

Convulsive  diseases  are  of  special  importance  in  childhood,  for  they 
occur  not  merely  as  complications  of  grave  disorders  of  the  brain  or  from 
urajmia,  as  in  the  adult,  but  also  as  manifestations  of  general  disorder  and 
disturbance.  Thus,  in  the  acute  fevers,  or  in  pneumonia,  we  may  have 
convulsions  ushering  in  the  illness  or  occurring  during  its  progress ;  as  Dr. 
West  puts  it,  "in  a  large  jn-oj^ortion  of  cases  convulsions  in  the  infant 
answer  to  delirium  in  the  adult," — a  most  suggestive  view,  taken  in  con- 


120  DIAGNOSIS. 

nection  with  the  demonstration  of  motor  centres  in  the  cerebral  convohitions. 
But  in  early  life,  errors  in  diet  or  disorders  in  the  digestion  which  in  adults 
might  be  called  trivial  may  give  rise  not  only  to  diarrhoea  or  vomiting  but 
to  violent  convulsions.  No  doubt  some  special  susceptibility  may  exist  in 
the  nervous  system  to  favor  such  an  occurrence  in  some  children  or  families 
rather  than  in  others ;  and  in  connection  with  rickets  this  predi,sposition 
undoubtedly  exists  in  many,  so  that  trivial  disturbances,  not  always  easy  to 
trace,  may  reveal  themselves  by  convulsive  attacks.  In  connection  with 
violent  spasm  of  the  glottis, — itself  a  convulsion, — whether  in  whooping- 
cough  or  in  laryngismus  stridulus,  we  often  see  general  convulsions  super- 
vening. In  cases  of  prolonged  diarrhoea  or  other  forms  of  exhausting 
disease,  we  may  have  convulsions  apparently  in  the  same  way  as  from  loss 
of  blood.  After  scarlet  fever  which  may  have  been  so  slight  as  to  pass 
unrecognized  or  at  least  to  be  little  regarded,  the  renal  complication  may 
also  have  been  little  if  at  all  thought  of,  till  sudden  ureemic  convulsions 
may  startle  all  concerned  :  those  physicians  who  have  been  once  surprised 
thus  are  usually  very  careful  to  see  that  nothing  is  wanting  in  the  care  of 
,  scarlatina  convalescents. 

Convulsive  twitching  movements  of  the  face  and  limbs,  with  erratic 
behavior  of  the  voluntary  muscles  when  called  into  action,  are  character- 
istic of  chorea.  This  is  essentially  a  disease  of  childhood ;  it  may,  how- 
ever, appear  in  those  who  have  attained  puberty  in  both  sexes,  although 
very  uncommon  in  young  men.  It  is  less  rare  in  girls  of  this  age,  but 
usually  then  occurs  as  a  relapse ;  it  is  well  known,  also,  that  it  may  com- 
plicate pregnancy,  usually  as  a  recurrence.  Not  a  few  diseases,  however, 
termed  chorea  are  scarcely  entitled  to  be  called  so :  the  post-hemiplegic 
chorea  already  referred  to  (which  is  not  limited  to  children)  clearly  points 
to  grave  mischief  in  the  brain,  and  some  other  of  the  chronic  forms  of 
chorea,  or  of  very  localized  variety  of  chorea,  no  doubt  point  in  the  same 
direction.  Occasionally  a  tremulous  jerky  state  of  the  arms  may  simulate 
chorea  pretty  closely,  although  really  constituting  an  early  symptom  of 
cerebral  tumor ;  and  in  certain  cases  of  congenital  mental  defect  the  excited 
jerky  movements  of  the  body  and  limbs  may  suggest  the  idea  of  chorea  to 
the  on-looker.  Whenever,  indeed,  chorea  departs  from  its  known  charac- 
teristics as  regards  age,  duration,  localization,  and  concurrent  symptoms,  we 
must  always  suspect  that  something  worse  may  be  actually  present.  Some 
varieties  of  the  so-called  electric  choreas  are  probably  momentary  epileptic 
attacks. 

The  diagnosis  of  epilepsy  in  children  is  often  raised  in  connection  with 
the  occurrence  of  convulsions,  a  subject  of  great  importance,  which  must  be 
fully  discussed  elsewhere.  The  early  discrimination  is  often  impossible. 
The  wisest  course  is  usually,  in  all  cases  of  doubt,  to  let  our  treatment  be 
guided  by  the  graver  view,  and  to  let  our  prognosis,  as  expressed,  lean 
always  to  the  more  hopeful  side.     The  course  of  the  case  alone  can  decide. 

A  remarkable  form  of  convulsion  limited  to  children  is  that  known  as 


DIAGNOSIS.  121 

eclampsia  nutans.  These  "nodding  convulsions"  usually  consist  in  tlie  rapid 
bobbing  of  the  head  up  and  down  or  back  and  forward.  Occasionally 
they  are  more  extensive,  with  a  bending  or  bowing  of  the  whole  bodv,  so 
as  to  merit  the  name  of  "  salaam  convulsions."  The  disease  is  probably 
closely  allied  to  epilepsy ;  and,  like  epileptiform  seizures  of  the  more  ordi- 
nary kind,  these  nodding  fits  are  probably  at  times  due  to  the  presence  of 
tubercles  in  the  brain. 

The  curious  spasms  of  the  fingers  and  toes,  or  of  the  wrists  and  feet, 
known  as  "  tetany,"  may  be  regarded  as  almost  special  to  children,  although 
they  occur  in  others  also,  and  especially  in  nursing  women.  Occasionally 
a  graver  and  more  continuous  form,  resembling  tetanus  more  closely,  may 
occur  in  childhood.  Slighter  forms,  again,  of  these  "  carpo-pedal"  spasms 
are  often  detected  as  manifestations  of  partial  convulsicms,  or  as  the  pre- 
cursors or  remnants  of  general  eclampsia.  In  connection  with  wasting 
diarrhoea  a  chronic  spasm  of  these  parts  is  often  associated  with  a  swollen 
state  of  the  backs  of  the  hands  and  feet,  due  apparently  to  anaemia :  in 
such  cases  the  nervous  affection  may  pass  ofP  as  the  general  state  improves, 
without  any  generalization  of  the  spasms. 

Hysteria  is  by  no  means  excluded  by  early  age  from  our  diagnosis :  it 
may  occur  even  in  young  boys.  It  would  be  useless  to  give  illustrations  of 
the  various  forms  it  may  assume  in  children,  one  of  the  most  striking  being 
the  paralytic.  Closely  allied  to  hysteria  in  various  ways,  although  never 
to  be  regarded  as  synonymous  with  it,  is  simulation, — pretended  deafness, 
dumbness,  twitchings,  paralysis,  etc.  Even  the  remarkable  phenomena  of 
hystero-epilepsy  may  occur  in  children ;  the  writer  has  seen  typical  attacks 
of  this  in  boys ;  and  in  one  boy  it  was  associated  with  the  most  distinct 
"  crucifixion  attitude"  as  described  and  figured  by  Charcot. 

Of  mental  disorders,  idiocy  and  imbecility  are  the  most  important  in 
childhood.  These  defects  cover  a  multitude  of  special  ailments, — inability 
to  speak,  to  walk,  etc.  Frequently  the  mother  brings  her  child  to  have  the 
frasnum  linguae  cut  (as  she  considers  the  inability  to  speak  depends  on  the 
child's  being  "  tongue-tied"),  without  any  notion,  so  far  as  we  can  gatlier, 
that  there  is  any  mental  defect  at  all. 

Violent  maniacal  fits  after  epileptic  attacks,  or  replacing  them,  it  may 
be,  are  likewise  well  known  in  children.  A  certain  passionate  violence  in 
children  sometimes  goes  to  such  a  length  as  to  suggest  hysterical  mania  or 
some  other  instability  of  the  mental  faculties  :  in  some  cases  similar  attacks 
are  connected  with  the  uric  acid  diathesis. 

In  this  connection,  but  much  short  of  any  serious  mental  aberration, 
may  be  classed  the  terrible  "  night  terrors"  of  young  children,  arising  from 
the  vividness  of  their  imagination,  coming  on  during  night,  probably  in 
connection  with  dreams.  Somnambulism  also  in  various  forms  and  dcirrees 
occurs  in  children,  or  excessive  talking  in  bed  M'hen  asleep,  or  it  may  be 
with  the  eyes  open ;  in  this  condition  the  cliild  may  be  able  to  answer,  in  a 
kind  of  way,  various  questions  directed  to  him.     These  conditions  of  sleep- 


122  DIAGNOSIS. 

walking  and  sleep-talking  are  often  dependent  on,  or  at  least  aggravated 
by,  undue  application  to  studies  or  continuous  anxiety  in  connection  with 
them. 

Headaches  in  children  are  discussed  in  a  special  chapter. 

PULMONAEY  AND   CAEDIAC   SYSTEM. 

One  of  the  most  striking  symptoms  in  disorders  of  the  respiratory  system 
in  childhood  consists  in  the  appearance  of  rapid  or  labored  breathing,  with 
excited  action  of  the  alse  of  the  nose,  so  that  when  we  see  this,  with  heat  of 
skin,  we  can  scarcely  go  wrong  in  alleging  a  respiratory  disease  or  compli- 
cation. Another  very  striking  feature  of  respiratory  distress  in  children  at 
the  breast  consists  in  their  giving  over  sucking  or  in  their  readily  aban- 
doning the  attempt,  although  perhaps  eager  to  try ;  they  have  not  breath 
enough  to  suck  from  the  breast,  and  may  even  be  unable  to  suck  from  a 
bottle,  although  this  is  a  less  taxing  eifort  in  such  conditions.  When  this 
inability  is  reported,  we  always  think  of  pneumonia  or  severe  bronchitis. 

The  violent  efforts  at  inspiration  occurring  in  croup,  or  other  obstructive 
diseases  in  the  upper  passages,  have  already  been  referred  to  in  connection 
with  the  appearance  of  the  chest.  But  the  presence  of  stridor  in  the  respi- 
ration, with  a  curious  hoarse  or  squeaking  sound,  and  the  hoarse  yet  clang- 
ing sound  in  the  cough,  with  at  times  a  similar  hoarseness  in  the  voice,  con- 
stitute points  of  equal  importance  in  the  diagnosis.  Some  of  these  croupy 
attacks,  although  alarming  to  look  at,  are  practically  devoid  of  danger,  the 
affection  being  only  a  catarrhal  laryngitis  aggravated  by  spasm :  in  cases 
with  deposits  in  the  larynx  or  trachea,  on  the  other  hand,  the  danger  is 
always  great ;  the  alarming  dyspnoea  is  in  such  children  more  constant, — 
never  quite  relaxing  even  for  a  moment, — although  in  them  also  the  element 
of  spasm  is  clearly  present,  aggravating  the  permanent  obstruction.  The 
throat  should  always  be  examined  for  diphtheritic  patches ;  but  there  is  often 
laryngeal  diphtheria  without  any  affection  of  the  fauces. 

Occasionally  retro-pharyngeal  abscess  gives  rise  to  symptoms  somewhat 
similar  to  croup,  and  so  the  case  may  be  misunderstood.  Spasm  of  the 
glottis  from  nervous  causes  o''  from  foreign  bodies  in  the  windpipe  may 
also  do  so. 

Sometimes  very  rapidly  increasing  pleural  effusions — especially  in  scarla- 
tinal nephritis — may  induce  the  most  awful  efforts  at  respiration,  resembling 
the  paroxysms  of  asthma  rather  than  croup.  The  sniffling  noises  in  the 
nose  with  the  respiration,  from  congenital  syphilis,  constitute  a  well-known 
sign  of  much  importance. 

The  absence  of  sputum  in  children  with  disease  of  the  respiratory  organs 
is  habitual :  in  chronic  pulmonary  phthisis  with  excavation  (usually  in 
children  over  five)  we  may,  however,  have  the  well-known  nummular  and 
globular  sputa.  Even  cough  is  often  absent  or  obscured  in  many  cases.  A 
peculiar  squeaky  cou.gh  is  heard  sometimes  in  bed,  pleuritic  accumulations 
threatening  suffocation.     In  empyema  children  sometimes  spit  up  the  pus 


DIAGNOSIS.  123 

from  the  pleura  with  a  favorable  result.  The  aspect  of  children  as  regards 
flushing  and  lividity  has  been  mentioned  already.  The  decubitus  is  similar 
to  that  in  adults,  and  has  similar  variations,  or  is  even  more  varied,  from 
the  restlessness  of  youth ;  in  bad  pleural  effusions  the  child  lies  on  the 
affected  side. 

The  rhythm  of  the  breathing  is  sometimes  very  irregular  in  children. 
Irregular  or  sighing  respiration  is  frequent  in  cerebral  affections,  especially 
in  meningitis.  This  is  usually  characterized  by  a  few  slow  or  shallow 
breaths,  almost  imperceptible,  followed  by  a  deep  inspiration.  At  times  the 
implication  of  the  breathing  is  the  terminal  phase  of  a  case  of  cerebral 
tumor,  the  breathing  stopping  while  the  pulse  is  good ;  it  may  even  be  pos- 
sible to  re-establish  the  breathing  for  a  time  in  such  cases  by  artificial  means. 
A  certain  slowness  of  the  respiration  is  very  common  in  cerebral  cases. 
Occasionally  this  altered  rhythm  becomes  "  regular  in  its  irregularity,"  the 
ascending  and  descending  series  of  respirations,  with  a  period  of  apnoea, 
described  as  "  Cheyne-Stokes  respiration,"  being  perfectly  marked  in  cases 
with  gross  cerebral  lesions  :  in  the  opinion  of  the  writer  there  is  no  differ- 
ence in  kind,  but  only  in  degree,  between  the  perfect  Cheyne-Stokes  rhythm 
and  the  irregular  or  sighing  or  cerebral  respiration  so  frequent  in  menin- 
gitis. But  this  same  irregular  respiration  may  occur  in  cases  not  primarily 
of  a  cerebral  nature,  and  it  is  frequent  in  grave  cases  of  enteric  fever  with 
cerebral  symptoms :  the  writer  has  seen  the  most  perfect  Cheyne-Stokes 
respiration  in  an  infant  overwhelmed  with  the  poison  of  scarlet  fever. 

The  irregular  breathing  of  opium  narcosis,  perhaps  from  an  overdose 
of  medicine,  must  likewise  be  mentioned  :  it  resembles  the  cerebral  breathing 
just  referred  to,  but  is  more  characterized  by  intermissions  in  the  breath 
than  by  irregularity  or  by  any  definitely  altered  rhythm. 

In  chorea  we  often  see  a  very  marked  irregularity  in  the  breathing  both 
when  the  child  is  lying  quietly  and  when  it  is  trying  to  speak  or  swallow, 
the  management  of  the  breathing,  as  regards  time,  being  so  far  out  of 
control  as  to  prove  troublesome  in  these  actions. 

In  rickets  we  have  often  a  very  great  increase  in  the  rate  of  respiration, 
so  that  it  may  run  up  to  fifty  or  sixty  in  the  minute,  and  this  not  only  in 
connection  with  catarrhs  and  slight  pneumonic  attacks,  but  apparently  as 
the  normal  condition  of  the  rickety  child's  respiration. 

In  auscultation  and  percussion  we  have  the  same  general  facts  as  in 
adults.  Chinking  percussion  and  the  "bruit  skodique"  are  relatively 
common  in  childhood  during  advancing  and  receding  ])neumonias  and 
pleurisies,  and  the  student  must  beware  of  making  a  diagnosis  of  cavity 
from  tlie  "  cracked-pot  sound,"  in  the  case  of  an  infaut,  unless  supported 
by  other  strong  evidence. 

Phthisical  disease  of  the  lung  is  much  commoner  in  early  life  than  it 
was  formerly  supposed  to  be  :  we  must  not  expect,  however,  the  same  great 
liability  of  the  very  apex  of  the  lung  to  be  involved  as  in  adults  :  this  aiid 
the  implication  of  both  sides  in  the  consolidation  help  to  make  the  diagnosis 


124  DIAGNOSIS. 

more  difficult,  and  we  have  to  rely  much  on  the  general  aspect,  the  course 
of  the  case,  and  the  family  history. 

"  Bronchial  phthisis"  is  often  suspected  in  the  case  of  children  with  a 
suspicious  appearance  and  history  of  phthisis  when  auscultation  gives  little 
sign  of  pulmonary  softening.  We  may  have  tubular  breathing  especially 
between  the  scapulas ;  dulness  on  percussion  there  and  at  the  upper  part 
of  the  sternum ;  and  perhaps  loud  fits  of  coughing,  with  almost  a  crowing 
inspiration,  resembling  pertussis.  Occasionally  in  such  cases  cheesy  fetid 
masses  are  expectorated. 

Bronchitis  is  seldom  difficult  of  recognition,  from  the  presence  of  wheez- 
ing, snoring,  or  moist  rales,  or  of  all  kinds  mixed  up  together.  The  very 
high  pitched  wheezing  sounds  suggest,  of  course,  the  finest  tubules  as  im- 
plicated. 

Pneumonia,  however,  is  often  very  difficult  of  recognition.  In  the 
lobar  form  this  arises  from  the  physical  signs  frequently  being  late  in 
appearing,  so  that,  although  the  disease  may  be  suspected  and  careful  watch 
kept  on  the  chest,  day  after  day  may  pass  without  physical  signs,  and  thus 
the  violent  fever,  delirium,  or  other  forms  of  nervous  excitement  may  lead 
to  the  suspicion  of  cerebral  inflammation, — particularly  if  the  child  passes 
by  and  by  into  a  kind  of  comatose  state.  The  physician,  now  thrown  off 
his  guard,  may  have  given  over  the  exploration  of  the  chest  at  the  very 
time  physical  signs  could  be  made  out :  and  when  hope  is  almost  given  up, 
in  view  of  meningitis,  we  may  see  the  child  recovering,  and  perhaps  a 
troublesome  cough  coming  on  for  the  first  time.  The  clue  to  the  case  is 
often  found  in  the  very  violence  of  the  fever,  and  of  the  symptoms  gen- 
erally, at  the  onset ;  for  with  the  ordinary  meningitis  pronounced  cerebral 
symptoms  usually  coincide  with  comparatively  moderate  fever. 

Cerebral  excitement  from  pneumonia  has  been  supposed  to  be  specially 
common  when  the  disease  affects  the  upper  lobe :  in  such  cases  the  pneu- 
monia is  of  the  lobar  or  croupous  form.  It  is  of  special  importance  to 
recall  this  situation  of  the  disease,  as  experience  in  the  adult  leads  us  to 
search  for  pneumonia  rather  at  the  base.  In  children  the  localization  of 
the  disease  in  the  upper  lobe  has  not  quite  as  much  gravity,  in  indicating  a 
tubercular  origin,  as  in  the  adult. 

In  broncho-pneumonia  (which  may  also  simulate  cerebral  affectious)  the 
lobules  are  involved  in  the  catarrhal  process,  and'  so  the  physical  signs  vary 
much  in  distinctness.  If  extensive,  we  may  have  the  dulness,  tubular 
breathing,  etc.,  as  plain  as  in  the  other  form ;  but  if  the  condensed  patches 
are  small  and  scattered,  the  physical  evidence  of  their  presence  may  be 
obscure,  and  the  signs  are  often  fluctuating,  one  day  pretty  clear,  another 
scarcely  recognizable ;  one  day  we  may  think  the  right  lower  back  is  the 
site  of  the  disease,  the  next  we  may  think  the  dulness  and  alteration  in  the 
breathing  are  in  the  left;  one  day  the  whole  side  may  seem  implicated, 
another  only  the  base.  The  auscultatory  signs  vary  much.  Often  we  have 
tubular  breathing  more  or  less  marked ;  sometinjcs  there  is  rather  feeble- 


DIAGNOSIS.  125 

ness  of  the  breath-sounds.  If  either  of  these  changes  coincides  with  dis- 
tinctly appreciable  relative  dulness  in  the  back  (however  slight),  fine  moist 
rales,  rapid  or  labored  breathing,  excited  action  of  the  nostrils,  and  high 
temperature,  we  may  put  the  case  down  as  a  pneumonia  in  some  form : 
having  done  so,  we  do  not  readily  change  our  opinion  although  the  physical 
signs  may  seem  to  become  less  amidst  the  persistent  fever. 

Judging  from  the  signs  just  enumerated,  we  may  think  a  broncho- 
pneumonia impending,  or  already  begun,  when  the  sequel  shows  that 
whooping-cough  is  the  real  disease ;  but  the  local  conditions  in  the  lung 
are  probably  closely  allied  to  the  other  condition  if  much  fever  exists. 
Even  in  the  course  of  a  moderate  case  of  whooping-cough  the  signs  re- 
ferred to  may  be  all  present,  and  may  almost  completely  disappear,  for  a 
time,  after  a  fit  of  coughing,  with  or  without  vomiting. 

In  childhood  collapse  of  the  lung  plays  an  important  part  in  the  changes 
brought  about  in  bronchitis  and  catarrhal  pneumonia ;  but  patches  of  col- 
lapse, sometimes  of  large  extent,  may  occur  without  much  concurrent  inflam- 
mation, especially  in  whooping-cough  :  the  signs  are  dulness  on  percussion, 
feeble  respiration,  partial  immobility  of  the  affected  side,  and  by  and  by 
there  may  be  a  falling-in  of  the  ribs,  either  permanently  or  only  for  a  time. 

With  regard  to  special  auscultatory  signs  in  childhood,  the  name  of 
"  puerile  breathing"  will  recall  the  fact  that  a  very  full  and  somewhat  harsh 
inspiration  is  natural  to  children.  The  occurrence  of  tubular  breathing  in 
pleuritic  effusions,  especially  at  the  back,  instead  of  the  feeble  or  suppressed 
respiration  more  often  looked  for,  seems  to  be  relatively  more  frequent  in 
children  than  in  adults,  so  that  we  are  apt  sometimes  to  make  a  diagnosis 
of  consolidation  of  the  lung  when  there  is  really  a  pretty  large  effusion  in 
the  pleural  cavity. 

In  pleurisy  we  may  frequently  miss  in  the  child  the  initial  friction- 
sound  :  indeed,  the  diagnosis  at  this  age  has  usually  to  be  made  on  the 
ground  of  pain  in  the  side  with  restriction  in  the  breathing  without  any 
audible  friction ;  in  a  day  or  so  we  may  have  our  diagnosis  confirmed  by 
the  presence  of  dulness  on  percussion,  at  the  base  behind,  with  feeble  respi- 
ration and  diminished  vocal  resonance.  With  the  subsidence  of  the  effusion 
we  may  have  the  friction  audible  for  the  first  time. 

In  cardiac  diagnosis  we  have  the  same  phenomena  as  in  adults :  affec- 
tions of  the  heart  in  children  are  very  much  commoner  than  was  formerly 
supposed.  We  must  remember  the  occasional  occurrence  of  congenital 
malformations,  with  signs  of  stenosis  of  the  pulmonary  artery  and  other 
indications  of  defective  development :  there  may  or  may  not  be  concur- 
rent cyanosis.  We  may  practically  exclude  aueurismal  disease  from  our 
diagnosis  of  cardiac  disease,  althougli  dilatations  of  this  kind  have  been 
seen  at  this  age. 

With  regard  to  pericarditis,  we  may,  of  course,  have  it  in  acute  rheuma- 
tism ;  in  cases  of  chorea  also,  with  or  without  distinctly  rheumatic  symp- 
toms, pericarditis  may  supervene,  always  a  most  grave  complication  in  this 


126  DIAGNOSIS. 

disease.  In  young  subjects  the  tubercular  form  of  pericarditis  is  relatively 
commoner  than  in  adults.  With  the  extension  of  pleuritic  inflammation 
so  as  to  give  rise  to  pleuro-psricardial  friction  or  genuine  pericarditis,  we 
are  often  in  doubt  as  to  whether  there  may  not  be  a  tubercular  basis  for 
the  extensively  distributed  mischief.  The  course  of  the  case  alone  can 
decide.     The  pericarditis  of  Bright's  disease  must  also  be  remembered. 

A  very  special  variety  of  pericarditis  may  be  said  to  be  limited  to  young 
subjects,  essentially  of  pysemic  origin,  but  developed  in  connection  with 
"  acute  phlegmonous  periostitis  :"  this  usually  involves  the  tibia,  but  other 
long  bones  may  also  suffer.  In  such  cases  pericarditis  seems  to  mark  the 
constitutional  aifection :  it  may  persist  for  a  long  time,  or  it  may  be  rapidly 
fatal.  With  the  pericarditis  we  have  often  endocarditis  also,  and  the  dis- 
ease in  the  valves  gives  rise  to  fiirther  dangers  and  complications,  such  as 
pysemic  emboli  in  the  kidneys,  etc. 

In  children,  perhaps  even  more  than  in  adults,  rheumatic  pericarditis 
may  suddenly  become  highly  dangerous  from  the  excessive  eifusion,  but  the 
signs  are  not  peculiar  at  this  age. 

DIGESTIVE   SYSTEM. 

The  disorders  in  the  digestive  system  are  ftiU  of  peculiarities  in  children, 
and  especially  in  infants,  but  just  on  this  account  they  may  be  dealt  with 
slightly  in  this  chapter,  for  in  connection  with  weaning,  artificial  food,  diar- 
rhoea, etc.,  the  reader  will  find  all  the  matters  of  special  importance  enlarged 
on  elsewhere.  The  undigested  milk  with  curdy  motions ;  the  aspect  of  the 
faeces  when,  as  sometimes,  they  are  green  when  passed,  or  sometimes  only 
become  green  after  exposure  to  the  air ;  the  influence  of  feeding  in  deter- 
mining a  motion,  so  that,  as  the  nurses  say,  the  milk  seems  to  "  run  through" 
the  child  at  once ;  the  dreadful  smell  of  the  motions  at  times,  and  the  con- 
trolling influence  in  this  respect  of  boiling  the  milk ;  the  tenacity  of  the 
curd  as  vomited  by  the  infant, — the  importance  of  these  and  of  many  other 
such  matters  has  to  be  learned  by  the  student  of  pediatrics,  but  only  a  de- 
tailed discussion  of  the  subject  could  be  of  any  use,  and  this  must  be  sought 
in  other  chapters. 

The  significance  of  vomiting,  and  especially  of  persistent  vomiting,  in 
the  child,  has  even  a  wider  range — wide  as  that  is — than  pertains  to  disease 
of  the  digestive  system  itself.  Vomiting  is  extremely  common  at  the  be- 
ginning of  the  acute  fevers,  and  if  carefully  inquired  for  it  will  be  found 
that  it  is  very  usually  present  at  the  onset  of  scarlatina.  Even  with  pneu- 
monia it  is  very  common,  and  with  various  other  serious  febrile  illnesses. 
It  is,  however,  as  the  index  of  meningitis  or  other  cerebral  affections  that 
it  is  most  anxiously  considered  by  physicians  when  called  to  a  case  of  per- 
sistent or  very  frequent  vomiting.  Again  and  again  we  try  to  explain  it 
away  as  due  to  some  digestive  derangement,  to  the  use  of  purgatives  or  to 
the  want  of  them,  to  errors  in  diet  or  management,  and  the  like,  but  are 
forced  to  admit  that  these  explanations  are  untenable  and  that  we  are  deal- 


DIAGNOSIS.  127 

ing  with  the  vomiting  of  incipient  brain-disease.  At  other  times  wp  may 
have  the  greatest  anxiety  as  to  the  significance  of  such  vomiting,  till  the 
whole  disturbance  subsides  without  further  mischief.  From  this  it  will  be 
gathered  that  the  writer  knows  of  no  special  points  by  which  cerebral 
vomiting  can  be  discriminated  from  that  of  other  origin.  We  aim  at  dis- 
covering  if  the  vomiting  had  any  obvious  cause  in  the  diet  of  the  child,  or 
if  the  tongue  and  state  of  the  bowels  point  to  disorder  there ;  we  try  to 
make  out  if  the  vomiting  was  preceded  by  a  feeling  of  nausea  for  some 
time  before  it  occurred ;  for  it  is  when  the  vomiting  seems  most  "  causeless," 
in  these  respects,  that  we  suspect  a  cerebral  cause.  We  further  attach  great 
importance  to  the  concurrence  of  severe  headache  with  the  vomiting,  and 
even  to  the  concurrence  of  headache  with  any  special  turn  of  vomiting. 
The  state  of  the  temperature  may  also  guide ;  for  if  suddenly  rising  very 
high  we  rather  think  of  some  impending  fever,  the  elevation  being,  as  a 
rule,  very  moderate  in  tubercular  meningitis.  The  state  of  the  bowels  may 
guide,  for  if  there  is  concurrent  diarrhoea  the  chances  of  meningitis  are 
very  small,  since  this  disease  is  usually  attended  with  constipation,  and, 
further,  the  looseness  points  to  digestive  disorders  likely  of  themselves  to 
cause  vomiting.  If  constipation  is  present,  this  in  meningitis  can  usually 
be  overcome  after  a  little  trouble  by  physic ;  but  if  intractable,  both  consti- 
pation and  vomiting  may  be  due  to  intestinal  obstruction  of  some  kind ;  the 
state  of  the  abdomen  may  guide,  for  if  obstruction  exists  some  distention  is 
usually  present,  but  iu  meningitis  there  is  no  distention,  and  indeed  in  the 
course  of  the  case  we  may  even  have  retraction.  Very  often  we  can  only 
wait,  holding  possibilities  in  view  and  trying  to  steer  a  course  as  regards 
treatment  which  will  be  as  free  as  possible  from  objection  whatever  the 
eventualities  may  be. 

Intestinal  obstruction  has  just  been  referred  to  as  a  cause  of  vomiting. 
While  all  forms  may  occur  in  childhood,  we  must  remember  that  intus- 
susception is  relatively  common  in  infants  and  children,  and  the  presence 
of  intestinal  discharges  of  blood,  the  discovery  of  a  tumor  in  the  abdomen, 
or  an  examination  of  the  rectum  by  the  finger,  may  clear  up  cases  which 
were  doubtful  till  such  assistance  was  obtained. 

Another  cause  of  intestinal  obstruction  iu  childhood  which  is  apt  to  give 
rise  to  mistakes  and  confusion,  from  the  rarity  of  this  accident  in  adults,  is 
the  presence  of  tubercular  peritonitis.  Of  course  it  is  well  enough  known 
that  in  this  condition  there  may  be  troublesome  constipation ;  but  at  times 
we  liave,  apparently  from  the  agglutination  of  adjacent  coils  of  intestine,  a 
distinctly  mechanical  obstruction  produced,  revealing  itself  not  only  by 
general  abdominal  distention,  but  also  by  violent  peristalsis  of  the  coils  of 
bowel  above  the  obstruction,  this  being  visible  through  the  abdominal  wall, 
as  in  many  cases  of  stricture  of  the  intestine. 

An  examination  of  the  mouth  reveals  at  times  disorders  so  common  in 
childhood  as  almost  to  be  called  peculiar, — viz.,  stomatitis  in  its  various 
forms.     We  may  have  little  blisters  with  clear  fluid  on  the  tongue  and 


128  DIAGNOSIS. 

mucous  membrane  of  the  moutli,  or  the  spots  may  be  rather  like  little 
superficial  ulcers ;  iu  either  case  the  salivation  may  be  extreme,  and  there  is 
often  great  fetor  of  the  breath ;  the  tongue  also  is  often  foul  and  the  whole 
digestive  system  deranged.  A  further  form  of  stomatitis  is  the  gangrenous 
(noma,  cancrum  oris),  in  which  the  edges  of  the  mouth  on  one  side  become 
black ;  the  disease  may  also  involve  the  gums,  the  teeth  falling  out,  and 
great  destruction  of  the  parts  often  results.  This  destructive  disease  usually 
follows  measles  or  some  general  disease,  or,  at  any  rate,  occurs  in  connection 
with  some  great  constitutional  depression.  A  similar  gangrenous  disease 
may  attack  the  vulva  in  little  girls. 

Another  form  of  stomatitis  is  the  parasitic,  formerly  and  often  even  now 
spoken  of  as  aphthous :  its  popular  name  is  "  thrush,"  and  its  French  name 
^'muguef  In  this  we  see  white  patches  on  the  tongue,  on  the  inside  of  the 
cheeks,  or  on  the  throat.  It  is  specially  prone  to  occur  in  infants  reared 
artificially,  and  assumes  its  greatest  intensity  in  such  when  they  are  reduced 
to  the  last  stage  of  wasting.  Under  the  microscope  the  thallus  and  spores 
of  the  Oidium  albicans  may  be  recognized.  At  times  it  presents,  when  on 
the  fauces,-  a  certain  resemblance  to  diphtheria. 

The  examination  of  the  throat  has  greater  importance  in  children  be- 
cause we  cannot  always  be  guided  by  them  to  the  seat  of  their  pain.  A 
tonsillitis  may  at  once  explain  the  existence  of  a  violent  febrile  disturbance ; 
or  with  a  suspicious  scarlet  rash  the  appearance  of  the  throat  may  at  once 
enable  us  to  declare  scarlatina ;  in  other  cases  the  presence  of  the  white 
patches  of  diphtheria  may  explain  an  otherwise  unintelligible  illness. 

The  discrimination  of  the  various  forms  of  sore  throat  is  far  from  easy ; 
often,  indeed,  it  is  impossible.  Redness  with  patches  of  exudation  (so-called 
ulcers)  on  the  tonsil  or  on  both  tonsils,  coincident  with  a  high  temperature 
and  a  uniform  scarlet  rash,  we  must  always  regard  as  scarlatina ;  but  when 
the  rash  is  measly  rather  than  of  uniform  scarlet  color,  when  the  throat  is 
a  little  sore  and  red,  but  not  very  red,  and  quite  destitute  of  patches,  and 
when  the  rash  is  very  bright  and  abundant  and  the  temperature  only  slightly 
elevated,  we  get  into  great  difficulties.  Sometimes  the  so-called  German 
measles  (rotheln,  epidemic  roseola)  may  be  the  cause  of  the  symptoms.  At 
other  times,  with  slight  rashes  and  no  sore  throat  we  may  be  in  the  presence 
of  a  trifling  erythema,  or  perhaps  of  a  rash  due  to  some  special  surgical 
dressing  or  to  some  internal  remedies  which  are  being  used. 

Tonsillitis  with  patches  may  occur  Avithout  any  connection  with  scarla- 
tina, but  it  may  also  precede,  but  only  for  a  day,  the  appearance  of  the 
scarlet  rash.  We  may,  however,  miss  the  rash  if  very  evanescent,  or  if 
search  had  not  been  made  in  time  for  it.  Probably  also  scarlet  fever  may 
affect  the  child  and  its  throat  without  any  rash  appearing  at  all ;  and  also 
a  sore  throat  may  appear  as  a  local  manifestation  of  the  poison  (particularly 
in  those  already  protected  by  an  attack)  without  the  whole  system  being 
contaminated  by  the  contagion. 

Similar  difficulties  beset  the  diagnosis  of  diphtheria  :  when  well  marked, 


DIAGNOSIS.  129 

nothing  is  more  easily  recognized;  thus,  we  may  have  the  white  mem- 
branous exudation  on  the  uvula,  palate,  and  tonsils,  with  regurgitation  of 
fluids  through  the  nose,  moderately  high  fever,  and  albuminous  urine.  But 
in  a  case  with  one  or  two  insignificant  white  spots,  like  those  of  follicular 
tonsillitis,  we  may  subsequently  find,  either  in  the  same  case  or  in  another 
member  of  the  family,  that  the  trivial-looking  illness  was  the  fatal  diph- 
theria. All  such  cases  should  be  treated  with  care,  and  all  should  be 
labelled  as  more  or  less  infectious,  although  it  is  not  necessary  to  declare 
the  existence  of  diphtheria  openly  till  the  symptoms  or  the  sequel  make  it 
certain. 

Itching  at  the  nose  and  at  the  anus,  and  grinding  of  the  teeth  in  sleep, 
have  been  regarded,  with  justice,  as  evidences  of  gastro-intestinal  irritation  : 
the  first,  indeed,  has  acquired  a  reputation  as  diagnostic  of  intestinal  worms, 
especially  when  combined  with  pallor  and  wasting  notwithstanding  a  good 
appetite.  It  is  certain  that  picking  the  nose  is  very  common  in  a  multitude 
of  cases  where  no  worms  appear.  The  writer,  indeed,  would  counsel  the 
beginner  to  refuse  to  make  the  diagnosis  of  worms  till  some  are  seen.  Itch- 
ing and  scratching  at  the  anus,  if  cpiite  pronounced,  are  very  suggestive  of 
"  seat-worms"  (oxyurides  vermiculares),  but  even  then  delay  should  be  had 
till,  after  a  purgative  or  an  enema,  the  little  worms  are  actually  seen. 

The  "  round  worms"  passed  by  children,  or  sometimes  vomited  by  them, 
seem  often  to  be  expelled  rather  because  of  the  child's  illness  from  some 
other  cause  than  to  be  themselves  the  cause  of  the  acute  attack.  Sometimes 
they  lodge  in  enormous  numbers  in  the  intestines  of  unhealthy  children. 

Tape-worms  occasionally  infest  even  quite  young  children :  here,  too, 
segments  of  the  worm  must  be  seen,  to  warrant  a  diagnosis. 

Towards  the  beginning  of  this  paper  there  are  warning  words  against 
teething  being  regarded  as  a  cause  of  disease ;  but  these  remarks  do  not 
warrant  any  neglect  in  ascertaining  the  actual  state  of  the  dentition,  a  sub- 
ject to  be  fully  discussed  in  another  chapter. 

In  connection  with  the  physical  examination  of  the  child,  some  remarks 

have  been  already  made  in  the  present  chapter  on  peritoneal  effusions  and 

on  glandular  disease  in  the  abdomen.     Details  as  to  these,  and  the  varied 

disorders  of  the  digestive  organs,  must  be  studied  in  the  chapters  devoted  to 

them. 

GENITO-UKINAKY  SYSTEM. 

Disorders  in  the  genito-urinary  system  present  fewer  points  calling  for 
notice  than  in  the  case  of  the  other  physiological  systems. 

The  occurrence  of  renal  affections  after  scarlatina  is  in  this  connection 
one  of  the  most  important  considerations,  and  general  dropsy  or  albumi- 
nuria in  the  young  should  always  make  us  think  of  this,  although,  apart 
from  auy  fever,  parenchymatous  ncpliritis  is  specially  prone  to  affect  young 
subjects.  The  other  forms  f»f  Bright's  disease  likewise  occur  in  children, — 
contracted  kidney  occasionally,  and  amyloid  kidney  frequently. 

In  grave  cases  it  is  always  well  to  examine  the  urine  for  albumen  and 
Vol.  I.— 9 


130  DIAGNOSIS. 

sugar,  and  by  the  microscope.     To  do  this,  it  will  often  be  necessary  to 
have  recourse  to  the  catheter,  if  a  sample  cannot  otherwise  be  obtained. 

Gravel  in  the  urine  accounts  probably  for  many  painful  attacks  with 
screaming,  but  it  is  only  when  we  can  recognize  that  the  pain  is  with  mictu- 
rition, or  when  we  see  the  uric-acid  crystals  soon  after  the  water  is  passed, 
that  we  may  be  able  to  make  the  diagnosis.  Occasionally,  no  doubt,  there 
are  renal  colics  quite  unrecognizable  in  our  young  patients,  although  the 
urine  may  guide  the  treatment  if  charged  with  uric  acid  or  if  mixed  with 
blood. 

When  the  stone  is  in  the  bladder,  painful  micturition,  with  blood, 
especially  at  the  end  of  the  act,  or  the  occasional  stoppage  of  the  stream, 
or  the  presence  of  pus  and  mucus  in  the  urine,  may  help  the  diagnosis ;  but 
this  can  be  made  certain  only  by  sounding  the  bladder.  Vesical  calculus 
in  children  is  almost  always  limited  to  males. 

■■  Pyelitis  occurs  in  childhood ;  it  may  arise  from  a  calculus,  but  probably 
is  caused  more  often  by  scrofulous  deposits  in  the  pelvis  of  the  kidney.  The 
diagnosis  is  to  be  made  as  in  adults. 

Hydronephrosis  occurs  in  children,  and  may  indeed  be  congenital.  The 
presence  of  a  tumor  and  its  variations  in  size,  with  great  alterations  in  the 
quantities  of  urine  passed,  may  guide  the  examination. 

Cancer  or  sarcoma  of  the  kidney  often  attains  to  an  enormous  size  in 
children,  with  great  swelling  of  the  superficial  veins  and  the  most  extreme 
wasting. 

Diabetes,  both  in  the  saccharine  and  in  the  insipid  form,  is  found  in 
childhood :  the  saccharine  variety  is  at  times  clearly  traceable  as  an  heredi- 
tary affection.  The  diagnosis  is  made  as  in  adults,  but  the  prognosis  in 
childhood  of  diabetes  mellitus  is  the  worst  possible. 

,     Polyuria  from  granular  and  amyloid  kidney  must  be  remembered  in 
making  the  diagnosis  of  diabetes  insipidus. 

Urinary  sediments  in  childhood,  apart  from  pus,  blood,  casts,  and  epi- 
thelium, usually  consist  of  urates  or  uric  acid.  Both  deposits  are  oftener 
much  paler  than  in  adults,  and  white  urates,  sometimes  with  hedgehog 
crystals,  are  frequently  responsible  for  the  milky  urine  so  often  described  by 
mothers  and  nurses :  occasionally,  of  course,  the  milkiness  may  be  due  to 
pus.  Uric-acid  gravel  is  comparatively  common  in  childhood.  Oxalates 
are  often  seen  likewise  in  the  sediments.  Occasionally  cystine  is  found  in 
the  urine  of  children,  sometimes  with,  sometimes  without,  the  concurrence 
of  calculus ;  cystinuria,  although  really  rare,  may  be  found  in  several  mem- 
bers of  the  same  family.  Cholesterin  in  the  urine  is  very  rare :  the  writer 
has  seen  it  in  a  case  with  old  inflammatory  collections  in  the  kidney. 

Wetting  the  bed  at  night  (enuresis,  nycturia)  may  be  regarded  as  essen- 
tially an  affection  of  childhood :  it  will  be  discussed  elsewhere,  but  it  is 
mentioned  here  more  especially  because  the  passing  of  water  in  bed  may  be 
the  only  available  sign  of  an  epileptic  fit  occurring  during  the  night. 

Disorders  of  the  sexual  organs  need  not  detain  us.     The  precocious 


DIAGNOSIS.  131 

development  of  them  iu  childhood  has  been  already  mentioned.  The  dis- 
cussion of  malformatious  of  these  parts  will  be  dealt  with,  no  doubt  in 
great  detail,  elsewhere.  The  irritation  of  a  phimosis  or  its  influence  in 
determining  masturbation  or  enuresis  is  often  a  matter  for  inquiry  or  for 
surgical  treatment.  In  girls  the  occurrence  of  vulvitis  and  of  purulent 
discharges  from  the  genital  passages  may  at  times  raise  very  difficult  and 
disagreeable  questions ;  these  also  must  be  discussed  in  special  chapters. 

In  thus  passing  rapidly  in  review  some  of  the  symptoms  which  assume 
special  importance  in  childhood  or  which  occur  under  peculiar  forms  at 
early  ages,  it  may  seem  as  if  the  object  of  the  writer  had  been  to  accentuate 
such  peculiarities.  Such  accentuation  is  no  doubt,  in  a  sense,  important  and 
also  desirable ;  but  it  is  still  more  important  that  the  diseases  of  childhood 
should  be  studied  in  the  widest  possible  manner,  comparing  the  symptoms 
of  the  same  diseases  as  thev  occur  in  earlv  life,  in  adults,  or  in  the  ao^ed. 
The  study  of  the  diseases  of  children,  from  their  variety  and  multiplicity, 
is  not  so  apt  as  some  other  specialities  to  contract  the  mental  view  of  those 
devoted  to  it;  but  strenuous  efforts  must  be  made  to  resist  any  injurious 
educational  influence  which  may  tend  to  arise  even  from  the  restrictions  of 
age.  The  symptoms  of  disease  must  be  viewed  as  they  occur  at  all  ages  : 
the  value  and  significance  of  these  have  been  discussed  by  the  writer  at 
considerable  length  in  his  "  Clinical  Manual,"  to  which  he  ventures  to  refer 
the  reader,  especially  as  under  its  various  chapters  bibliographical  references 
to  standard  works  and  special  memoirs  will  be  found :  it  is  only  in  such 
full  and  elaborate  treatises  as  tliese  that  the  satisfactory  discussion  of 
symptoms  is  at  all  possible. 


THE 

INFLUENCE  OF  RACE  AND  NATIONALITY 

UPON  DISEASE. 

By  J.   WELLINGTON   BYEES,   M.D. 


Under  this  designation  it  will  be  appropriate  to  enumerate  and  discuss 
such  peculiarities  or  characteristics,  associated  with  the  phenomena  of  disease, 
as  are  perceived  to  be  dependent  upon  or  attributable  to  diiFerences  of  race 
and  nationality.  That  the  various  communities  of  mankind,  situated  as 
they  are  under  such  dissimilar  circumstances  of  life,  should  manifest  diver- 
sities in  their  morbid  proclivities,  as  well  as  in  their  physiological  tendencies, 
would  appear  worthy  of  acceptance.  While  it  is  true  that  each  race,  as  a 
rule,  possesses  susceptibility  to  the  morbjfic  influence  of  all  ordinary  dis- 
eases, and  that  none  can  lay  claim  to  complete  immunity  from  any,  still  we 
are  forced  to  concede  that  there  are  many  marked  variations  and  contrasts 
both  in  the  incidence  and  in  the  manifestations  of  morbid  phenomena. 
Bondin  has  remarked,  d  propos,  "  Man  is  not  born,  does  not  live,  does  not 
suffer,  does  not  die,  in  the  same  manner,  on  all  points  of  the  earth.  Birth, 
life,  disease,  and  death  all  change  with  climate  and  soil,  all  are  modified  by 
race  and  nationality."  In  passing  to  a  consideration  of  the  causes  or  condi- 
tions that  lead  to  these  differentiations  in  disease,  we  must  not  conjecture 
that  the  determining  factors  are  the  same  as  those  normal  or  physiological 
contrasts  that  subsist  between  the  various  races.  Deductions  based  upon 
ethnological  data,  such  as  color  of  skin,  character  of  hair,  size,  shape,  and 
proportional  dimensions  of  the  skull  and  face,  which  in  themselves,  as  can 
be  readily  appreciated,  could  not  possibly  modify  or  control  the  expression 
of  disease,  are  not  to  be  interrogated  here.  It  seems  best,  both  from  past 
experience  and  from  careful  estimations,  to  attribute  variation  in  suscep- 
tibility to  certain  fine  differences  in  the  structure  and  activity  of  the  tissues 
that  are  concerned  in  the  manifestations  of  morbid  processes, — particulars 
'that  belong  to  the  domain  of  the  histologist.  As  to  exactly  how  these  dis- 
parities between  people  came  to  originate  and  are  now  perpetuated,  without 
fiilly  comprehending  their  precise  nature,  we  cannot  ascribe  a  better  source 
132 


THE    INFLUENCE    OF    RACE    AXD    XATIOXALITY    UPOX    DISEASE.      133 

than  that  of  climate  acting  through  long  periods  of  time.  We  know  that  in 
this  we  have  a  powerful  element  for  good  and  for  bad.  Again,  we  know 
that  a  race  indigenous  to  a  certain  country  acquires,  through  many  genera- 
tions, charactenstics,  the  formation  of  which  can  be  distinctly  traced  to 
climatic  and  telluric  influences.  We  know,  further,  how  habits  of  life 
definitely  determine  the  susceptibility  and  non-susceptibility  to  certain  dis- 
eases, and  that  change  of  environment  always  induces  more  or  less  change 
in  the  physique,  mental  traits,  and  morals  of  any  man,  or  group,  or  even 
nation,  of  men.  While  no  attempt  will  be  made  to  theorize,  yet  it  does 
seem  probable  that  an  explanation  of  many  of  the  dissimilarities  which  are 
incidental  to  the  morbid  phenomena  of  the  different  races  might  be  traced 
to  these  contrasts  of  environment,  such  as  soil,  climate,  geographical  posi- 
tion, food,  and  social  condition,  all  of  which  are  known  to  be  influential  or 
qualified  to  alter  the  type  and  personnel  of  disease. 

Among  these  predisposing  conditions  that  are  found  to  modify  disease, 
none  seems  more  prominent  and  worthy  of  our  consideration  than  that  of 
climate.  Of  course  this  of  itself  is  totally  incapable  of  generating  specific 
disease ;  yet  that  it  does  institute  constitutional  peculiarities  and  tendencies, 
through  molecular  modifications  of  the  tissues,  which  gradually  become 
permanent  and  capable  of  hereditary  transmission,  would  seem  to  be  amply 
warranted  by  past  experience  and  observations.  Man,  like  the  animals  and 
plants,  bears  the  stamp  of  geographical  areas,  and  as  the  varied  regions 
have  their  natural  order  of  fauna  and  flora,  so  it  is  with  the  different  races  : 
neither  can  transgress  its  fixed  limits  without  danger,  deterioration,  aud 
ultimate  destruction.  By  reference  to  the  latitudinal  position  of  the  different 
races  it  will  be  seen  that  each  one  has  its  own  special  limits  of  health  defined 
by  rigorous  laws  of  climate.  The  Icelander  perishes  with  phthisis  if  trans- 
ported to  Copenhagen,  the  tropics  are  fatal  to  Europeans,  and  the  Dutch 
have  been  totally  unable  to  people  Sumatra  and  Java.  For  the  white  race, 
we  find  them  enjoying  the  most  perfect  health  and  the  highest  type  of 
physical  and  intellectual  development  in  the  temperate  zones,  above  45°  in 
the  Eastern  and  above  40°  in  the  Western  Hemisphere.  Whenever  they 
migrate  many  degrees  below  these  lines  a  series  of  profound  physiological 
changes  set  in,  which  continue  in  the  ratio  of  the  length  of  residence,  to- 
gether with  the  conjoined  effects  of  heat  and  other  influences  incident  to 
hot  climates  and  habits  of  life. 

On  the  other  hand,  if  we  look  at  the  intertropical  races  approaching  the 
latitudes  of  the  white  race,  we  see  a  list  of  deleterious  influences  begin  that 
gradually  grow  worse  as  they  come  nearer.  In  some  climates  everything 
tends  to  hinder.  No  Asiatic  race  has  ever  shown  that  it  possessed  the  power 
of  resistance  or  the  power  of  progress.  Neither  the  IMamelukes,  who  were 
a  Caucasian  race,  nor  the  Turks,  who  are  IMongolians,  unless  they  married 
native  women,  which  the  Mamelukes  never  did,  could  continue  their  racje  in 
Egypt,  all  their  offspring  perishing  in  the  first  or  second  year  (Volney). 

Dr.  Kenneth  Mclviunon  says  of  the  children  in  Bengal  that,  "  Even 


134     THE   INFLUENCE    OF   RACE    AND    NATIONALITY    UPON    DISEASE. 

when  there  is  no  tangible  disease,  nutrition  and  oxygenation  do  not  appear 
to  go  on  favorably ;  the  skin  is  pale,  the  muscles  wanting  in  substance  and 
tone ;  the  joyous  spirits  of  children  are  wanting,  the  body  is  inert  and  the 
mind  listless."  How  utterly  unfavorable  the  circumstances  are  here  is 
doubly  emphasized  by  Dr.  Twining,  who  states  that,  after  much  search  and 
careful  inquiry,  he  was  unable  to  find  anywhere  a  sample  of  the  third  gen- 
eration from  unmixed  European  stock.  The  Hindoos  are  of  Caucasian 
origin,  but  exposed  during  countless  generations  to  the  same  succession  of 
depressing  influences  of  climate,  so  that  a  temperament  is  begotten  which 
differs  widelv  from  that  of  Europeans,  as  is  seen  in  their  incapacity  to 
withstand  disease,  and  in  their  low  nervous  and  muscular  power. 

While  it  is  true  that  man  can  and  does  overcome  many  of  the  barriers 
of  climate,  yet  these  violations  of  his  natural  habitat  and  regime  are  always 
sooner  or  later  followed  by  reactions  that  bring  about  disaster  to  his  physi- 
cal well-being.  The  Khirghis  pasture  their  flocks  on  the  Pamir  plateau, 
perhaps  the  highest  steppe  in  the  world,  and  they  dwell  in  the  tropical  parts 
of  Southern  Egypt,  as  well  as  at  the  ill-famed  Massowah,  on  the  Red  Sea. 
We  find  the  Chinese  at  Kiakhta,  on  the  Siberian  boundary,  where  the 
mean  temperature  is  below  freezing  and  the  thermometer  falls  in  winter  to 
40°  Reaumur,  and  we  find  them  in  the  island  of  Singapore,  which  almost 
touches  the  equator.  Turkish  races,  such  as  the  Yakuts,  are  settled  on  the 
Lena,  where  Kennan  found  them  gossiping  in  the  open  air'  at  a  tempera- 
ture of  32°  Reaumur,  clad  only  in  a  shirt  and  a  fur  coat.  These  are  suffi- 
cient to  show  that  man  is  capable  of  forcibly  adapting  himself  to  almost 
any  circumstance  of  life ;  but  he  does  so  at  great  cost  to  his  physical  and 
intellectual  well-being,  for  in  every  instance  where  the  departure  from  his 
original  habitat  has  been  distant  and  at  short  intervals  of  time  he  has 
suffered  proportionally. 

There  are  certain  other  facts  associated  with  man's  geographical  distri- 
bution over  the  earth,  among  which  must  be  mentioned  that  in  approaching 
the  equator  it  has  been  found  that  the  mortality  is  increased,  and  conse- 
quently the  average  duration  of  life  is  lessened. 

Again,  further  observation  goes  to  show  that  the  proportional  number 
of  individuals  who  attain  a  given  age  differs  in  different  climates,  and  the 
warmer  the  climate,  other  things  being  equal,  the  shorter  the  average  life, 
early  puberty  being  always  associated  Avith  premature  decay.  In  Europe 
this  is  illustrated,  being  for  Italy  one  death  in  twenty-eight,  and  for  Eng- 
land one  in  forty-six.  From  estimates  made  a  few  years  since  (Dr.  C.  F. 
Campbell,  Science)  upon  the  adult  males  belonging  to  the  society  of  Odd- 
Fellows,  in  the  United  States,  it  was  found  that  the  death-rate  of  those 
of  the  Southern  or  tropical  States  was  just  twice  as  great  as  that  of  those 
in  the  temperate  ones  of  the  North,  it  being  for  the  former,  as  an  an- 
nual average,  1.42  per  100  death-rate  and  .946  week  of  sickness,  and 
for  the  latter,  as  an  annual  average,  .70  per  100  death-rate  and  .266  week 
of  sickness.     In  making  a  comparative  use  of  these  statements  to  govern 


THE    INFLUENCE    OF    RACE    AND    NATIONALITY    UPON    DISEASE.      135 

observations  in  regard  to  sickness  and  deaths  among  children,  it  must  be 
added  that,  while  high  temperature  is  nearly  always  inimical  to  them,  still 
the  causes  of  death  in  children  afford  very  many  contrasts  to  those  of  adults, 
and  consequently  our  conclusions  sliould  be  guarded.  Under  this  special 
heading  we  have  the  results  of  the  compilations  of  Dr.  Eklund,  of  Stock- 
holm, which  gives  the  annual  death-rate  of  children  under  one  year  in 
various  parts  of  the  world.  For  Europe,  the  average  he  states  as  being 
twenty-five  per  cent,  of  all  deaths,  and  for  the  largest  cities  of  the  United 
States  he  says,  "  The  infants  dying  under  one  year  average  fifty  per  cent, 
of  the  whole  number  born ;"  though  in  contrast  to  this  assertion  I  shall 
have  to  add  that  the  average  death-rate  of  such  children  for  thirty-one 
registered  cities,  as  given  by  the  Tenth  Census,  was  only  267.5  per  1000. 

Signor  Bodie  has  recently  published  some  figures  that  corroborate 
Eklund's  data  very  substantially  as  regards  Europe.  He,  however,  states 
that  only  twenty  per  cent,  of  the  children  die  in  the  first  year,  that  ten 
per  cent,  die  in  the  first  month,  and  that  full  thirty-three  per  cent,  of 
the  remainder  die  before  they  reach  the  fifth  year.  Following  the  data  of 
Eklund,  the  lowest  death-rates  are  found  in  Belgium,  Denmark,  Sweden, 
England,  and  Switzerland,  where  they  vary  from  14.3  to  26.2  per  100; 
the  highest  rates,  from  31  to  48  per  100,  being  found  in  Austria,  Ger^ 
many,  and  Russia.  For  Berlin  it  is  given  at  58.1,  for  Paris  30.8,  and 
for  St.  Petersburg,  where  the  death-rates  are  known  to  exceed  frequently 
the  births  by  as  many  as  100  per  month,  the  rate  is  32.5  per  100.  The 
variations  in  these  figures  are  not  sufficiently  marked  and  general  to  war- 
rant the  conclusion  that  the  factor  of  climate  is  as  important  in  gov- 
erning the  diseases  of  children  as  in  adults.  However,  when  we  come  to 
consider  the  factor  of  class  or  social  condition,  we  shall  find  a  decidedly 
prevalent  and  potent  influence  at  work  in  this  kind  of  individuals.  M. 
Kor5si,  of  Buda-Pesth,  has  found  the  following  to  represent  his  experience 
in  the  matter  of  susceptibility  to  infectious  and  contagious  diseases  among 
children.  Cholera,  small-pox,  measles,  and  typhoid  fever  are  more  preva- 
lent among  the  poor,  while  diphtheria,  croup,  pertussis,  and  scarlet  fever 
are  found  among  the  M-ell-to-do.  Zymotic  diseases,  as  a  whole,  are  sixty 
per  cent,  more  frequent  among  those  living  in  basements  than  in  higher 
domiciles.  But  the  increased  mortality  in  underground  tenements  applied 
only  to  certain  diseases,  especially  measles  and  pertussis,  while  diphtheria 
and  scarlet  fever  were  ten  per  cent,  less  than  in  people  living  above- 
ground.  In  regard  to  other  statistics  bearing  upon  the  subject,  those  of  the 
city  of  Dublin  show  that  class  has  a  decided  and  important  influence 
upon  the  longevity  and  health  of  town-dwellers.  For  the  first  class  of 
society,  including  the  members  of  the  professions  and  indcj)cndent  ])eoplc, 
the  death-rate  was  found  to  be  22.5  per  1000,  for  the  middle  or  second 
class  25.4,  for  the  third  class,  shopkeepers,  artisans,  and  trades-people, 
26.1,  and  for  the  fourth  class,  composed  of  those  in  service,  jails,  and 
workhouses,  37.2  per  1000.     In  London  the  death-rate  has  been  found 


136     THE    LN'FLUEXCE    OF    EACE    AND    XATIOXALITY    UPOX   DISEASE. 

to  be,  among  the  rich,  from  12 J  to  25  per  1000,  and  for  the  poor,  from 
25  to  35  per  1000.  The  well-to-do  in  England  have  an  average  life  of 
fifty-five  years,  while  the  artisan  class  live  only  a  little  over  half  of  this, 
— namely,  twenty-nine  and  a  half  years. 

From  the  foregoing  statements  of  climate,  and  its  undoubted  influence 
through  temperature,  food,  etc.,  of  geographical  distribution  and  its  rela- 
tions to  birth,  maturity,  and  decline,  and  of  class,  with  the  differences 
that  it  is  seen  to  produce  in  sickness  and  mortality,  I  think  that  we 
may  properly  infer  that  they  constitute  some  of  the  principal  sources 
through  which  we  may  explain  the  diversities  in  t^^pe  and  susceptibility  of 
the  different  diseases  among  different  people.  If,  as  will  be  seen,  the  negro 
and  the  yellow  race  differ  widely  from  the  European  in  their  suscepti- 
bility to  the  morbific  influences  of  certain  diseases,  then  we  must  concede 
that  this  is  because  of  the  differences  in  the  methods  of  their  living,  their 
location,  diet  and  habits,  together  with  the  other  peculiarities  that  exist  in 
the  structure  and  functions  of  their  tissues,  to  which  we  can  now  only 
briefly  allude.  Reasoning  from  analogy  of  those  diseases  that  we  know  do 
exist  by  acquired  constitutional  peculiarities,  such  as  ichthyosis,  where  it 
is  the  structure  and  mode  of  growth  of  the  epidermic  cells,  haemophilia, 
where  it  is  the  structure,  presumably,  of  the  blood-vessels,  and  Daltonism, 
w^here  it  is  the  finer  details  of  the  retina,  we  are  led  to  believe  that  it  is  the 
same  with  the  races,  and  that  in  each  it  is  the  peculiar  stnicture  and  activity 
of  the  tissues  which  are  mostly  concerned  in  each  disease,  that  are  at  fault. 
Of  course  our  present  knowledge  does  not  furnish  us  with  sufficient  data  to 
offer  a  description  of  these  subtile  changes ;  yet  that  this  is  a  proper  explana- 
tion appears  to  be  warranted  by  such  knowledge  as  we  do  possess,  being 
particularly  applicable  to  those  classes  of  disease  due  to  infection, — those 
obviously  attributable  to  morbid  animal  poisons  and  bacteria.  The  limits 
of  this  chapter  preclude  any  fiirther  notice  under  this  section,  and  we  shall 
now  enumerate  a  few  of  the  principal  diseases  in  which  race  and  nationality 
are  seen  to  affect  their  order  and  phenomena,  enabling  the  reader  to  see  the 
scope  and  purpose  of  these  distinctions. 

■Whooping'-Coug'h. — The  history  of  this  disease  begins  in  the  middle 
of  the  sixteenth  century,  when  Baillou  gives  the  first  description,  though  it 
must  be  said  that  a  disease  presenting  such  well-defined  characteristics  must 
have  existed  long  before.  The  native  habitat  of  it  is  probably  very  narrow, 
and  does  not  correspond  to  its  present  limits.  In  Europe  the  disease  is  toler- 
ably uniform  in  its  diffusion,  the  Scandinavian  countries  showing  it  quite 
extensively.  In  Sweden,  from  1749  to  1764,  more  than  43,000  children 
died  of  it  (Rosenstein,  "  Kiuderkranldieiten,"  1785),  and  from  1862  to 
1881,  according  to  official  returns,  there  died  86,000.  It  is  said  to  be 
equally  fatal  in  Russia,  Denmark,  and  Norway.  In  Prussia,  from  1875 
to  1880,  nearly  85,000  children  succumbed  to  pertussis.  In  England  and 
Wales,  from  1848  to  1855,  there  were  72,000  deaths,  and  from  1858  to  1867, 
120,000.     It  is  scarcely  less  fatal  in  France,  Belgium,  Germany,  Holland, 


THE    INFLUENCE    OF    EACE    AND    NATIONALITY    UPON    DISEASE.     137 

Scotland,  aud  Ireland.  In  the  latter,  according  to  Wylde's  acconnt  (Ed'm. 
Med.  and  Surg.  Jour.,  1845),  it  has  the  character  of  an  endemic  maladv, 
with  a  mortality  that  ranks  fifth  on  the  list  of  the  causes  of  death,  it  being 
in  1841  the  cause  of  37,300  deaths.  Only  four  examples  of  it  have  been 
noted  in  Iceland  during  the  present  century,  and  Finsen  in  a  practice  of  ten 
years  never  saw  a  case  there.  There  have  been  only  three  epidemics  in  the 
Faroe  Islands.  According  to  Tobler,  it  is  epidemic  in  Palestine.  In  Aus- 
tralia it  is  comparatively  a  new  disease,  and  has  occurred  only  since  1830, 
but  it  was  epidemic  in  the  years  1843  and  1855.  It  first  appeared  in  New 
Zealand  in  1847.  In  Africa  it  has  occurred  only  in  a  few  regions  and  some 
of  the  adjacent  islands,  such  as  Mauritius,  Madagascar,  and  Cape  Colony, 
also  in  the  interior  of  South  Africa,  Western  Soudan,  Algiers,  and  EgyjDt. 
In  Egypt,  Pruner  has  seen  it  in  children  of  every  color.  According  to 
Heymaun  aud  Waitz  ("Diseases  of  Children  in  Hot  Climates,"  1851),  the 
disease  in  the  East  Indies  is  found  as  much  among  the  children  of  the 
Malay  and  Japanese  population  as  among  theEuropeans.  Milroy,  Mackay, 
and  others  speak  in  general  terms  of  its  occurrence  among  the  native  chil- 
dren of  India  :  there  it  occurs  from  the  lowest  altitude  up  to  6500  and  8000 
feet.  It  is  rarely  found  in  Central  America,  though  often  seen  in  Brazil, 
Chili,  and  Peru.  In  the  Northern  and  Western  States  of  this  country  it 
is  frequently  as  common  as  in  Europe,  and  occurs  in  all  seasons  of  the 
year.  According  to  experience,  it  attacks  all  circles  and  classes  of  popula- 
tion, though  it  is  more  fatal  in  the  poor  than  in  the  rich.  The  disease  is 
more  fatal  in  males  than  in  females,  in  the  country  than  in  cities,  and 
assumes  its  most  unfavorable  type  in  mountainous  sections.  In  regard  to 
the  influence  of  race,  it  is  more  than  twice  as  fatal  for  blacks  as  it  is  for 
whites,  the  proportion  being,  according  to  the  Tenth  Census,  for  whites  14.3 
and  for  blacks  33.0  for  each  1000  deaths  from  all  causes. 

Cerebro-Spinal  Meningitis. — The  general  history  of  this  disease  until 
quite  recently  seems  to  have  been  largely  occupied  by  Europe.  The  coun- 
tries that  it  has  been  oftenest  and  most  extensively  seen  in  are  France, 
mostly  in  the  southern,  western,  and  northern  parts,  Italy,  particularly  in 
the  provinces  of  Sicily,  and  Sweden  as  far  north  as  63°.  It  has  been 
prevalent,  though  rarely,  in  Ireland,  Russia,  Denmark  (previous  to  1848), 
Hungar}^,  Austria,  and  Greece.  It  is  absolutely  rare  in  the  Iberian  Penin- 
sula, Roumania,  and  Turkey.  It  is  not  common  in  England,  the  Nether- 
lands, and  Switzerland,  except  in  very  slight  and  occasional  forms.  Scot- 
land, Belgium,  North  and  Central  Italy,  and  Iceland  seem,  as  yet,  to  have 
well-nigh  complete  immunity.  The  only  references  to  it  in  the  Orient  arc 
from  Persia,  Syria,  and  Asia  ISIinor,  and  some  few  cases  that  have  been  met 
with  in  India.  So  far  as  published  reports  arc  calculated  to  give  informa- 
tion, the  West  Indies,  Mexico,  and  Centi-al  America  are  free  from  it.  ^Vhh 
regard  to  Africa,  Algiers  is  the  only  place  where  we  hear  of  it,  and,  according 
to  Pruner,  the  Arabs  suffered  equally  with  the  wliites.  There  seem  to  be 
some  discrepancies  in  the  accounts  of  this  disease  as  it  pertains  to  the  white 


138     THE    INFLUENCE    OF    RACE    AND    NATIONALITY    UPON    DISEASE. 

and  colored  races.  In  several  epidemics  that  have  visited  the  United 
States,  the  negro  race  has  suffered  with  unusual  severity.  Of  85  patients 
treated  by  Ames,  of  Montgomery,  Alabama,  23  were  white  and  63  black. 
In  the  epidemic  at  New  Orleans  in  1850  the  negroes  suffered  most,  and 
it  was  chiefly  confined  to  them.  The  same  was  the  case  in  Memphis,  Ten- 
nessee, in  1862-63,  when  it  broke  out  among  the  colored  troops.  There 
were  strong  evidences  of  the  unusual  susceptibility  of  the  colored  race 
in  the  epidemics  in  Mississippi,  1862-63  (Hughes,  "Titans.  Miss.  Med. 
Convention,  1878"),  in  Mobile,  Alabama,  1864-65,  and  in  Maryland  in 
1864.  According  to.  Williams,  of  Montgomery,  in  1848,  out  of  84  patients 
10  were  under  10  years,  and  23  between  10  and  20,  the  disease  being  par- 
ticularly severe  in  the  negro.  In  the  disease  at  Philadelphia  in  1867, 
Githens  says  that  it  was  "particularly  severe  in  the  negroes."  At  the 
present,  and  for  several  years  past,  this  country  has  been  the  chief  seat  of 
the  disease.  In  distribution  it  has  extended  from  Canada  to  the  Gulf,  and 
from  ocean  to  ocean.  The  first  outbreak  presenting  an  epidemic  character 
occurred  in  1814,  and  swept  over  the  New  England  States,  lasting  until 
1816.  A  remarkable  feature  of  this  occurrence  was  its  being  limited  nearly 
entirely  to  children,  the  various  epidemics  throughout  the  world  heretofore 
showing  marked  differences  in  this  respect.  There  can  be  no  doubt,  judging 
from  the  data  of  past  experience,  that  this  disease  is  more  severe  in  the 
dark  races  than  in  the  whites,  the  ratio  of  susceptibility  and  severity  being 
exactly  proportional  to  the  depth  of  color,  the  blackest  suffering  most. 

Trismus  Neonatorum. — One  of  the  most  notable  points  connected  Avith 
the  geographical  distribution  of  this  disease,  as  compared  with  tetanus  in 
the  adult,  is  the  much  greater  prevalence  of  the  former  in  the  higher  lati- 
tudes, and  even  in  the  extreme  polar  regions,  of  both  hemispheres.  This  is 
particularly  true  of  large  and  populous  towns,  where  most  of  the  deaths 
from  trismus  among  new-born  infants  are  among  the  poorer  classes  and 
in  the  ill-kept  foundling  or  lying-in  hospitals.  In  Cayenne  this  disease  is 
terribly  fatal.  In  British  Guiana,  according  to  Hancock,  it  kills,  upon  an 
average,  more  than  half  the  children  born.  In  Cuba  it  is  very  disastrous, 
there  being  369  deaths  reported  in  the  official  documents  in  two  years.  In 
Jamaica  twenty-five  per  cent,  of  the  negro  children  die  of  it  each  year ;  and 
it  is  said  to  be  equally  destructive  in  Barbadoes,  Grenada,  and  St.  Thomas. 
Bourel-Ronciere  estimates  the  deaths  from  trismus  in  Rio  Janeiro  at  one- 
fourth  of  all  the  infants  born  in  one  year.  In  the  city  of  Buenos  Ayres, 
with  a  population  of  200,000  and  a  yearly  increase  of  one  thousand,  the 
deaths  from  trismus  in  1875  were  445,  though  they  have  steadily  declined 
ever  since,  and  in  1880  were  only  108  for  the  first  six  months  of  the  year. 
Mantegazza  witnessed  a  frightful  epidemic  in  Montevideo  in  1852.  The 
deaths  in  New  Orleans  during  the  same  year  were  249  out  of  a  total  mor- 
tality of  6617,  or  37.6  per  1000.  The  mortality  in  Charleston,  South  Caro- 
lina, in  1856.  was  40  per  1000.  In  the  tropical  regions  of  the  Eastern 
Hemisphere  the  disease  is  equally  severe,  epidemics  having  visited  India, 


THE    INFLUENCE    OF    RACE    AND    NATIONALITY    UPON    DISEASE.     139 

Africa,  and  the  Malay  Archipelago.  Tliere  seems  to  be  little  information 
of  recent  date  concerning  this  disease  in  Southern  Europe.  According  to 
Wylde,  in  1854  it  became  quite  common  in  Ireland.  It  has  also  been  men- 
tioned by  Patema  as  occurring  in  Italy  in  1835.  It  became  epidemic  in 
Iceland  a  good  many  years  since,  and  was  attended  with  great  loss  of  life : 
during  the  endemic  which  visited  the  Westmanna  Islands,  oif  the  southern 
coast,  the  mortality  reached  as  high  as  sixty-four  per  cent.  Trismus  is  said 
to  be  more  common  among  Jewish  and  Mohammedan  children  than  among^ 
those  of  other  races.  We  are  indebted  to  Baldwin,  of  Alabama,  and  Dowell 
for  a  description  of  this  malady  in  the  negro  child.  Experience  shows  that 
in  negroes  the  disease  is  always  attended  by  a  high  rate  of  mortality,  very 
few  getting  well  when  once  attacked.  In  the  Dublin  Rotunda  Hospital  the 
death-rate  from  1757  to  1882  was  sixteen  per  cent.,  and  a  large  proportion 
of  these  were  said  to  be  caused  by  trismus.  Viewing  this  disease  in  any  of 
its  causative  relations,  whether  filth,  urine  on  the  cord,  pressure  upon  the 
brain,  or  what  not,  one  thing  is  always  prominent,  and  that  is  neglect  or 
inattention  to  the  ordinary  care  of  the  infant.  I  have  never  seen  a  case 
in  a  well-kept,  clean,  and  sanitary  place.  On  the  other  hand,  in  my  expe- 
rience, every  colored  child  born  in  dirty  surroundings  that  takes  it  certainly 
dies. 

Scarlet  Fever. — The  area  of  diffusion  of  scarlet  fever  is  much  less 
than  that  of  small-pox  or  measles.  That  the  continents  of  Asia  and  Africa, 
which  are  the  chief  seats  of  the  latter  two  diseases,  have  never  been  severely 
visited  by  scarlet  fever,  is  a  remarkable  fact.  It  occurs  as  an  epidemic 
much  less  frequently  than  measles,  and  in  some  places  its  visits  are  ten  or 
twenty  years  between.  Again,  there  are  great  fluctuations  in  its  types,  some 
severe,  others  mild.  Withering,  one  of  the  earliest  and  best  authorities 
upon  scarlet  fever,  states,  from  his  Birmingham  experience  of  1778,  that 
the  disease  raged  severely  in  many  elevated,  dry,  and  airy  places,  while  the 
dwellers  in  low,  damp,  and  ill- ventilated  parts  of  the  toAvn  suffered  to  only 
a  slight  degree.  Graves  says  ("  System  of  Medicine,"  1843)  of  the  epidemic 
of  1839  in  Ireland,  "  The  nature  of  the  disease  was  not  in  the  least  affected 
by  the  situation  of  the  dwelling,  it  being  equally  bad  in  Dublin  as  in  the 
hills."  The  origin  and  first  habitat  of  scarlet  fever  are  unknown,  its  his- 
tory being  linked  with  that  of  measles.  It  appeared  in  England  and 
Scotland  in  1661  (Sibbald,  "Scotia  Illustrated,"  1684),  at  Berlin  in  1716, 
at  Florence  in  1717,  and  in  Denmark  in  1740.  When  and  where  it  first 
appeared  in  Asia  and  Africa  cannot  now  be  determined.  At  present  it  is 
most  met  with  in  Europe, — in  the  countries  of  Germany,  France,  England, 
Russia,  and  the  Netherlands.  It  goes  as  far  north  as  Iceland,  and  in  the 
south  extends  to  Brazil  and  Chili.  Greenland  has  escaped,  and  it  occurs 
only  at  rare  intervals  in  Newfoundland. 

Pruner  states  that,  so  far  as  he  knows,  the  colored  races  are  exempt  from 
scarlet  fever,  though  Moulin  liclieves  that  the  negroes  of  Senegambia  have  it 
rarely.     It  seems  from  the  account  of  the  disease  given  by  Frick,  of  Balti- 


140     THE    INFLUENCE    OF    RACE    AND    NATIONALITY    UPON    DISEASE. 

more,  in  Amer.  Jour.  Med.  Sci.,  1855,  that  the  Avhites  and  negroes  at  one 
time  suifered  in  equal  proportions,  the  figures  given  being  for  the  epidemic 
of  1850-54  at  Bahimore  as  follows :  for  whites,  13.8,  and  for  negroes, 
10.8,  per  10,000  of  population.  According  to  Drake,  the  South  is  less  fre- 
quently visited  than  the  North.  In  South  America,  following  the  accounts 
of  Brunei,  Sigaud,  and  others,  the  disease  is  frequently  of  the  same  type 
among  the  colored  as  among  the  whites.  Mantegazza  {Edin.  Med.  Jour., 
1849)  states  that  the  Creoles  suffer  more  than  the  Avhites;  and  that  the  red- 
skinned  natives  of  jS^orth  America  (in  Canada)  are  at  least  not  exempt  fol- 
lows from  the  remark  of  Stratton  {^Lancet,  1870),  "In  epidemic  scarlatina 
it  appeared  to  me  that  the  Indians  were  less  susceptible  of  an  attack  than 
the  whites." 

The  United  States  Tenth  Census  shows  the  difference  of  mortality  in 
the  races  as  follows  :  for  whites,  20.9,  for  negroes,  3.9, — a  veiy  marked  con- 
trast. As  to  nationality,  the  German  has  a  death-rate  of  30.1,  and  the  Irish 
24.0,  though  the  mortality  of  the  latter,  in  children  under  five  years,  is 
very  much  higher.  The  census  shows  that  this  disease  is  far  more  preva- 
lent in  the  northern  portion  of  the  United  States,  especially  in  New  York, 
Pennsylvania,  the  Ohio  Valley,  Wisconsin,  jNIinnesota,  Kansas,  and  Ne- 
braska, than  in  the  South.  This  corroborates  past  experiences,  though  the 
disease  is  much  rarer  now  in  the  South  than  in  former  times. 

Measles. — The  area  of  distribution  of  this  disease  extends  nearly 
around  the  entire  earth.  Accordino;  to  Lang-e,  it  had  not  occurred  in 
Greenland  previous  to  1864.  Vinson  says  that  New  Caledonia  has,  up  to 
the  present  time,  also  escaped.  The  susceptibility  to  the  virus  of  it,  as  is 
seen  from  its  geographical  distribution,  is  uniformly  shared  by  the  whole  of 
mankind,  of  whatever  race  or  nationality.  If  among  the  colored  people  it 
puts  on  its  worst  forms,  and  leads  to  disastrous  results  exceptionally  often, 
the  reason  does  not  lie  in  their  physiological  peculiarities,  but  in  their  un- 
favorable conditions  of  life.  It  appears  to  be  quite  independent  of  climatic 
influence,  though  the  disease  occurs  mostly  during  the  colder  seasons  of 
spring,  autumn,  and  winter.  It  seems  to  run  as  mild  a  course  in  troj^ical 
and  subtropical  as  in  temperate  climates,  though  in  some  sections,  as  the 
Himalaya,  and  in  Honduras  and  Madagascar,  the  disease  takes  on  pecu- 
liarly malignant  forms.  Fuchs  says  of  parts  of  England,  France,  and 
Holland  that  the  disease  is  most  malignant  especially  in  the  presence  of 
malaria.  Squire  gives  an  account  {Medical  Times  and  Gazette,  1877)  of  an 
epidemic  in  the  Fejee  Islands  which  destroyed  twenty  thousand  people,  or 
nearly  one-fourth  of  the  entire  population.  Among  uncivilized  peoples  it 
is  known  that  the  disease  often  assumes  its  worst  forms.  In  1749  an  epi- 
demic destroyed  thirty  thousand  Amazon  Indians,  of  Brazil.  In  1849,  one- 
half  of  an  entire  tribe  of  American  Indians  perished.  It  was  equally  fatal 
in  1846  among  the  inhabitants  of  Hudson  Bay,  and  in  1852  among  the 
Hottentots.  In  Paris  during  the  siege  (1871),  out  of  215  of  the  Garde 
Mobile  who  took  measles,  ^Q,  or  40  per  cent.,  died.     In  the  epidemic  which 


THE    INFLUENCE    OF    RACE    AND    NATIONALITY    UPON    DISEASE.     141 

prevailed  among  the  Confederate  forces  during  the  civil  war  (18(34)  there 
were  38,000  cases,  and  1900  died,  the  mortality  being  in  some  hospitals 
as  high  as  twenty  per  cent.  Mastermau  says  of  the  epidemic  of  the 
National  Army  of  Paraguay,  at  the  beginning  of  the  war  with  Brazil, 
that  "  it  swept  away,  in  three  months,  nearly  one-fifth  of  the  entire  army." 
Hirscli  considers  that  malignancy  of  type  is  due  more  to  mistakes  in 
dieting  and  treatment  than  to  other  influences,  and  he  accounts  for  the 
severity  of  the  disease  upon  these  grounds.  Fuchs  says,  ''  In  the  north, 
and  in  the  elevated  districts,  the  inflammatory  forms  occur,  while  in  the 
south,  and  in  the  flat  districts,  it  is  more  usually  the  asthenic  and  putrid 
forms  that  occur."  Among  the  Chinese  measles  is  quite  common,  though 
with  the  peculiarity  of  not  protecting  them  against  the  kind  that  afflicts  the 
white  race.  Measles  has  increased  in  Paris  since  1865  from  31  to  46  per 
100,000  in  1887.  For  the  United  States  the  average  age  of  those  dying 
from  measles  is  seven  years.  The  deaths  are  greater  in  the  rural  districts 
(12.3)  than  in  the  cities  (7.4).  Among  the  whites  the  ratio  is  9.1  per  1000, 
for  negroes  17.7,  for  Germans  8.5,  and  for  Irish,  only  5.3. 

In  regard  to  the  peculiarities  connected  with  eruptive  fevers  in  the 
dark  races,  of  course  the  feature  of  color  is  a  variable  one.  In  the  pure 
negro  the  eruption  of  measles  appears  as  yellowish  spots  slightly  elevated 
and  giving  a  sensation  of  roughness ;  in  the  mulatto,  as  dusky  brown,  ill- 
defined  spots ;  and  in  the  lighter  shades,  as  more  distinct,  reddish-brown 
spots,  approaching  the  characteristics  of  the  disease  in  the  white  race.  The 
high  mortality  of  this  disease  among  the  negro  race  is  doubtless  due  to 
want  of  attention  and  absence  of  proper  diet,  although  the  subtile  influence 
of  race  certainly  has  some  contributing  power.  Among  them  in  the  South, 
as  a  rule,  the  disease  is  considered  harmless,  and  no  precaution  is  taken  for 
protection  or  to  prevent  its  spreading.  Among  the  Indians  this  disease 
occupies  a  prominent  position  on  the  list  of  death-causes,  and  it  is  often 
followed  by  serious  sequelae,  which  lead  to  fatal  results. 

Diphtheria. — This  is  one  of  the  standard  diseases  of  modern  times. 
Whether  some  races  are  especially  predisposed  to  take  diphtheria,  while 
others  enjoy  a  pronounced  immunity  from  it,  cannot  be  decided  for  certain 
with  the  scanty  and  conflicting  information  that  we  possess  relating  to  epi- 
demics in  localities  where  the  population  is  a  mixed  one.  The  statement 
of  Odriozla,  that  the  negro  is  protected  in  Peru  from  diphtheria  as  well  as 
yellow  fever,  is  contradicted  by  Tschudi,  who  says  very  emphatically  that  it 
is  the  children  of  the  negroes  in  that  country  who  suflcr  from  malignant  sore 
throat,  an  opinion  that  has  also  been  supported  by  the  jiublishcd  experiences 
of  Goldsmitli,  of  Oakland,  Missouri,  and  of  Smart,  of  the  Bermudas.  The 
inference  drawn  from  the  exemjition  of  tlie  Chinese  during  the  epidemic  in 
Victoria,  that  the  Mongolian  race  lias  immunity,  is  just  as  little  warranted 
in  fact,  for  the  disease,  according  to  Dudgeon,  is  widely  diffused  tli rough 
Northern  China,  and  has  not  spared  the  Japanese.  According  to  the  reports 
of  the  English,  Southern  China  has  not,  as  yet,  been  visited  by  the  disease. 


142     THE    ESTFLUENCE    OF    RACE   AND    NATIOXALITY   UPON    DISEASE. 

In  the  epidemic  which  visited  Pekin  in  1866  there  died  from  diphtheria 
no  fewer  than  twenty-five  thousand  Chinese.  Japan  was  visited  in  1877, 
and  Yokohama  suffered  severely.  In  other  parts  of  Asia,  such  as  Smyrna, 
it  became  epidemic  in  1865  and  spread  throughout  Asia  Minor,  though  up 
to  1868  the  disease  had  not  been  severe  in  Syria.  Persia  had  a  disastrous 
visitation  in  1874-78.  In  India  there  have  been  several  epidemics,  the  first 
occurring  in  1800.  In  Africa  there  are  but  few  accounts  of  the  disease,  and 
up  to  the  present  it  seems  to  have  occurred  only  in  Senegambia  and  on  the 
West  Coast  sporadically,  though  in  South  Africa  there  was  a  general  and 
severe  epidemic  in  1866.  'New  Caledonia  has  never  been  visited.  On  the 
Eastern  coast  the  disease  has  been  indigenous  since  1837.  Pruner  found  it 
in  Egypt,  and  it  occurs  in  Algeria  and  Tunis.  It  has  been  epidemic  in  most 
South  American  countries  and  the  West  Indies.  Climate  and  season  do  not 
seem  to  influence  the  disease, — the  same  features  appearing  in  Sweden  as  in 
Spain.  The  inference  is  that  the  exemption  of  those  countries  which  have 
thus  far  escaped  it  is  due  rather  to  a  want  of  disease-producing  cause  than 
to  non-susceptibility  on  the  part  of  the  race  or  nation.  Since  1856  the  dis- 
ease has  become  generally  diffused  throughout  Xorth  America  and  Europe. 
From  statements  made  in  the  United  States  Tenth  Census,  it  appears  that 
diphtheria  is  especially  prevalent  among  the  German  population  of  the 
I^orthern  States ;  and  upon  the  whole  the  disease  seems  to  be  making  prog- 
ress. In  England  during  the  year  1880  the  deaths  from  diphtheria  were 
532  per  100,000  deaths  from  all  causes.  W.  Roger  Williams,  from  an 
examination  of  ten  million  hospital  cases  of  various  diseases  in  England, 
concludes  that  the  disease  is  more  common  in  females  than  in  males, — a 
result  that  finds  corroboration  in  the  government  statistics  of  this  countr}'. 
In  regard  to  my  personal  experience  among  the  colored  race  of  the  Southern 
States,  I  have  found  that  they  are  less  disposed  to  contract  the  disease  than 
the  whites,  and  out  of  one  hundred  deaths  from  this  cause  I  have  not  found 
more  than  one-fifth  to  occur  among  the  blacks.  From  statistics  obtained 
by  the  government,  it  appears  that  diphtheria  is  more  fatal  in  rural  than  in 
urban  districts,  the  order  of  frequency  in  the  different  races  being,  for  each 
1000  deaths  from  all  causes,  as  follows :  whites,  52.63 ;  Indians,  37.36 ; 
blacks,  23.27.  From  these  figures  it  will  be  seen  that  diphtheria  as  it 
occurs  in  this  country  is  more  than  twice  as  fatal  among  whites  as  among 
colored,  notwithstanding  the  fact  that  diphtheria  is  a  disease  of  the  poorer 
classes  and  mostly  confined  to  the  country,  or  at  least  most  fatal  there. 

Cholera  Infantum. — We  are  indebted  to  Benjamin  Push  for  the  first 
account  of  cholera  infantum  in  this  countiy.  The  disease  certainly  occurs  all 
over  the  globe,  and  it  is  proportionally  worse  in  those  localities  where  im- 
purities of  water  and  soil  exist,  together  with  extreme  heat  and  a  crowded 
population.  As  regards  the  influence  of  race  on  the  incidence  of  cholera 
infantum,  it  must  be  mentioned  that  in  1855  Frick,  of  Baltimore,  regarded 
the  mortality  as  being  twice  as  great  in  the  white  as  in  tiie  colored  race 
{Amer.  Jour.  Med.  Sci.,  1855).     Upon  reference  to  the  last  census  we  find 


THE    INFLUE^X'E    OF    RACE    AND    NATIONALITY    UPON    DISEASE.     143 

that  the  proportion  of  deaths  for  each  1000  from  all  causes  is  as  follows : 
whites,  99.2 ;  colored,  71.2  ;  Irish  parentage,  68.0  ;  German  parentage,  90.2  • 
though  as  regards  these  figures  it  must  be  added  that  the  term  employed 
by  the  census  enumerators  also  embraced  dysentery,  cholera  morbus,  and 
enteritis.  The  total  number  of  deaths  from  this  cause  has  largely  increased 
during  the  past  two  decades,  and  the  number  dying  under  five  years  consti- 
tuted sixty-six  per  cent.  The  death-rate  in  cities  is  higher  than  in  the  conn-, 
try,  being  for  the  former  96.1  and  for  the  latter  86.7  per  1000.  A  study 
of  the  geographical  distribution  of  this  disease  reveals  the  fact  that  the 
regions  showing  the  largest  proportion  of  deaths  are  the  Valley  of  the  Mis- 
sissippi, Texas,  Kansas,  part  of  Missouri,  Georgia,  and  South  Carolina.  In 
Massachusetts  and  Michigan  the  death-rate  from  this  disease  amounts  to  15 
per  cent,  of  the  annual  mortality,  and  in  Boston  it  is  22.18.  In  the  city 
of  New  York,  from  1805  to  1837,  the  deaths  from  cholera  infantum  were 
nearly  2  per  1000  of  population,  and  in  recent  years  it  has  increased  con- 
siderably. In  Philadelphia  the  mortality  in  1872  was  reckoned  at  2.6  per 
1000  of  population,  while  from  1819  to  1860  it  amounted  to  one-fourth 
and  one-third  of  the  deaths  from  all  causes  (Trans.  Penna.  3Ied.  Assoc, 
1873).  It  has  been  higher  than  this  in  Baltimore,  Louisville,  Natchez, 
St.  Louis  (1841-43),  and  at  Memphis,  which  has  been  termed  the  grave- 
yard of  children  (Grant,  Amer.  Jour.  Med.  Sd.,  1853). 

There  is  lack  of  information  concerning  this  disease  in  ^lexico  and  Cen- 
tral and  South  America.  At  St.  Pierre,  in  Martinique,  we  learn  from  Rufz 
(Arch,  de  Med.  Nav.,  1869)  that  it  is  the  chief  cause  of  death  in  those  under 
one  year.  At  Barbadoes,  Jackson  says,  "  it  is  by  no  means  as  common  as 
might  have  been  expected  from  the  tropical  situation."  In  Africa  the  only 
mention  made  of  the  disease  is  at  Port  Said.  For  Asiatic  countries  there 
are  no  accessible  reports  or  data.  Kichardson  says  (Edin.  Med.  Jour.,  1869) 
that  the  mortality  is  very  high  in  Australia. 

In  Europe  there  is  unanimity  in  the  opinion  of  its  being  one  of  the  lead- 
ing causes  of  death  in  children,  if  not  the  first.  This  is  especially  true  of 
the  large  cities.  There  appears  to  be  little  diiference  in  the  death-rates  of 
the  cities  of  the  Eastern  and  those  of  the  Western  Hemisphere.  In  Berlin 
from  1877  to  1882  the  death-rate  had  a  mean  of  2.6  per  1000  of  popula- 
tion. In  Hamburg  from  1874  to  1884  it  was  1.9,  and  in  Stuttgart  from 
1873  to  1878  it  was  2.4,  per  1000  of  population.  In  Birmingham,  Eng- 
land, the  mortality  for  each  1000  population  was,  from  1873  to  1875,  2.04. 
In  St.  Petersburg,  where  the  mortality  of  infants  is  extremely  high,  the 
death-rate  for  1887  was  3.08  to  each  1000  of  population.  In  Cairo  for  the 
same  period  it  reached  12.08  per  1000  of  population,  which  is  doubtless  the 
highest  of  any  city  in  the  world. 

With  regard  to  this  disease  in  the  colored  people  of  this  countiy,  my 
personal  experience  shows  the  mortality  to  be  very  high.  Very  few  of  the 
cases  get  well,  if  at  all  protracted.  Tlie  absence  of  proper  food,  nursing, 
and  skill,  together  with  the  inherent  impotence  that  the  darker  races  have 


144     THE    INFLUENCE    OF    RACE   AND    NATIONALITY    UPON    DISEASE. 

always  shown  when  attacked  with  cliarrhosal  diseases^  makes  it  peculiarly 
fatal. 

Small-pox. — Experience  shows  that  the  colored  races,  and  especially  the 
negro  race,  are,  oseteris  paribus,  in  greater  risk  from  this  disease  .than  whites. 
"  The  human  family,"  says  Pruner,  "  that  are  most  susceptible  to  this  poison 
are  negroes.  Not  only  in  their  native  lands,  but  in  other  parts  of  the  world 
as  well,  they  are  the  first  to  succumb  to  the  epidemic  influence,  and  also  the 
last.  It  is  no  unusual  thing  to  see  negroes  attacked  by  this  disease  as  soon 
as  they  arrive  in  Egypt  (where  they  certainly  change  their  way  of  living  as 
well  as  climate),  and  that,  too,  at  times  when  the  disease  does  not  exist 
among  the  other  inhabitants."  Similar  statements,  equally  emphatic,  as  to 
the  increased  intensity  of  the  disease  in  negroes,  are  made  by  Daniell  for  the 
West  Coast  of  Africa,  for  Martinique  by  Rufz  (according  to  his  observations 
in  the  epidemic  of  1836—37  and  1848—50),  for  Cura9ao,  and  for  Cayenne. 
For  Peru,  Bajon  says  the  same.  During  the  epidemic  of  Baltimore  in  1850 
the  deaths  among  10,000  of  population  were  8.1  for  the  whites  and  14.5 
for  the  negroes.  In  1838  an  epidemic  of  small-pox  among  the  Mandan 
Indians  swept  away  all  but  133  persons  of  the  entire  tribe  of  1800  souls. 

Hirsch  considers  India  and  the  countries  of  Central  Africa  as  the  native 
foci  of  this  disease.  Martin  says  that  he  has  never  seen  a  case  of  small-pox 
in  India  in  a  European  child,  although  there  was  not  a  year  in  which  it  did 
not  occur.  Among  the  yellow  races  of  the  East,  the  Chinese,  Japanese,  and 
Coreans,  this  forms  the  chief  scourge  to  which  they  are  subjected,  it  being 
a  common  thing  to  be  daily  jostled  in  the  streets  by  those  in  every  stage  of 
eruption.  In  the  countries  of  South  America  small-pox  frequently  plays  sad 
havoc  with  the  native  population  of  Indians  and  half-breeds.  The  of- 
ficial report  for  the  city  of  Rio  Janeiro  for  1887  shows  a  mortality  from 
small-pox  of  22.5  per  100  deaths  from  all  causes.  The  southern  countries 
of  Europe — Italy,  Spain,  and  Portugal — furnish  the  largest  annual  con- 
tingent to  the  total  mortality  from  small-pox.  Pome  showing  for  1887  a 
rate  of  35  per  1000,  and  Lisbon  65  per  1000.  Small-pox  is  often  severe 
in  the  higher  and  colder  sections  of  Siberia  and  Russia.  My  own  expe- 
rience in  an  epidemic  at  Atlanta,  Georgia,  in  1882,  leads  me  to  believe  that 
negroes  are  far  more  susceptible  to  the  pathogenic  factors  of  this  disease 
than  the  whites,  since  out  of  one  hundred  cases  the  death-rate  for  the  blacks 
Avas  ten  per  cent.,  the  whites  escaping  without  a  single  death. 

Syphilis. — This  disease  has  extended  its  influence  over  the  entire  habi- 
table globe.  Like  typhoid  fever,  it  relentlessly  dogs  the  steps  of  man,  and 
no  race,  people,  or  nation  enjoys  complete  exemption  from  its  withering 
curse.  Reference  to  the  past  history  of  syphilis  shows  that  it  has  pursued 
very  different  careers  among  the  various  races.  The  first  outbreaks  of  this 
disease  among  a  people  are  generally  considered  the  worst,  and  these  are, 
commonly  speaking,  proportionally  severe  as  the  people  approaches  a  state  of 
nature.  Certain  sections,  such  as  Iceland,  Greenland,  Newfoundland,  South 
Africa,  and  Madagascar  and  the  adjoining  islands,  have  so  far  been  signally 


THE   INFLUENCE   OF   RACE   AND   NATIONALITY   UPON   DISEASE.     145 

free  from  its  visitations.  For  Iceland,  Finsen,  after  a  practice  of  nine  years, 
says  he  saw  only  five  cases,  and  these  were  in  strangers.  It  has  been  known 
to  be  twice  imported  into  Iceland,  once  in  1756  and  again  in  1824,  the  latter 
epidemic  infecting  the  natives  to  the  extent  of  only  twenty-two  cases. 

Lange  is  reported  as  saying  for  Greenland,  "  It  is  a  remarkable  feet  that 
there  is  absolutely  no  syphilis  here.  About  this  fact  there  is  no  doubt ; 
and  the  strangeness  of  it  will  be  less  when  we  remember  that  the  same  is 
true  of  Iceland.  The  circumstance  is  explicable  simply  and  solely  on  the 
ground  that  Greenlanders  and  Icelanders  have  an  immunity  from  syphilis, 
for  there  is  no  lack  of  opportunities  for  infection,  since  vessels  frequently 
visit  here  with  the  disease  on  board,  and  prostitution  is  far  from  uncom- 
mon." The  Icelanders  are  of  the  same  Scandinavian  stock  that  pays  a 
heavy  tribute  to  syphilis  in  Sweden,  Norway,  and  Denmark,  while  the 
Greenlanders  are  of  the  same  blood  as  the  Esquimaux  that  inhabit  the 
west  coast  of  North  America,  and  they  from  time  to  time  have  had  terrible 
visitations  from  the  disease.  Dr.  Moncorvo,  of  Rio  Janeiro,  stated  during 
the  International  Medical  Congress  of  1887  that  syphilis  furnished  full 
65  per  cent,  of  all  causes  of  infantile  disease  in  Brazil. 

Darwin  and  Borius  assert  that  the  negroes  of  Madagascar  are  exempt, 
while  the  Hovas,  of  the  Malay  race,  are  frequently  and  seriously  affected. 
There  seems  to  be  some  ground  for  the  popular  notion  that  syphilis  con- 
ti'acted  from  persons  of  Mongolian  blood  by  Europeans  is  particularly 
noxious,  as  all  examples  of  such  prove  very  intractable.  The  yellow  races 
of  the  Orient  are  great  sufferers  from  this  disease,  the  countries  of  Japan 
and  China  being  particularly  infected.  The  Indians  of  North  America 
have  shown  during  recent  years  a  steady  increase  of  venereal  diseases,  and 
the  hereditary  form  has  well-nigh  pervaded  a  majority  of  them.  With  re- 
gard to  syphilis  in  Africa,  Dr.  Livingstone  says  in  his  Travels,  "  A  certain 
loathsome  disease  which  decimates  the  North  American  Indian  and  threatens 
extirpation  to  the  South  Sea  Islanders  dies  out  in  the  interior  of  Africa 
without  the  aid  of  medicine ;  and  the  Bangwatse,  who  brought  it  from  the 
West  Coast,  lost  it  Avhen  they  came  into  their  own  country,  southwest  of 
Kolobeng.  It  seems  incapable  of  permanence  in  any  form  in  persons  of 
pure  African  blood  anywhere  in  the  interior  of  the  country.  In  persons  of 
mixed  blood  it  is  otherwise,  and  the  virulence  of  the  secondary  symptoms 
seemed  to  be,  in  all  the  cases  that  came  to  my  care,  in  exact  proportion  to 
the  greater  or  lesser  amount  of  European  blood  in  the  patient.  Among  the 
Corannas  and  Griquas  of  mixed  blood  it  produces  the  same  ravages  as  in 
Europeans ;  among  half-blood  Portuguese  it  is  equally  frightful  in  its  in- 
roads upon  the  system ;  but  in  the  pure  negro  of  the  central  part  it  is  quite 
incapable  of  permanence."  Fritsch,  in  commenting  upon  tliis  opinion  of 
Livingstone,  says  "  that  syphilis  is  very  rare,  and  it  occurs  in  Bechuana 
Land  only  in  scattered  cases,  mostly  imported  from  Cape  Colony,  though 
there  are  materials  with  whicli  to  controvert  the  assertion  that  this  disease 
does  not  hold  with  pure  Ethiopian  blood."  That  this  disease  does  attack 
Vol.  I.— 10 


146     THE   INFLUENCE   OF   RACE   AND   NATIONALITY   UPON   DISEASE. 

the  negro  in  a  mitigated  and  less  virulent  form  than  it  does  the  white  and 
other  races  appears  probable  from  past  experiences  in  this  country.  The 
last  census  shows  the  disparity ;  and  from  my  own  personal  observation  the 
disease  is  far  less  formidable  in  the  negro,  and  is  readily  cured  by  aj^pro- 
priate  treatment.  It  certainly,  upon  the  whole,  pursues  a  milder  course, 
there  is  less  damage  to  the  system,  and  there  are  fewer  lesions  of  any  kind. 

Scrofula. — Europe  is  the  classic  ground  for  scrofula.  Few  or  none  of 
its  countries  are  free  from  the  inroads  of  this  disease.  In  Italy,  Sormani 
says,  it  has  so  contaminated  the  populace  that  3.5  recruits  out  of  each  1000 
are  exempt  on  account  of  it.  In  France  aifairs  are  worse,  the  exemptions 
from  militaiy  duty  being  three  times  as  many  as  for  Italy,  the  proportion 
reaching  as  high  as  15  to  20  per  1000  in  some  sections.  Belgium,  Holland, 
Switzerland,  Germany,  and  Austria  are  equally  infected.  Scrofula  is  gen- 
erally diifused  throughout  the  Scandinavian  countries,  and  Ireland  pays  a 
heavy  tribute.  For  England  the  number  of  scrofulous  persons  in  each  1000 
has  been  estimated  by  Phillips  to  be  24.5,  in  some  parts  as  low  as  11,  and 
in  others  as  high  as  72. 

Cooper  says  that  it  is  common  for  people  who  leave  England  for  the 
Indies  to  acquire  it  upon  their  return  home.  Pritchard  alleges  the  same  for 
those  who  leave  the  Southern  States  and  Brazil  and  go  to  reside  in  Paris. 
Scrofula  was  so  prevalent  in  Lisbon  in  1842  that  Rozas  asserts  that  the 
children  of  the  orphanage  of  that  city  had  it  to  the  extent  of  35  per  cent. 
In  Asia  it  is  one  of  the  commonest  diseases  met  with,  it  being  well-nigh 
universal  among  the  Japanese  and  the  Chinese.  The  harems  of  Egypt  are 
said  to  be  infected,  while  in  Tunis  and  Algiers  it  occupies  among  the 
negroes  the  first  place  as  a  disease.  Black  affirms  that  scrofula  is  fre- 
quent among  the  Kaffirs  and  Hottentots  of  Cape  Colony,  though  Living- 
stone says  that  it  is  rare  in  Africa,  being  quite  unknown  between  latitudes 
15°  and  25°  south  in  Central  Africa.  Among  the  negroes  of  the  Southern 
States  this  disease  is  seen  very  often,  being,  according  to  the  last  census,  more 
than  twice  as  common  as  amono-  whites.  The  Indians  are  fast  becomiuo-  the 
most  scrofulous  people  on  the  earth.  Sixby  writes  of  the  Shetland  Islands, 
"  Scrofula  is  connected  with  every  family."  In  Australia  and  the  Hawaiian 
Islands  this  disease  has  existed  only  during  recent  years.  In  Greenland 
and  Iceland,  according  to  Lange,  it  is  exceptionally  rare.  Gordon,  writing 
of  India,  in  the  Medieal  Times  and  Gazette,  1855,  says,  "Scrofulous  affec- 
tions were  the  most  frequent  ailments  of  children  of  both  sexes,  and  the 
mortality  Avas  exceedingly  high." 

In  brino;ina:  this  article  to  a  close,  I  must  here  sav  that  the  list  of  dis- 
eases  presented  by  no  means  exliausts  the  list  of  those  manifesting  racial 
characteristics ;  for  some  of  the  most  important  ones,  such  as  malaria,  typhoid 
fever,  yellow  fever,  cholera,  dengue,  etc.,  have  been  purposely  omitted.  I 
must  acknowledge  my  very  great  indebtedness  to  Prof  Hirsch's  "  Hand- 
book of  the  Distribution  of  Disease"  for  mauv  of  mv  citations. 


OUTLINES  OF  PRACTICAL  BACTERIOLOGY. 

By  EDWARD   O.   SHAKESPEARE,  M.D.,  Ph.D.,  Etc. 


Ijst  this  article  it  is  proposed  to  outliDe  only  practical  methods  which 
have  been  found,  in  the  writer's  own  experience,  to  be  useful  in  examination 
of  the  relations  of  bacteria  to  disease.  The  limited  space  makes  it  impos- 
sible, and  the  requirements  of  such  an  article  perhaps  also  undesirable,  to 
enter  into  historical  or  theoretical  considerations. 

This  field  of  investigation  was  opened  for  the  medical  scientist  by  the 
classical  researches  of  Pasteur  in  the  settlement  of  the  question  of  sponta- 
neous generation  and  in  his  subsequent  studies  of  the  processes  of  fermen- 
tation. With  the  investigations  of  that  distinguished  French  savant  con- 
cerning the  etiology  of  chicken-cholera,  began  our  first  positive  knowledge 
of  the  definite  relations  of  bacteria  to  disease  in  the  animal  kingdom.  The 
next  great  step  in  this  direction  was  gained  when  absolute  proof  was  fur- 
nished that  a  certain  bacillus  is  the  specific  cause  of  splenic  fever  (charbon, 
milzbrand)  in  sheep  and  other  herbivora.  Through  his  experiments  con- 
cerning this  latter  disease,  Prof.  Robert  Koch,  of  Berlin,  first  became  widely 
known  to  the  scientific  world.  Since  these  investigations,  progress  in  knowl- 
edge of  the  etiological  relations  of  bacteria  to  disease  has  been  rapid  and 
constant.  Perhaps  the  greatest  strides  made  are  due  to  improvement  of  old 
and  invention  of  new  methods  of  research  more  than  to  any  other  cause ; 
and  to  three  men  chiefly  are  we  indebted  for  the  greatest  advances  in  this 
respect, — namely,  Pasteur  and  Chauveau,  of  France,  and  Koch,  of  Germany. 
To  the  latter,  however,  we  owe  the  greatest  debt  in  this  direction  for  the 
means  which  he  has  devised  and  perfected  of  isolating,  with  rapidity,  ease, 
and  certainty,  different  species  of  bacteria,  and  of  following  their  cycles  of 
development  in  pure  cultures  under  varying  circumstances.  It  is  to  the 
description,  more  or  less  in  detail,  of  methods  of  examination,  isolation,  and 
cmltivation  of  bacteria  that  most  of  this  chapter  will  be  devoted. 

Although  the  knowledge  of  the  characters  and  peculiarities  of  numerous 
species  of  bacteria  which  has  been  acquired  in  recent  years  has  been  con- 
siderable, it  is  not  yet  sufficiently  comprehensive  to  render  a  satisfactory 
classification  of  these  organisms  possible.  No  classification  thus  far  pro- 
posed is  free  from  serious  faults  and  objections.  Perhaps  that  offered  by 
W.  Zopf  is  the  most  preferable  in  the  main,  because  it  is  based  upon  the 

147 


148  OUTLINES   or   PEACTICAL   BACTERIOLOGY. 

whole  cycle  of  development  of  the  species  with  which  it  deals,  and  by  fol- 
lowing it  systematically  in  investigations  of  new  as  well  as  of  known  species 
we  shall  probably  sooner  be  in  possession  of  that  full  information  necessary 
upon  which  an  exact  and  entirely  satisfactory  classification  must  be  based. 

The  classification  of  Cohn  has  been  perhaps  most  generally  followed. 
We  introduce  it  here  in  order  that  the  reader  may  comprehend  the  terms 

so  frequently  used. 

TRIBE   1.     GLJEOGENES. 

Cells  free  or  united  in  glairy  families  by  an  intercellular  substance. 

A.  Cells  free  or  united  by  2  or  4 : 

Cells  spherical Chkoococcxjs,  Nag. 

Cells  cylindrical Synechococcus,  Nag. 

B.  Cells  united  in  glairy  families,  amorphous  in  state  of  repose: 

a.  Cellular  membrane,  confounded  with  the  intercellular 

substance : 

1.  Cells  without  phycochrome,  very  small : 

Cells  spherical Micrococcxjs,  Hallier. 

Cells  cylindrical •.    .    .    .    Bacterium,  Duj. 

2.  Cells  with  phycochrome  larger : 

Cells  spherical Aphanocapta,  Nag. 

Cells  cylindrical Aphancetice,  Niig. 

b.  Intercellular  substance  formed  of  several  membranes  en- 

closed one  within  the  other : 

Cells  spherical    . Gl(EOCAPSA,  Kg. 

Cells  cylindrical Glceoethiece,  Nag. 

C.  Cells  united  in  glairy  families  of  definite  form : 

a.  Families  of  a  single  layer  of  cells  disposed  in  plates  : 

1.  Cells  in  fours  forming  a  plane  surface Merismopedia,  Meyen. 

2.  Cells  without  regular  arrangement,  forming  a  curved 

surface : 
Cells  spherical,  families  with  reticulated  rupture   .    Clathrocystis,  Henfr. 
Cells  cylindrical,  cuneiform,  families  divided  by 

constriction Collosph^rium,  Nag. 

b.  Families  with  several  layers  of  cells  united  in  spherical 

corpuscles  : 

1.  Number  of  cells  determined  : 

Cells  spherical,  colorless,  arranged  in  fours    .    .    .    Sarcina,  Goods. 
Cells  cylindrical,  cuneiform,  with  phycochrome, 

without  regular  arrangement Gomphosph.eria,  Kg. 

2.  Number  of  cells  very  great  and  indeterminate  : 

Cells  colorless,  very  small Ascococcus,  Billr. 

iPOLYCISTIS,  Kg. 
COCCOCHLORIS,  Spr. 
POLYCOCCUS,  Ke 


^!    -"-^iD- 


TPvIBE  2.     NEMATOGENES. 

Cells  disposed  in  filaments. 
A.  Filaments  not  branched : 
Filaments  free  or  interlaced  : 

1.  Filaments   cylindrical,   colorless,   articulations   not 
very  distinct : 

Filaments  very  slender,  short Bacillus,  Cohn. 

Filaments  very  fine,  long Leptothrix,  Kg. 

Filaments  larger,  long Beggiatoa,  Trev. 


OUTLINES   OF   PRACTICAL   BACTERIOLOGY.  149 

2.  Filaments  cylindrical,  with  phycochrome,  the  arti-  r  jr  ,   -i^ 

cles  well  defined,  without  cellular  reproduc-     OsciLrA^'Bosc"' 
tion ^ 

3.  Filaments  cylindrical,  articulated,  with  conidia : 

Filaments  colorless Creijothrix,  Cohn. 

Filaments  with  phycochrome Cham^siphoi^'. 

4.  Filaments  spiral,  without  phycochrome : 

Filaments  short,  light,  sinuous Vibrio,  Ehr. 

Filaments  short,  spiral,  rigid Spirillum,  Ehr. 

Filaments  long,  spiral,  flexible Spiroch^ete,  Ehr. 

With  phycochrome  : 

Filaments  long,  spiral,  flexible Spirulina,  Link. 

5.  Filaments  in  chaplet : 

Filaments  without  phycochrome Streptococcus,  Billr. 

Filaments  with  phycochrome <  '        °' 

LSpermosira,  Kg. 

6.  Filaments  flagelliform,  slender Mastigothrix,  etc. 

b.  Filaments  united  into  glairy  families,  by  intercellular 

substance : 

1.  Filaments  cylindrical,  colorless Myconostoc,  Cohn. 

2.  Filaments  cjdindrical,  with  phycochrome \ 

C  LlMNOCLIDE,  Kg. 

3.  Filaments  in  chaplet Nostoc,  etc. 

4.  Filaments  flagelliform,  slender Kioularia,  etc. 

B.  Filaments  with  false  ramiflcation  : 

1.  Filaments  cylindrical,  colorless <  '         "" 

C  Streptothrix,  Cohn. 

2.  Filaments  cylindrical,  with  phycochrome     ....-(  '  '      &• 

(.  SCYTONEMA,  Ag. 

3.  Filaments  in  chaplets Merizomyria,  Kg. 

4.  Filaments    flagelliform,    slender    towards    the    ex- f  Schizosiphon,  Kg. 

tremity 1  Geocyclus,  Kg. 


According  to  Zopf,  "  from  the  latest  investigations  concerning  algae  and 
bacteria  there  can  be  no  doubt  that  between  certain  representatives  of  both 
these  groups  there  is  a  perfect  morphological  homology.  This  homology 
might  easil}^  lead  to  the  classification  of  the  bacteria  as  forms  of  algfe  which 
contain  no  chlorophyl,  as  Cohn,  Kirchner,  and  Van  Tieghem  have  already 
done  on  the  basis  of  a  very  limited  knowledge  of  morphological  relations. 
Although  such  a  classification  might  not  appear  to  be  undesirable,  yet  it 
must  frequently  be  misleading ;  for,  as  the  latest  investigations  show,  our 
knowledge  of  the  development  of  algse  is  still  not  perfect,  and  on  that 
account  the  present  classification  will  probably,  through  the  close  study  of 
its  various  representative  forms  from  this  new  point  of  view,  suffer  here  and 
there  more  or  less  important  modifications." 

The  difficulty  of  even  using  a  proper  nomenclature  in  the  descriptions 
of  bacteria  is  still  frequently  experienced  on  account  of  variation  in  forms 
during  the  cycle  of  development  of  many  individual  species.  Doubt  has, 
consequently,  not  infrequently  arisen  as  to  what  technical  term  should  be 
employed  for  the  conveyance  of  an  exact  idea  of  the  object  under  view,  and 
some  uncertainty  and  misconception  of  the  exact  meaning  of  writers  dis- 


150 


OUTLINES   OF   PRACTICAL   BACTERIOLOGY. 


cussing  or  reporting  bacteriological  observations  have  sometimes  been  un- 
avoidable. It  should  be  premised  that  in  the  subsequent  pages  the  term 
"  bacteria"  in  a  general  sense  may  apply  to  any  or  all  of  the  forms  included 
in  the  foregoing  or  following  classifications.  In  this  sense  it  is  intended  to 
be  synonymous  with  the  general  French  term  "  microbe,"  exclusive  of  fiingi 
or  moulds. 

Eabenhorst  presented  the  following  classification,  which  has  been  adopted 
by  Fliigge : 


«■  r 


SCHIZOMYCETES. 

Isolated,  or  in  chains,  or  united  in  amorphous  gelatinous  families Micrococcus. 

Colonies  solid,  filled   |   In    large    numbers,    in 
with  cells.  irregular  colonies .  .   .    Ascococcus. 

Forming  gelatinous  families   I  !   '^^    small    but    definite 


of  definite  form. 


numbers,    in    regular 

^-      groups Saecina. 

Colonies   with    simple    layer   of   cells    at    the 
periphery Clathrocystis. 


Short,  isolated,  or  in  small  groups  loosely  united,  or  in  irregular  gelatinous 

families Bacterium. 

f  Short,  distinctly  jointed.  Bacillus. 


Long, 
cylin- 
drical, 
form- 
ing fila- 
ments. 


Filaments 
isolated, 
interlaced, 
or  in 
bundles. 


Without 
ramifi- 
cations. 


Straight 
filaments. 


Long, 
r  i,r,  .!,.„.        ""t.!l"l.„   i      indis-       f  Very  thin  .    Leptothrix. 
j      tinctly     (  Thicker  .  .    Beggiatoa. 
I-     jointed. 

f  Short,  rigid Spirillum 

<       bundles.  I       insnirals.  "I  (Vibrio). 

Long,  flexile Spiroch.et.e. 

f  Streftothrix. 

1  Clathrotheix, 

I-  Cells  included  in  roundish  gelatinous  masses Mycokostoc. 


Wavy,  or 
I      in  spirals. 

Pseudo-ramifications  .  . 


In  the  system  proposed  by  Zopf  the  imperfectly-known  bacteria  are  not 
included.     Those  concerning  which  we  are  in  possession  of  more  or  less 

exact  knowledge  are  placed  in  the  fol- 
FiG.  1.  lowing  four  great  groups  : 


abed 

^0038 

a  b     c       c 
B  O  o    o: 
O    nr 


00 
00 


^    £3 


f 


^Mf^ 


M 


;\b 


E 


1.  CoccACE^.  Thev  include  only  cocci  and 
cliaiiis  of  cocci. 

Genus :  Leuconostoc. 

2.  BACTERiACEiE.  Thcv  include  four  forms  of 
development :  —  Cocci,  bacteria  (short 
rods),  bacilli  (long  rods),  and  leptothrix 
forms  (filaments).  The  latter  contain  no 
subdivisions  from  one  end  to  the  other, 
and  no  typical  appearance  of  spirilli. 

Genera:  Bacterium,  Clostridium. 

3.  Leptothmche^.  They  include  cocci,  short 
rods,  filaments  (which  show  division),  and 

spiral  forms. 
Genera:  Leptothrix,  beggiatoa,  crenothrix,  phragmidiothrix. 
4.  Cladothriche.^.     They  include  cocci,  short  rods,  filaments,  and  spiral  filaments, 
filaments  present  pseudo-branches. 
Genus :  Cladothrix. 

This  classification  has  been  followed  by  Crook.sliank,  and  we  shall,  with 
some  slight  modification  of  order,  introduce  here  for  convenient  use  a  short 


A,  formation  of  tetrads;  B,  formation  of  sar- 
cina :  C,  formation  of  tetrads  and  sarcina  in 
irregular  masses;  D,  E,  irregular  groups  of 
short  rods.    (After  Hiippe.) 


The 


OUTLINES   OF   PEACTICAL   BACTERIOLOGY, 


151 


abstract  of  the   elaboration  of  tliis   system  which  the  latter  author  has 
published. 

Group  1.     Coccace^e. 

Oenus  I.     Micrococcus. — Division    in   one  direction   and   the   cocci   after  division  remain 
isolated  or  aggregated  in  irregular  clumps  or  masses.     (Photo.  No.  1.) 
M.  pyogenes  aureus  (staphylococcus  pyogenes  of  Eosenbaeh),  round  ;  yellow  growth. 
Pathogenic. 

Fig.  2. 


a  b    c 


6 
a 

®     0 


Capsule  formation  of  tetrads,  A;  of  sarcina,  B;  of  single  and  double  micrococci,  C;  of 
streptococci.  D;  multiplication  and  capsule  formation  of  micrococci  (leueonostoc),  Eto  Hr 
spiral  forms  within  gelatinous  capsule  or  zooglcea  of  myconostoc,  J,  K.    (After  Hiippe.) 

M.  pyocyaneus :  ellipsoidal ;  produce  pyocyanin,  green-blue  or  blue  pus.  Patho- 
genic. 

M.  cholerse  gallinarum  (or  bacterium  of  fowl-cholera, — they  should  be  classed  among 
bacteria) :  mono-  and  diplococci,  the  latter  in  fig.  8  form ;  2.  to  3.  [i  in  diam. 
Pathogenic. 

M.  prodigiosus :  round;  in  masses,  rose- or  blood-red  ;  single,  without  color ;  0.5  to  L 
fi  in  diam. 

M.  septicsemife  in  rabbits :  ellipsoidal  (should  properly  be  classed  as  bacteria) ;  0.8  to  1. 
II  long.     Pathogenic. 

M.  pysemise  of  rabbits  :  mono-  and  diplococci ;  0.25  ji  in  diam.     Pathogenic. 

M.  of  progressive  suppuration  in  rabbits  :  0.15  n  in  diam.     Pathogenic. 

M.  auranticus  :  oval ;  single  or  diplo  ;  orange  growth  ;  L5  //  long. 

M.  chlorinus  :  green  growth. 

M.  violaceus  :  violet-blue  color  ;  ellipsoid. 

M.  luteus  :  yellow  growth  ;  ellipsoid. 

M.  fulvus  :  rusty-red  growth  ;  1.5  fi  in  diam.  ;  frequently  diplo. 

M.  hsematodes  :  red  growth  ;  human  sweat  of  axilla  ;  and  in  other  localities. 
Ge?ius  II.     Streptococcus. — Division  in  one  direction  only ;  individual  cocci  remain  united 
together  to  form  chains  or  chaplets.     (Fig.  4,  A.) 

Streptococcus  pyogenes  (chain  cocci  in  pus ;  c.  of  pyaemia) :  cocci  single  and  in  chains. 
Pathogenic. 

Str.  coc.  erysipelatis  :  0.4  to  0.8  /i  in  diam.  ;  round.     Pathogenic. 

Str.  coc.  diphtheriticus  (Oertel) :  oval  ;  0.35  to  1.1  /i;  mono,  diplo,  and  strepto.  Path- 
ogenic (?). 

Str.  coc.  of  progressive  necrosis  in  mice  (Koch) :  0.5  //.     Pathogenic. 

Str.  coc.  bombycis  \n  ■flache-rie :  oval;  mono,  diplo,  and  strepto;  0.5//.     Pathogenic. 

Str.  coc.  vaccinaj :  mono,  diplo,  and  strepto  ;  0.5 /i/.     Pathogenic  (?). 

Str.  coc.  perniciosus  (Parrot  disease).     Pathogenic. 

Str.  coc.  urese  (m.  ureae  or  bacterium  ureae) :  mono-  or  streptococci  or  short  rods ;  may 
have  capsules. 


152  OUTLINES   OF   PEACTICAL   BACTERIOLOGY. 

Genus  III.     MerlsmopecUa. — Cocci ;    division   in   two   directions  only.     (Fig.    1,   A,   and 

Fig.  2,  A) 
Gonococcus :  mono,  diplo,  and  tetra  ;  0.83  //  in  diam.     Pathogenic  (?). 

M.  tetragenus :  tetrads  held  together  in  hyaline  envelope  or  capsule  (often  asso- 
ciated with  phthisis). 
Oenus  IV.   Sarcina. — Cocci ;  division  in  three  directions  or  less.    (Fig.  1,  B,  C,  and  Fig.  2,  B.) 
Sarcina  ventriculi :  4.  /z  in  diam.  ;  united  in  cubes  of  8  or  multiples  of  4  ;  cells  greenish 

or  yellowish  red. 
Sarcina  intestinalis  (Zopf) :  very  regular  in  form ;  never  in  such  large  packets  as  in  the 

stomach. 
Sarcina  lutea :  mono,  diplo,  tetra,  and  cube-groups,  etc.  ;  individuals  of  a  tetrad  may 

themselves  be  divided  ;  canary-yellow  growth. 
Sarcina  urinse  (Welcker)  :  1.2  fx  in  diam.  ;  cvibes  or  multiples  thereof.     (Sometimes  in 

the  bladder.) 
Sarcina  littoralis  (in  sea-water) :  1.2  to  2.  /i  in  diam. ;  cells  contain  one  to  four  sulphur 

granules. 
Sarcina  Keitenbachii  (on  putrefying  water-plants)  :  1.5  to  2.5  /i  in  diam.  ;  colorless  cell- 
wall  lined  with  rose-red  layer  of  plasma. 
Sarcina  hyalina  (in  marshes)  :  2.5  jU  in  diam.  ;  nearly  colorless  groups  of  4  to  24  cocci. 


Group  2.     Bacteriace^. 

Genus  I.     Bacterium. — Short  rods,  with  blunt,  rounded  or  pointed  ends  ;  individuals  may  be 

*  indistinguishable  from  cocci ;  single,  diplo,  or  united  to  form  threads  (strepto) ;  endo- 
genous spores  unknown.     (Fig.  1,  D,  and  Fig.  4,  B,  C.) 

Bacterium  urese  (m.  virea?) :  oval ;  1.25  to  2.  fi  long  ;  single  or  in  chains  and  short  rods  ; 
tendency  to  form  capsules  and  zoogloea  masses.  Produce  ammoniacal  fermenta- 
tion.! converting  urea  into  urea  carbonate. 

Bact.  aceti :  cocci,  bacteria,  bacilli,  filaments,  and  zoogloea  masses  ;  converts  the  alcohol 
in  wine  and  in  other  fruit  juices  into  vinegar. 

Bact.  Pasteurianum  (Hansen)  :  morphology  similar  to  bact.  aceti,  but  cells  contain  a 
starch-like  material  made  blue  by  iodine  ;  occurs  in  beer  wort. 

Bact.  Zopfii  (Kurth) :  cocci,  bacilli,  and  wavy  filaments,  which  again  break  up  into 
cocci  (in  intestine  of  fowls). 

Bact.  merismopedioides  (Zopf) :  filaments,  1.  to  1.5  (i  thick,  subdivide  into  long  and  short 
rods,  finally  into  cocci ;  the  latter  divide  in  one  and  two  directions  forming  tetrads 
grouped  in  64  or  more ;  these  again  form  rods  and  filaments  (in  putrid  water). 

Bact.  pneumonise  crouposse ;  cocci  round  and  oval,  and  rods ;  single  or  in  pairs ;  ten- 
dency to  form  capsules  when  naturally  growing  in  animal  tissues,  but  not  in  arti- 
ficial cultures.     Pathogenic  (?). 

Bact.  Pfliigeri  phosphorescens  (Ludwig) ;  round  cocci  and  threads. 

Bact.  isuthinum  (Zopf) :  short  and  long  rods  breaking  up  into  cocci.  Colonies  intense 
violet. 

Bact.  synxanthum  (bact.  of  yellow  milk) :  oval,  motile,  0.7  to  1.  |U  long,  much  resembles 
bact.  termo  ;  lemon-yellow  growth. 

Bact.  of  diphtheria  in  man  and  pigeons  :  cocci  or  short,  thick  rods.     Pathogenic  (?). 

Bact.  Panhistophyton  (nosema  bombycis,  corpuscules  du  ver  a  sole) :  oval  cocci ;  2.  to  3. 
H  long  and  2.  ft  wide  ;  single  or  diplo  or  short  rods,  2.5  fi  thick  and  twice  as  long 
(cause  of  pebrine).     Pathogenic. 
Genus  II.     Leuconostoc. — Cocci  and  shoi-t  rods ;  spore  foi-mation  present  in  cocci ;  thick, 
tough,  gelatinous  capsules. 

Leuconostoc  mesenterioides  (Cienkowski)  (gomme  de  sucrerie,  froschlaichpilz,  frog- 
spawn  fungus)  :  cells  single,  in  chains  or  zoogloea ;  cocci  elongate  into  rods  ; 
latter  segment  and  form  endogenous  spores ;  exceedingly  rapid  development, — 49 
hectolitres  of  molasses  containing  10  per  cent,  of  sugar  was  converted  within 
twelve  hours  into  a  gelatinous  mass. 


OUTLINES   OF   PEACTICAL   BACTERIOLOGY. 


153 


Fig. 


b 


}■ 


»•;;;>  <5^  '=5>='  c=.t5,^ 


A,  spirillum  undula;  B,  recurreus  spi- 
rochsete ;  C,  spirochaete  of  the  mouth ;  X>, 
anthrax-bacilli,— a,  of  mouse,  6,  of  rat;  E, 
bacillus  of  malignant  oedema;  F,  bacillus 
slibtilis.    (After  Koch.) 


endogenous  spore  formation  ; 


Genus  III.     Bacillus. — Cocci  and  rods,  or  rods  only  ;  may  form  straight  or  twisted  threads  ; 
endogenous  spore  formation.     (Fig.  3,  D,  E,  F.) 

Bacillus  subtilis  (hay  bacillus) :  cylindrical 
rods,  and  threads,  rounded  ends  with 
flagella  attached,  motile ;  0.6  fi  thick 
and  about  6.  /j.  long  ;  rapid  multiplica- 
tion in  sufhcient  nourishment,  by  trans- 
verse fission ;  slower  multiplication  by 
endogenous  spore  formation  in  impov- 
erished media.  If  the  multiplication 
be  rapid  the  filament  may  include  cocci 
and  short  rods  ;  aerobic  ;  whitish  or  yel- 
lowish-white growth. 

Bacillus  anthracis  (cause  of  splenic  fever  of 
sheep,  etc.,  charbon,  milzbrand) :  rods 
5.  to  20.  fi  long  and  1.  to  L25  fi  thick; 
long  chains  of  cocci  and  rods ;  the  ends 
are  square,  have  no  flagella,  are  non- 
motile  ;  multiply  by  fission  and  endo- 
genous spore  formation  ;  aerobic.  Path- 
ogenic. 

Bacillus  tumescens  (Zopf ) :  cocci,  short  and  long  rods 
forms  gelatinoid  masses. 

Bacillus  megaterium  (De  Barry):  large  rods,  2.5  ii  thick  and  4  to  6  times  as  long; 
usually  slightly  curved ;  multiply  by  fission  and  endogenous  spores ;  may  form 
irregular  chains  ;  motile.  • 

Bacillus  Fitzianus  (Zopf) :  cocci.  Fig.  4. 

short  and  long  rods  and  fila- 
ments ;  causes  fermentation 
and  produces  ethyl  alcohol; 
accompanies  hay  bacillus. 

Bacillus  tuberculosis  (Koch)  : 
very  fine  rods.  2.  to  4.,  occa- 
sionally 8.  fi  long  ;  straight  or 
slightly  curved,  often  beaded, 
rounded  at  ends ;  single,  in 
pairs  or  bundles ;  some- 
times associated  with  gran- 
ules stained  in  some  manner  ; 
non-motile ;  spore  formation 
within  animal  body.  Cause 
of  tuberculosis.  (Photo.  No. 
3.) 

Bacillus  leprae  (Hausen) :  slender 
rods  4.  to  6.  fi  long,  less  than 
1.  n  thick,  sometimes  pointed 
at  ends  ;  some  motile,  others 
not ;  may  contain  spores  and 
present  beaded  appearance ; 
resembles  bacillus  tuberculosis.     Probably  the  cause  of  leprosy. 

Bacillus  mallei  (bacillus  of  glanders) :  fine  rods  2.  to  6.  fi  long.     Cause  of  glandei-s. 

Bacillus  cyanogenus  (bacillus  of  blue  milk) :  rods  single  or  in  pairs,  2.5  to  3.5  fi  long; 
multiply  by  fission  ;  they  may  form  chains';  may  be  surrounded  by  capsule. 

Bacillus  acidi  lactici :  short  and  long  rods  3.  to  4.  fi  long,  also  filaments ;  endogenous 
spores.  Causes  acidity  of  milk  if  not  above  45.5°  C.  (not  identical  with  bact. 
acidi  lactici). 


A,  streptococci ;  B,  C,  strepto-bacteria ;  D.  jointed  thread ; 
E,  unjointed  thread;  F,  wavy  thread;  G,  H.  J,  K,  spirilli 
more  or  less  stiff;  L,  M,  N,  spirilli  more  or  less  flexile 
and  looped.    (After  Hiippe.) 


154 


OUTLIJSTES    OF    PRACTICAL    BACTERIOLOGY. 


Bacillus  oedematis  maligni  (Koch)  (vibrion  septique  of  Pasteur)  :  rods  3.  to  3.5  //  long 
and  1.  to  1.1  //  thick  ;  usually  in  pairs  ;  rounded  ends  ;  may  form  filaments,  straight 
or  slightly  curved  ;  motile;  anaerobic;  spore  formation.    Pathogenic.    (Fig.  3,  £.) 
Bacillus  septicsemise  of  mice  (Koch) :  very  small  and  slender  rods,  0.8  to  1.  /z  long  and 
0.1  to  0.2  jM  thick  ;  single,  in  pairs  or  in  chains  of  3  or  4  links  ;  no  filaments  ;  often 
collected  together  in  masses  ;  spore  formation. 
Bacillus  typhosus  (bacil.  of  typhoid  fever,  Eberth,  Gaffky) :    rods,  0.2  [i  thick  and 
length  3  to  4  times  as  great ;  filaments  upwards  of  40.  n  in  length  ;  or  short  rods, 
rounded  at  ends  and  sometimes  constricted  in  the  middle.     Motile ;  doubtful  spore 
formation.     Pathogenic.     (Photo.  No.  2.) 
Bacillus  diphtheriticus  of  man  :  rods  2.  to  5.  n  or  more  long,  twice  as  thick  as  bacillus 
of  tuberculosis ;    may  be  linked  in  pairs  or  chains.      Found  also  in  calves  and 
pigeons. 
Bacillus  malariae  (Klebs) :  rods  2.  to  7.  n  long  ;  may  develop  spiral  filaments  ;  spores  may 

form  at  centre,  ends,  or  sides ;  aerobic.     (Probably  not  the  cause  of  malaria.) 
Bacillus  dysodes  (Zopf )  :  cocci,  long  and  short  rods ;  spore  formation  ;  causes  a  destruc- 
tive fermentation  of  bread ;  may  accidentally  accompany  yeast. 
Bacillus  Hausenii  (Rasmussen) :  rods  2.8.  to  6.  jj.  long,  0.6  to  0.8  (i  thick  ;  spore  forma- 
tion ;  growth  chrome-yellow  ;  volatile  aromatic  gas  of  fruit-like  odor  given  ofl". 
Bacillus  erythrosporus  (Cohn) :  rods,  with  spore  formation,  and  filaments;  motile. 
Bacillus  ruber  (Frank) :  minute  rods,  single,  in  pairs  and  in  fours ;  growth  brick-red. 

Genus  IV.  Clostridium. — Same  as  bacillus, 
but  spore  formation  takes  place  in 
characteristically  enlarged  rods. 
Clostridium  butyricum  (bacillus  amy- 
lobacter,  bacillus  butyricus,  bacil- 
lus of  butyric  acid  fermentation — 
Prazmowski) :  rods  less  than  1.  fj. 
thick,  3.  to  10.  fi  long,  motile,  an- 
aerobic ;  develops  into  long  un- 
jointed  filaments ;  both  rods  and 
filaments  may  be  slightly  curved  ; 
spore  formation  by  swelling  of 
the  rod  or  filament  at  the  point 
of  its  location ;  changes  lactic 
acid  of  milk  into  butyric  acid  and 
causes  ripening  of  cheese  ;  also  ac- 
tive in  formation  of  sauer-kraut ; 
cells  sometimes  jield  iodine  reac- 
tion for  starch. 
Closti'idium  polymyxa  (Prazmowski) : 
filaments,  rods  of  variable  length, 
cocci,  and  spores  ;  cause  of  certain 
fermentations ;  some  yield  weak 
iodine  reaction  for  starch. 
Clostridium  of  symptomatic  anthrax 
(blackleg,  quarter  evil,  rausch- 
brand,  charbon  symptoniatique — 
Arloing) :  rods,  with  rounded  ends,  motile,  usually  containing  an  end  spore.  In 
cultures  develop  into  chains  of  rods  and  cocci. 
V.  Vibrio. — Filaments,  screw  form,  in  long  or  short  turns  ;  spore  formation.  (Fig. 
4,  F,  G.) 
Vibrio  rugula  (Mtiller) :  rods  and  filaments  0.5  to  2.5  fi  thick,  6.  to  16.  //  long  ;  motile, 
with  an  end  flagellum,  mostly  axial  rotation  and  progressive  motion;  rods  simply 
curved  or  slightly  spiral ;  filaments  more  or  less  spiral ;  one  end  may  enlarge  and 
a  round  spore  fonn  therein. 


A,  bullet  forms,  and  G  to  K,  monas  forms,  of  Beg- 
giatoa  roseo-persioina,  and  D,  E,  rod  and  spiral  forms 
of  cladothrix,  erenothrix,  and  beggiatoa  (Zopf) ;  B, 
bacterium;  C,  spirillum  uiidula  (Koch);  F,  spirillum 
volutans  (Cohn);  i,  3f,  ophido  monas  forms  (Warm- 
ing) :  with  flagella. 


Genu 


OUTLINES   OF   PRACTICAL   BACTERIOLOGY, 


loo 


Genus  VI.     Spirillum. — Filaments  more  or  less  spiral,  rods  curved  or  partly  spiral  ;  spore 

formation  doubtful  or  unknown.     (Fig.  3,  A,  B,  C;  Fig.  4,  G  to  JS^;  Fig.  5,  Cto 

F;   Fig.  7,  H,  J.      Photo.  Nos. 

11,  12,  13.)  Fig.  G. 

Spirillum   cholerse   Asiaticse   (comma 

bacillus  of  Koch) :    curved  rods, 

spirilli,  and  filaments;   the   rods 

about  half  as  long  as  the  average 

tubercle-bacillus,  their    thickness 

about  5  to  1  their  length  ;  single 

or  attached  end  to  end  in  pairs  so 

as  to  form  shape  of  the  letter  S ; 

or  they  may  be  attached  in  chains 

of  three   or  more ;    multiply  by 

lengthening  and  transverse  fission. 

In   old   cultures   there   are   often 

spherical  bodies  of  variable  size, 

isolated  or  connected  with  the  rods, 

and   they  are   regarded   by  most 

observers  as  involution  forms  ;  by 
•  Ferran  and  Hiippe  they  are  looked 

upon  as  vegetative  forms  endowed 

with  a  greater  power  of  resistance, 

— the  former  names  them  oogonia, 

the   latter  arthrospores.      Nearly 

all   observers    admit    absence   of 

spore  formation  ;  exceedingly  mo- 
tile with  more   or   less    rounded 

ends.    Pathogenic.    (Fig.  1,  H,  J. 

Photo.  No.  13.) 
Spirillum  plicatile  (marsh  spirocha3te 

— Ehrenberg) :    thin    spiral    fila- 
ments with   close   coils,  many  fi 

long  ;  besides  the  shorter  regular 

curves,  they   have   also  coils   of 

greater  length  and  depth ;  blunt 

ends,  rapid   movement.     In  cul- 
tures  the    filaments    divide    into 

short  or  long  rods,  or  ultimately 

cocci,  observed   in  drop  cultures 

and  in  stained  preparations. 
Spirillum  Obermeieri  (spirochsete  Ob.  ; 

spr.  of  relapsing  fever — Obermeieri) :  exceedingly  thin  filaments  resembling  spir. 

plicatile ;  length  16.  to  40.  /i ;  motile  ;  occurs  in  blood  of  relapsing  fever  during  tln' 

access.     (Fig.  3,  if.) 

Group  3.     Leptothricheve. 
Genus  I.     Lepiothrix. — Thi-eads  articulated  or  unarticulatod  ;  successive  subdivision  of  cells 

not  continuous  ;  cells  sulphurless.     (Fig.  4,  iJ.) 
Leptothrix  baccalis  (Eobin) :  long,  thin  threads,  often  united  in  thick  bundles  or  felted 

together  ;  are  composed  of  long  rods,  short  rods,  and  cocci. 
Leptothrix  gignntea  (Miller) :  long  rods,  short  rods,  and  cocci,  which  vary  in  thickness 

often  in  the  same  thread. 
Gcnics  II.     Crenothrix. — Threads  articulated  ;  cells  sulphurless  ;  habitat  water. 

Crenothrix  kuhniana  (Rabenhorst) :  cocci,  rods,  and  filaments,  which  latter  are  color- 
less and  may  be  club-shaped,  and  the  ends  are  articulated  and  ensheathed ;  the 

sheath  bursts,  the  cells  are  set  free  and  develop  into  new  threads. 


Cladothrix  dichotoma  (Zopf ).  A,  branched,  witu 
longer  (a)  and  with  shorter  (6)  screw-like  curves;  B, 
spirillum,  one  of  whose  ends  (a)  shows  greater  curves 
than  the  other  (b) ;  C,  longer  spirochaBte-like  branch, 
with  loops;  D,  a  portion  of  branch,  with  close  and 
with  loose  coils;  E,  spirilli, — a,  unjointed,  b,  appear- 
ance of  joints,  longer,  c,  shorter  ;  F,  spirocheete  form, 
at  a  unjointed,  at  b  to  d  schematic  joints,  at  c  into 
short  rods,  at  d  into  cocci.    (Hiippe.) 


156  OUTLINES   OF   PRACTICAL   BACTERIOLOGY. 

Genus  III.     Phragmidiothrix. — Threads  jointless  ;  successive  subdivision  of  cells  is  continu- 
ous ;  cells  sulphurless  ;  habitat  water. 
Phragmidiothrix  multiseptata. 
Genus  IV.      Beggicdox. — Threads   unarticulated ;   cells    with   sulphur    granules ;    habitat 
water.     (Fig.  7,  ^  to  -E.) 
Beggiatoa  alba  (Yauch) :    cocci,  rods,  spirals,  and  threads ;  the  protoplasm  contains 

numerous  highly-refractive  granules,  consisting  of  sulphur. 
Beggiatoa  roseo-persicina  (Bacterium  rubescens) :  cocci,  rods,  spirals,  and  threads. 
Beggiatoa  mirabilis  (Colin) :  the  threads  are  filled  with  sulphur  granules. 

GkOITP  4.       CLADOTHRICHEiE. 

Genus  I. — Cladothricheffi  (Cohn) :  threads  resembling  those  of  leptothrix.     (Fig.  6.) 
Cladothrix  dichotoma. 
Cladothrix  Foersterii. 
Spherotillus  natans. 

MOEPHOLOGT. 

From  a  purely  morphological  stand-point,  and  simply  for  descriptive 
purposes,  bacteria  may  be  divided  as  follows :  1,  Coccus ;  2,  Bacterium ; 
3,  Bacillus ;  4,  Filament  (straight,  wav}^,  or  spiral — long  rod,  vibrio,  spiril- 
lum, spirochaete). 

1.  Cocci  are  spherical  or  ovoid  forms:  isolated  (inonococci) ;  in  pairs 
(diploGoeci) ;  or  in  chains  {streptococci)  ;  four  together  in  the  form  of  a 
square  or  rosette  (tetragoni) ;  in  cubes  or  oblong  packets  of  eight,  sixteen, 
thirty-two,  sixty-four,  or  multiples  of  either  {sarcinse).  (Figs.  1,  2.)  These 
forms  may  be  isolated,  grouped  in  irregular  clumps,  or  in  a  mass,  held 
together  by  a  gelatinoid  substance  in  which  they  are  embedded  (zoogloea). 
(Fig.  2.)  They  are  frequently  the  subject  of  active  Brownian  movement, 
but  they  have  no  individual  progressive  motion.     (Photo.  No.  1.) 

2.  Bacteria  are  short  cylinders  of  an  average  thickness  equal  to  one- 
half  their  length,  with  square,  blunt,  rounded,  or  more  or  less  spindle- 
shaped  extremities,  and  various  species  may  be  provided  with  one  or  more 
extremely  fine  terminal  motile  cilia  {flagella)  w^hich  serve  for  the  purpose 
of  locomotion.  (Fig.  5.)  The  bacteria  may  be  single  or  double,  united  to- 
gether end  to  end,  or  they  may  form  chains  with  three  or  more  links ;  and 
the  terms  "  mono,"  "  diplo,"  and  "  strepto"  may  be  applied  to  them,  as  in 
the  case  of  cocci.  They  may  be  motile  or  non-motile.  (Fig.  1,  A,  D ; 
Fig.  4,  B.) 

3.  Bacilli  are  long  cylinders  of  variable  length,  but  longer  than  the 
bacteria.  Their  extremities  may  be  square,  rounded,  or  pointed,  and  when 
motile  they  also  may  be  furnished  with  one  or  more  cilia.  They  may  be 
joined  together  end  to  end,  forming  chains  or  jointed  filaments,  and  these 
filaments  may  be  straight  or  wavy,  motile  or  non-motile.  (Fig.  1,  E ;  Fig. 
3,  D,  E,  F;  Fig.  5,  B.) 

4.  Spirilli  fully  developed  consist  of  a  somewhat  stiif  filament,  more  or 
less  regularly  coiled  in  the  form  of  a  spiral,  and  more  or  less  indistinctly 
jointed  or  not ;  the  extremities  may  be  provided  with  cilia,  and  progressive 
motion  is  chiefly  secured  by  an  axial  rotation.     The  smallest  developmental 


OUTLINES   OF   PEACTICAL    BACTEEIOLOGY. 


157 


form  of  the  spirillum  is  usually  a  short,  slightly  curved,  more  or  less  pointed 
bacillus,  and  these  latter  forms  may  be  united  in  pairs,  end  to  end,  repre- 
senting more  or  less  perfectly  the  outline  of  the  letter  S ;  united  end  to  end 
in  greater  numbers  they  form  a  longer  or  shorter,  more  or  less  spiral,  wavy 
line.  (Fig.  3,  A,  B,  C;  Fig.  4,  G  to  N;  Fig.  5,  C  to  F;  Fig.  7,  H,  J; 
Photo.  Nos.  11  to  13.) 

The  cocci  increase  in  number  by  elongation  of  the  diameter  in  one  direc- 
tion until  it  is  about  double  the  former  length,  then  constrict  in  the  middle, 
and,  by  continuation  of  the  process  of  transverse  fission,  form  diplococci, 
streptococci;   when  fission  occurs  in  two  directions,  tetragon! ;  and  when 


Fig.  7. 


c 


A,  B,  C,  D,  E,  beggiatoa  tubes,  showing  macro-  and  microgonidia ;  F,  bacterium  Zopfii, 
— formation  of  arthrospores,  c;  S,  streptococci,  showing  larger  cells,  a  and  b,  regarded  by 
Van  Tieghem  as  cystic,  by  Du  Bary  and  Hiippe  as  arthrospores;  H,  J,  spirilli  of  Asiatic 
cholera,  also  showing  arthrospores  (Hiippe,  or  gonidia  of  Ferran) ;  K,  process  of  arthrospore 
formation  in  bacterium.    (After  Hiippe.) 


fission  is  in  three  directions,  sarcinse, — the  final  result  of  the  process  of  fission 
resulting  in  the  formation  of  entirely  separate  and  distinct  forms  more  or 
less  identical  with  those  from  which  they  sprang. 

The  process  of  multiplication  of  the  bacterium  is  also  by  transverse 
fission.  The  bacterium  first  elongates,  then  becomes  constricted  in  the 
middle,  and  finally  forms  in  this  manner  a  diplobacterium  or  a  streptobac- 
terium.  The  member  may  remain  thus  attached,  or  the  process  of  fission 
may  continue, to  end  in  separation. 

The  process  of  multiplication  of  bacilli  is  in  some  species  twofold ;  in 
others  it  is  simj^lc.  The  simple  process  of  multiplication  is  also  by  trans- 
verse fission.  The  rod  may  elongate  and  divide  into  two  or  more  by  tlie 
process  of  fission,  which  may  or  may  not  extend  to  complete  separation  of 


158  OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 

the  joints  and  a  new  formation  of  isolated  bacilli  similar  to  those  whence 
they  sprang.  The  other  process  of  multiplication  consists  in  the  endogenous 
formation  of  one  or  more  spores  in  the  interior  of  the  rod,  usually  after  it 
has  more  or  less  elongated  and  slightly  increased  in  thickness,  particularly 
at  the  point  where  the  spore  is  to  be  formed.  The  location  of  the  spore  may 
be  at  the  end  or  near  the  middle  of  the  rod.  The  spore  consists  of  a  more 
or  less  oval,  glistening,  highly  refracting,  resistant  body  (Fig.  7,  K,  h), 
which  usually  when  fully  formed  occupies  the  whole  diameter  of  the  cylin- 
der, and  indeed  at  this  point  the  diameter  of  the  latter  may  be  somewhat 
increased.  After  the  spore  is  formed,  the  protoplasm  of  the  cylinder  retro- 
grades, the  delicate  limiting  membrane  disappears,  and  the  spore  is  set  free 
to  undergo  its  cycle  of  development.  Development  from  the  spore  may 
take  place  from  one  of  its  more  or  less  pointed  extremities  or  from  the  side 
of  the  spore,  and  by  the  extrusion  of  a  bud  of  protoplasm  which  grows 
into  a  rod  similar  to  the  original,  the  remains  of  the  spore  ultimately  disap- 
pearing. 

According  to  Du  Bary,  Hiippe,  and  others,  micrococci,  bacteria,  bacilli, 
and  spirilli  have  still  another  mode  of  propagation, — by  arthrospores.  (See 
Fig.  7,  F,  G,  H,  J,  K.) 

METHODS    OF   EXAMINATION   OF   BACTERIA. 

The  bacteria  are  so  minute  that  their  examination  taxes  the  utmost 
powers  of  the  microscope  both  in  magnification  and  in  definition ;  con- 
sequently, the  best  instruments  in  every  respect  are  required.  The  micro- 
scope must  be  exceedingly  firm,  with  a  steady,  stiff  stage ;  the  sub-stage 
illumination  must  be  of  such  a  character  as  to  pass  a  great  flood  of  light 
upward,  through  and  around  the  object.  Although  it  is  possible  to  see 
many  of  the  larger  forms  of  bacteria  with  the  old  style  dry  objective  as 
weak  as  a  quarter,  if  it  have  excellent  defining  and  resolving  powers,  yet 
such  a  lens  is  at  best  an  extreme  tax  on  the  eye,  and,  moreover,  there  are 
many  of  the  minute  forms  which  are  practically  invisible  under  such  a 
lens.  The  immersion  objectives  are  essential  for  bacteriological  investi- 
gations, and  those  of  a  homogeneous  oil-immersion  system  are  greatly  to 
be  preferred.  The  focal  length  should  be  from  a  twelfth  to  an  eighteenth  of 
an  inch,  with  a  good  working  distance  and  high  angular  aperture.  Among 
the  best  of  the  cheaper  lenses  of  such  a  character  are  the  Leitz  twelfth  oil- 
immersion  and  Reichert  fifteenth  oil-immersion.  Among  the  best  of  the 
high-priced  objectives,  those  of  Powell  and  Leland  oil-immersion  sixteenth 
and  of  Zeiss  or  Spencer  oil-immersion  twelfth  or  eighteenth  may  be  pre- 
ferred. The  very  best  lens  which  can  be  obtained  at  the  present  time  for 
bacteriological  work  is  the  new  Zeiss  system  oil-immersion  apochromatic. 
It  is  quite  expensive,  but  in  resolving  and  defining  power  is  a  wonderful 
advance  over  the  best  oil-immersion  lenses  heretofore  made.  It  may  be 
stated  that  there  are  also  a  few  water-immersion  lenses  of  a  short  focus 
and  high  angular  aperture  which  can  be  used  with  more  or  less  satisfaction. 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY.  159 

The  best  sub-stage  illuminating  apparatus  above  referred  to  is  that 
devised  by  Abbe,  which  is  somewhat  expensive.  But  there  are  numer- 
ous cheaper  modifications  of  this  apparatus  which  work  satisfactorily. 
Perhaps  the  simplest  form,  constructed  after  the  design  of  the  writer,  is 
that  which  consists  essentially  of  an  upper  hemispherical  lens  a  half-iuch 
in  diameter  and  a  lower  biconvex  of  two  inches  focus  and  a  diameter  of 
an  inch,  suitably  mounted  in  a  cylindrical  holder  which  slides  up  and  down 
below  the  stage  of  the  microscope.  Such  an  ajjparatus  can  be  made  in  this 
country  for  the  sum  of  six  dollars,  and  gives  satisfaction  in  its  use. 

It  should  be  stated  in  connection  with  the  sub-stage  illuminating  appa- 
ratus that  in  the  examination  of  bacteria  it  is  desired  to  obtain  the  greatest 
flood  of  light  possible,  quite  contrary  to  the  use  of  the  sub-stage  condenser 
for  ordinary  histological  purposes. 

METHODS   OF  PREPAEATIOiSr   OP   BACTEEIA  POR   MICROSCOPIC 

EXAMINATION. 

With  the  best  lenses  bacteria  can  be  examined  with  some  satisfaction 
in  their  native  condition, — that  is  to  say,  without  staining.  They  may  be 
examined  fresh  in  fluids  or  in  thin  films  dried  upon  the  under  surface  of  a 
thin  cover-glass.  For  such  an  examination  the  light  of  the  sub-stage  con- 
denser must  be  toned  down  by  diaphragms  much  in  the  same  manner  as  for 
ordinary  histological  work. 

Examinations  of  unstained  bacteria  are,  however,  more  or  less  unsatis- 
factory, and,  as  a  rule,  are  exceedingly  trying  to  the  eyes.  Moreover,  ex- 
amination of  the  smallest  forms  taxes  greatly  the  resolving  and  defining 
powers  of  the  very  best  lenses  at  present  known. 

In  later  years  it  is  regarded  as  essential  to  color  bacteria  artificially  in 
preparing  them  for  close  study.  They  may  be  examined  in  fluids,  or  the 
material  containing  the  bacteria  may  be  spread  in  a  thin  film  upon  the  sur- 
face of  a  thin  cover-glass.  The  latter  method  is  the  one  at  present  most 
generally  in  use.  Furthermore,  bacteria  may  be  examined  directly  in  the 
tissues  which  contain  them.  Here  also  they  may  be  observed  in  the  natural 
state — that  is,  free  from  artificial  coloring — or  they  may  be  subjected  to  a 
process  of  staining.  In  this  case  it  is  usually  necessary  to  make  thin  sec- 
tions of  fresh  tissues  by  means  of  the  freezing  microtome,  or  sections  of 
tissues  which  have  been  previously  hardened.  For  examination  of  bac- 
teria in  sections  of  hardened  tissue,  the  best  hardening  agent  is  absolute 
alcohol ;  for  bacteria  in  tissues  without  staining,  it  is  necessary  to  make 
use  of  the  clearing  effect  of  some  of  the  strong  acids  or  alkalies,  such  as 
glacial  acetic  acid,  pure  or  slightly  dilute,  or  a  strong  solution  of  caustic 
potash  or  soda. 

In  examination  of  a  film  upon  a  cover-glass,  it  is  usually  necessary  to 
employ  some  means  of  fixing  the  film  firmly  thereon.  This  is  conveniently 
done  in  the  case  of  albuminous  fluids  l)y  employing  heat.  The  cover-glass 
should  be  held  between  the  thumb  and  finger  by  the  edges,  and  quickly 


160  OUTLINES   OF   PRACTICAL   BACTERIOLOGY. 

passed  through  the  flame  of  the  spirit-lamp,  or  Bimsen  burner  turned  very 
low,  care  being  taken  to  have  the  film  side  uppermost.  The  usual  pro- 
cedure is  to  pass  the  cover-glass  quickly  through  such  a  flame  three  times 
successively  in  as  many  seconds.  The  sensibility  of  the  fingers  will  prevent 
any  danger  of  overheating.  It  is  found  that  by  employing  heat  in  such  a 
manner  the  bacteria  are  not  injured  for  staining  purposes  and  are  but  little, 
if  at  all,  altered  in  form. 

METHODS   OF   STAINING. 

It  has  been  known  for  a  number  of  years  that  certain  solutions  of 
carmine,  particularly  the  ammoniacal,  possess  the  property  not  only  of 
staining  various  histological  elements  of  tissues,  but  also  of  tingeing,  more 
or  less,  certain  kinds  of  micrococci ;  and  it  was  later  learned  that  lisema- 
toxylin  possesses  a  similar  capability.  In  the  systematic  study  of  methods 
of  staining  tissues  for  histological  examination,  it  was  found  that  numerous 
aniline  dyes  possess  the  power  of  staining  intensely  various  forms  of  bacteria. 

To  Weigert,  Ehrlich,  and  Koch  we  are  indebted  for  the  first  systematic 
employment  of  the  aniline  dyes  for  the  special  tingeing  of  bacteria.  This 
special  use  of  the  latter  coloring-agents  is  based  upon  two  fundamental 
principles :  the  relative  affinity  of  the  various  histological  elements  for 
these  dyes,  and  the  persistency  with  ^hich  they  retain  them.  It  has  been 
found  that  for  most  of  the  aniline  colors  the  selective  affinity  of  bacteria  is 
greater  than  that  of  the  other  histological  elements,  and  that  the  persistency 
with  which  the  bacteria  resist  decoloration  after  staining  is  also  greater. 

Aniline  dyes  may  be  divided  into  two  principal  groups, — the  acid  and 
the  basic;  that  is,  those  which  are  simple  acids  or  acid  salts,  and  those 
which  are  simple  bases  or  alkaline  salts.  The  acid  aniline  colors  may  be 
subdivided  further  into  four  classes  : 

1.  Fluorescine  :  e.g.,  fluorescin,  eosin. 

2.  Nitro-substances  :  e.g.,  martins  yellow,  picric  acid,  aurautia. 

3.  Sulphur  acids  :  e.g.,  tropseolin. 

4.  Primary  acid  colors  :  e.g.,  rosalic  acid,  alizarin,  purpurin. 

Of  the  basic  aniline  colors,  the  following  are  most  generally  used : 
fuchsin  (hydroehlorate  of  rosanilin) ;  methyl-violet  (hydrochlorate  of  tri- 
methyl-rosanilin) ;  gentian-violet ;  methyl-blue ;  vesuvin.  Less  frequently ; 
methyl-green,  cyanin,  safranin,  jnagdala,  dahlia.  Of  these,  especially  the 
violets  (methyl-violet,  gentian-violet,  iodine-violet,  dahlia)  possess  a  species 
of  double  coloring  power  which  is  sometimes  made  use  of.  Methyl-violet, 
for  example,  colors  an  amyloid  substance,  not  violet, — like  the  bacteria  and 
the  nuclei, — but  red ;  methyl-green  colors  the  nuclei  and  bacteria  green  and 
the  amyloid  substance  violet. 

The  intensity  of  the  coloring  and  the  persistence  with  which  it  resists 
decolorization  vary  sometimes  to  a  considerable  extent,  according  to  the 
nature  of  the  color  and  to  the  species  of  bacteria.  It  has  been  found  that 
alcohol,  glycerin,    and  acetic  and  other  acids  possess  in  high  degree  the 


OUTLINES   OF   PEACTICAL   BACTERIOLOGY.  161 

faculty  of  discharging  auiliue  colors  from  all  the  elements,  including  the 
bacteria,  which  have  absorbed  them. 

Theoretically  the  brown  anilines  (vesuvin,  Bismarck-brown,  aniline- 
brown)  possess  in  the  highest  degree  the  power  of  selective  affinity  and  at 
the  same  time  resist  the  action  of  decolorizing  agents.  They  are  also  for  the 
ordinary  photographic  plates  most  useful  for  photographic  purposes.  Xext 
after  the  bro^^•ns,  in  selective  affinity  and  persistence  with  which  the  color 
is  retained,  come,  in  regular  order,  fuchsin,  methvl-violet,  gentian-violet, 
methyl-blue.  It  must  be  remarked,  however,  with  respect  to  this  order, 
that  certain  dyes  have  been  found  bv  experience  to  be  preferable  for  staining 
certain  species  of  bacteria. 

EMPLOYMENT   OF   ANILINE   DYES   FOR   THE   DEMONSTRATION   OF 

BACTERIA. 

The  basic  aniline  colors  are  most  commonly  used,  and  are  conveniently 
prepared  in  the  following  manner  : 

1 .  Concentrated  Watery  Solutioivs. — These  are  used  either  in  fidl  strength 
or  in  solutions  diluted  with  distilled  water.  The  concentrated  solution  is 
made  by  boiling  the  required  quantity  in  distilled  water ;  after  settling,  the 
supernatant  fluid  is  drawn  off  and  kept  for  use.  It  is  found  necessary  to 
freshly  filter  these  watery  solutions. 

2.  Concentrated  Alcoholic  Solutions. — Commonly  about  twenty  to  twenty- 
five  parts  of  the  color-material  to  one  hundred  parts  of  alcohol  are  sufficient 
for  saturation.  These,  concentrated  alcoholic  solutions  are  not  commonly 
used  in  full  strength,  but  generally  after  dilution  with  a  certain  quantity  of 
water.  Five  or  six  drops  of  the  concentrated  alcoholic  solution  may  be 
added  to  a  small  watch-glass  of  distilled  water  to  make  a  proper  fluid  for 
immediate  use. 

3.  Vesuvin,  Bismarck-brown,  aniline-brown,  are  usually  not  employed 
in  alcoholic  solutions,  for  when  water  is  added  precipitation  occurs.  If  a 
concentrated  solution  is  desired  for  use,  it  is  commonly  made  in  equal  parts 
of  glycerin  and  water. 

4.  Alkaline  Solutions. — (a.)  Weak  alkaline  solution  of  Koch  :  1  c.cm. 
of  concentrated  alcoholic  solution  of  methyl-blue ;  200  c.cm.  of  distilled 
water ;  2  c.cm.  of  a  ten-per-cent.  solution  of  caustic  potash. 

(6.)  Strong  concentrated  solution  of  Loeffler :  33  c.cm.  of  concentrated 
alcoholic  solution  of  methyl-blue;  100  c.cm.  of  a  weak  solution  of  caustic 
potash  (1  part  to  10,000  parts  of  water). 

5.  Aniline  Water. — 5  c.cm.  of  pure  aniline  oil  are  shaken  fur  a  moment 
or  two  with  100  c.cm.  of  distilled  water  and  allowed  to  stand  fbr  five 
minutes  or  so ;  the  emulsion  is  then  filtrated  through  filter-paper  previ- 
ously moistened  with  distilled  water.  The  filtrate  should  be  clear ;  if  not 
so,  it  should  be  again  filtrated.  It  is  best  to  prepare  this  aniline  oil-water 
freshly,  for  it  becomes  darkened  by  the  action  of  light  and  a  fine  deposit 
occurs.     This  precipitation  may,  however,  be  impeded  by  the  addition  of 

Vol.  I.— 11 


162  OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 

five  to  ten  per  cent,  of  strong  alcohol.  The  aniline  water  thus  prepared  is 
used  as  a  solvent  for  the  various  aniline  colors,  most  commonly  fuchsin,. 
methyl-violet,  and  gentian-violet ;  and  it  is  strongly  recommended  that 
when  the  most  satisfactory  results  are  desired  these  aniline-water  color- 
mixtures  should  be  made  freshly. 

6.  Instead  of  aniline,  toluidin  may  serve  as  a  menstruum ;  so  also  tur- 
pentine, carbolic  acid  in  five  per  cent.,  and  ammonia  in  one-half  per  cent., 
or  even  borax  solutions. 

For  double  staining,  carmine  or  hematoxylin  may  be  used  for  coloring 
the  histological  elements  of  tissues, — the  first  for  bacteria  stained  blue  or 
violet,  the  latter  for  those  stained  red ;  and  of  the  aniline  colors,  especially 
eosin,  in  dilute  alcoholic  solution,  may  be  used  in  preparations  where  the 
bacteria  are  stained  blue  or  violet.  Instead  of  the  ordinary  carmine  solution^ 
picro-carmine  may  be  used  for  staining  preparations  of  bacteria  tinged  blue  : 
it  colors  the  nuclei  an  intense  red,  the  fibrilli  of  the  connective  tissues  a 
light  red,  and  the  protoplasm  of  the  cellular  body  more  or  less  yellow, — so 
that  really  a  threefold  coloration  is  the  result. 

One  of  the  best  hsematoxylin  solutions  for  this  purpose  is  constituted  as 
follows : 

Hsematoxylin 2  parts ; 

Alcohol 100  parts  ; 

Distilled  water 100  parts  ; 

Glj^cerin 100  parts  ; 

Alum 2  parts. 

This  hsematoxylin  solution  stains  cocci  and  several  forms  of  bacilli,  and 
at  the  same  time  also  to  some  extent  their  zoogloea  masses.  When  picric 
acid  enters  into  the  staining  employed,  in  order  to  preserve  the  yellow  tone 
of  this  dye.  it  is  necessary  after  staining  to  treat  the  preparations  with 
alcohol  containing  picric  acid,  and  to  use  dammar  varnish  as  a  permanent 
mounting-medium. 

COMMON    METHOD    OF    TJSING    STAINING    SOLUTIONS    FOR    DEMON- 
STEATION   OF   BACTERIA. 

Cover- Glass  Preparaiions. — (a).  The  fresh  fluid  containing  the  bacteria 
to  be  examined  is  spread  out  over  the  surface  of. a  perfectly  clean  cover-glass 
and  allowed  to  evaporate  partially.  After  the  diying  has  progressed  some- 
what, but  while  the  film  is  still  moist,  a  drop  of  the  dilute  color-solution 
selected  is  placed  upon  the  film,  and  the  cover-glass  is  inverted  upon  an 
ordinary  object-slide.  The  bacteria,  surrounded  by  the  staining  fluids,  may 
be  directly  observed  under  the  high  power  of  the  microscope,  a  certain  amount 
of  the  coloring  matter  having  been  quickly  absorbed  by  the  bacteria.  This 
method  allows  the  motile  bacteria  to  be  observed  while  in  motion,  and  in 
certain  cases  is  adv^antageous  to  employ. 

(6.)  The  dried  film  fixed  upon  the  surface  of  the  cover-glass  by  the 
agency  of  gentle  heat  after  the  maimer  already  described  is  best  stained  by 


OUTLIXES    OF    PRACTICAL    BACTERIOLOGY.  163 

placing  a  drop  or  two  of  the  color-fluid  upon  the  film  and  inverting  the 
cover-glass  upon  an  object-slide.  After  the  film  has  thus  been  subjected 
for  a  few  moments  to  the  action  of  the  color-solution,  the  latter  is  drawn 
off  by  capillary  attraction  in  the  following  manner :  a  drop  of  sterilized 
distilled  water  is  placed  at  one  edge  of  the  cover-glass,  and  at  the  opposite 
edge  a  small  piece  of  bibulous  paper  is  placed  in  contact  with  the  color- 
fluid,  which  is  thus  drawn  off,  and  at  the  same  time  replaced  by  the  clear 
distilled  w^ater  at  the  side.  The  same  method  may  be  made  use  of  for 
removal  of  the  coloring  fluid  in  the  case  of  the  bacteria  examined  before 
complete  desiccation,  as  above  described,  and  is  especially  useful  where  films 
of  non-albuminous  liquids  cannot  be  fixed  upon  the  cover-glass  by  the 
agency  of  heat.  Occasionally  it  may  be  found  beneficial  to  use,  in  place 
of  simple  distilled  water,  that  which  has  been  rendered  slightly  acidulated 
by  the  addition  of  acetic  acid  (one  drop  to  a  half-ounce  or  more,  according 
to  circumstances). 

After  the  coloring  matter  has  been  thus  washed  out,  the  object  may  be 
at  once  examined  under  the  microscope,  or  the  film  may  be  prepared  for 
permanent  mounting  in  the  following  manner.  The  cover-glass  may  be 
slid  sideways  to  the  edge  of  the  object-glass  and  gently  withdrawn.  The 
water  is  then  allowed  to  drain  off  the  surface  by  resting  the  cover-glass  in 
a  more  or  less  vertical  position  upon  a  small  piece  of  bibulous  paper.  In  a 
few  moments  the  film  becomes  dry.  Or  the  dehydration  may  be  expedited 
by  plunging  it  for  an  instant  in  strong  alcohol,  which  latter  is  also  to  be 
drained  off  in  a  similar  manner ;  but  frequently  the  use  of  alcohol  for  this 
purpose  is  objectionable  because  of  its  decolorizing  power.  In  many  in- 
stances the  bacteria  lose,  even  during  treatment  for  such  a  short  time  by 
alcohol,  a  considerable  amount  of  color. 

After  the  film  has  become  quite  dry  it  may  now  be  permanently  mounted  ; 
and  the  best  mounting-medium  for  the  permanent  preservation  of  bacterio- 
logical specimens  is  perhaps  Canada  balsam,  preferably  dissolved  in  xylol. 
The  tendency  of  all  objects,  including  bacteria,  stained  with  the  aniline 
dyes,  is  to  become  decolorized  in  the  course  of  time,  and  after  a  few  mouths 
to  a  few  years  the  coloring  which  originally  may  have  been  quite  intense 
may  be  found  quite  faint,  or  to  have  entirely  vanished,  and  this  tendency 
is  increased  by  the  existence  in  the  washing  fluids  or  in  the  permanent 
mounting-medium  of  substances  which  naturally  have  the  power  of  decolor- 
izing. For  tliis  reason,  in  the  processes  used  in  preparation  of  bacteria,  it 
is  always  well  to  avoid,  unless  absolutely  necessary,  the  use  of  acids  and  of 
most  of  the  volatile  and  essential  oils. 

(c.)  The  staining  of  bacteria  in  tissues  is  accomplished  with  somewhat 
greater  difliculty  than  in  cover-glass  films.  It  should  go  without  saying 
that  the  sections  should  be  exceedingly  thin  and  regular  in  thickness.  They 
should  be  either  fresh  or  from  tissues  hardened  (and  not  too  long  preserved) 
in  absolute  alcohol,  and  they  should  not  be  cut  long  befi)ro  they  are  stained. 
It  is  found  that  long  soaking,  in  strong  alcohol,  of  lumps  of  tissues  con- 


164  OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 

taining  bacteria  sometimes  seriously  interferes  with  or  entirely  prevents  a 
subsequent  satisfactory  staining  of  the  bacteria ;  and  when  thin  sections 
containing  the  latter  are  kept  even  for  twenty-four  or  forty-eight  hours  in 
strong  alcohol  before  staining,  much  the  same  difficulty  is  met  with.  The 
sections  should,  therefore,  immediately  after  cutting,  be  subjected  to  the , 
staining  solution.  And  it  may  be  said  in  a  general  way  that  the  color- 
solutions  to  be  used  should  be  of  greater  intensity  than  those  required  for 
the  treatment  of  cover-glass  preparations  ;  furthermore,  the  sections  should 
be  subjected  to  the  action  of  the  coloring  fluid  for  a  longer  time,  vaiying 
from  a  few  moments  to  as  many  hours,  according  to  the  nature  of  the  bac- 
teria to  be  stained.  After  sufficient  staining,  the  section  is  removed  from 
the  coloring  fluid  and  for  a  short  time  subjected  to  the  action  of  from  70  to 
90  per  cent,  alcohol.  This  decolorizes  all  the  elements,  but  the  bacteria  to 
a  lesser  degree  than  the  others, — ^the  object  being  to  secure  such  a  state  of 
decolorization  that  the  bacteria,  and  perhaps  the  nuclei  also  to  a  lesser  extent, 
alone  shall  retain  the  color.  To  accomplish  this  desirable  decolorization, 
alcohol  slightly  acidulated  with  acetic  or  lactic  acid  is  sometimes  used,  and 
even  distilled  water  acidulated  in  a  similar  manner  is  often  employed ;  but 
in  all  cases  where  acids  are  employed  greater  care  is  necessary  to  prevent 
discharge  of  the  color  from  the  bacteria. 

Although,  as  a  rule,  the  various  species  of  bacteria  possess  a  singular 
aviditv  for  the  absorption  of  the  aniline  colors,  yet  there  are  some,  and  even 
mauv  of  the  most  important  from  a  pathological  stand-point,  which  form 
exceptions  to  this  rule.  For  instance,  the  bacillus  typhosus  (Photo.  No.  2 
of  typhoid  fever)  is  one  of  a  number  of  varieties  of  bacteria  which  are 
frequentlv  quite  difficult  to  stain  well.  In  sections  of  tissues  these  bacteria 
are  frequently  difficult  to  find  on  this  account.  For  their  demonstration, 
Gaff  ky  has  recommended  that  the  coloring  solution  employed  be  a  concen- 
trated, watery  solution  of  methylin-blue  freshly  prepared.  The  sections 
should  be  immersed  in  this  strong  solution  from  twenty  to  twenty-four 
hours,  and  should  then  be  washed  in  simple  distilled  water  free  of  any  acid  ; 
they  are  to  be  now  dehydrated  for  a  feio  instants  in  absolute  alcohol,  cleared 
in  tuqientine  or  cedar  oil,  and  then  mounted  in  balsam. 

Loeffler  has  suggested  the  following  solution  as  especially  useful  for  the 
staining  of  the  ts'phoid  l^acillus,  the  bacillus  of  glanders,  of  septicaemia,  and 
other  bacteria  which  are  more  or  less  difficult  to  stain  :  a  saturated  alcoholic 
solution  of  methylin-l)lue  or  other  color-material,  33  c.cm. ;  a  solution  of 
caustic  potassa  (1  part  to  10,000),  100  c.cm.  After  the  section  has  been 
subjected  to  this  fluid  for  a  certain  time,  from  a  few  minutes  to  half  an 
hour,  they  are  washed  rapidly  in  distilled  water  sliglitly  acidulated  with 
acetic  acid  (about  one  drop  to  the  half-ounce).  This  strong  staining  fluid  is 
especially  useful  for  demonstration  of  the  bacillus  of  glanders. 

(d.)  There  are  certain  bacteria  already  known  which  require  sj^ecial 
methods  of  staining  for  their  demonstration.  Among  these  are  the  bacillus 
of  tuberculosis,  of  leprosy,  of  syphilis,  of  glanders,  etc. 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY.  165 

Bacillus  tuberculosis. — This  bacillus  does  not  stain  by  the  ordinary 
methods.  In  fact,  there  are  some  of  the  aniline  colors  for  which  it  has  no 
selective  avidity  whatever.  For  instance,  it  cannot  be  stained  brown.  On 
the  other  hand,  the  tenacity  with  which  it  retains  certain  colors  which  it 
absorbs  with  avidity  is  so  phenomenal  as  to  remove  it  entirely  from  the  class 
of  bacteria  which  become  readily  decolorized  through  the  action  of  acids, 
especially  the  mineral  acids.  These  peculiarities  have  been  utilized  by  Koch, 
Ehrlich,  and  others  for  devising  a  color-method  of  differentiation  which  makes 
it  possible  and  easy  to  distinguish  this  micro-organism  from  others  known, 
and  to  furnish  also  a  ready  means  of  clinical  diagnosis  of  great  practical 
value. 

For  the  demonstration  of  the  tubercle-bacillus  the  following  methods  are 
readily  applicable  and  at  the  same  time  reliable.  A  color-solution  is  made 
in  the  following  manner  : 

A  saturated  solution  of  aniline  oil  in  water 90  parts ; 

A  saturated  alcoholic  solution  of  methyl-violet  (or  of  fuchsin)    .    .    11  parts ; 
Absolute  alcohol 10  parts. 

Although  the  mixture  containing  this  proportion  of  alcohol  may  keep 
for  eight  to  ten  days,  or  even  longer,  it  should  be  filtered  previous  to  each 
application  ;  and  in  cases  of  great  importance  for  diagnostic  purposes,  it  is 
better  to  prepare  the  fluid  freshly.     The  method  of  staining  is  as  follows  : 

Have  six  watch-glasses  in  a  row,  and  in  imagination  let  us  number  them 
from  left  to  right :  No.  1,  a  small  watch-glass,  is  nearly  full  of  the  aniline- 
water  coloring  mixture  above  mentioned ;  in  No.  2,  which  should  be  a  large 
watch-glass,  is  a  considerable  quantity  of  dilute  nitric  acid  (1  to  3) ;  in  No. 
3,  also  a  large  watch-glass,  is  a  considerable  quantity  of  60  per  cent,  alcohol ; 
No.  4,  a  large  watch-glass,  contains  a  considerable  quantity  of  90  per  cent, 
alcohol ;  No.  5,  a  small  watch-glass,  contains  a  dilute  watery  solution  of 
Bismarck-brown  (or  vesuvin)  if  methyl- violet  has  been  used  in  No.  1,  or  of 
methyl-blue  if  fuchsin  has  been  used ;  No.  6,  a  large  watch-glass,  contains 
distilled  water. 

The  matter  to  be  examined,  if  it  be  sputum  or  other  semi-fluid  or  fluid 
material,  should  be  spread  in  as  thin  a  film  as  possible  over  the  surface  of  a 
previously-cleaned  cover-glass.  Care  should  be  taken  to  use  for  this  pur- 
pose the  thick  purulent  matter,  avoiding  the  saliva,  in  the  case  of  sputum. 
The  film  is  dried  and  fixed  upon  the  cover-glass  in  the  usual  mannei',  by 
heat.  It  is  then  inverted  upon  the  surfiice  of  the  coloring  fluid  in  watch- 
glass  No.  1.  The  latter  is  placed  over  the  flame  of  a  spirit-lamp  or  Buusen 
burner,  and  heat  carefully  applied  until  steam-bubbles  begin  to  rise  in  the 
fluid.  The  watch-slass  is  then  set  aside  and  allowed  to  cool  for  a  few 
moments  (from  two  to  five).  The  cover-glass  with  the  film  intensely 
stained  is  now  taken  up  between  the  points  of  fine  forceps  and  for  a  sec- 
ond or  two  is  dip])ed  and  moved  to  and  fro  in  the  acid  fluid  contained  in 
watch-fflass  No.  2.     It  is  then  at  once  immersed  and  moved  backward  and 


166  OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 

forward  in  the  alcohol  of  watch-glass  No.  3,  until  the  most  of  the  color  has 
disappeared.  It  is  then  removed  and  washed  in  the  strong  alcohol  of  watch- 
glass  No.  4,  until  to  the  naked  eye,  by  transmitted  light,  the  film  seems  to 
be  completely  decolorized  and  has  become  decidedly  gray.  Then  the  cover- 
glass  is  floated  film  downward  upon  the  surface  of  the  contrast  watery  color- 
ing fluid  in  watch-glass  No.  5,  where  it  is  allowed  to  remain  for  a  minute. 
It  is  removed  from  this  and  washed  in  the  contents  of  No.  6.  When  the 
superfluous  fluid  has  been  thus  washed  oif,  the  cover-glass  is  then  stood 
up  on  edge  upon  a  small  piece  of  bibulous  paper  to  drain  and  dry,  or  dehy- 
dration is  secured  more  rapidly  by  immersion  for  a  few  instants  in  strong 
alcohol,  after  which  it  is  likewise  stood  upon  edge  and  completely  dried. 
It  is  now  mounted  in  Canada  balsam  for  permanent  preservation.  Care 
should  be  taken  that  the  film  be  completely  dried  before  the  l^alsam  is  ap- 
plied ;  otherwise,  if  there  is  any  moisture  still  present,  the  film  will  remain 
cloudy  and  furnish  an  indistinct,  unsatisfactory  View  for  the  microscope. 

After  washing  the  film  in  watch-glass  No.  6,  the  cover-glass  may  be  at 
once  inverted  upon  an  ordinary  object-glass  and  examined  under  the  micro- 
scope immediately. 

By  skill  and  practice  in  the  use  of  this  rapid  method  there  is  no  difli- 
culty  in  preparing  the  tubercle-bacilli  and  demonstrating  them  under  the 
microscope  in  less  than  six  minutes.  In  fact,  less  time  is  required  for  such 
an  examination  than  is  necessary  for  an  ordinary  microscopic  examination 
of  urine,  such  as  the  clinician  has  long  been  familiar  with. 

If  heat  be  not  applied  in  the  staining  process,  it  is  necessary  that  the 
film  should  be  subjected  to  the  action  of  the  coloring  fluid  for  twelve  to 
twenty-four  hours,  and  in  the  opinion  of  some,  where  absolute  exactness 
is  desirable,  not  only  in  finding  tubercle-bacilli  in  the  matter  examined,  but 
also  in  estimating  their  number,  this  long,  tedious  process  is  essential ;  but 
in  the  experience  of  the  writer,  and  in  that  of  many  others  in  the  habit 
of  making  such  examinations,  the  shorter  method,  by  the  intervention  of 
heat,  is  quite  as  reliable. 

It  is  often  desirable  to  search  for  the  existence  of  tubercle-bacilli  in  situ 
naturse  in  animal  tissues.  In  this  case  it  is  necessary  to  harden  a  piece  of 
tissue  in  absolute  alcohol  and  cut  from  it  exceedingly  thin  sections.  The 
latter  are  treated  in  a  manner  very  similar  to  that  above  described,  except 
that  the  use  of  heat  is  discarded  and  the  tissues  allowed  instead  to  remain 
in  the  staining  fluid  for  twenty-four  hours  or  more.  The  decolorization  by 
the  agency  of  nitric  acid  and  alcohol  is  more  difficult  than  in  the  case  of 
films.  The  sections  should  be  flirted  in  the  dilute  nitric  acid  for  a  little 
longer  time  and  afterwards  subjected  still  longer  to  the  action  of  the  alcohol. 
Indeed,  it  may  become  difficult,  or  sometimes  even  impossible,  to  render  the 
section  absolutely  colorless  to  the  naked  eye ;  but  when  the  color  becomes 
quite  faint,  the  sections  may  be  treated  by  the  contrast-color  in  watch-glass 
No.  5  for  a  few  moments,  then  quickly  washed  in  distilled  water  and  sub- 
sequently dehydrated  rapidly  in  absolute  alcohol.     When  this  is  completed, 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY.  167 

the  absolute  alcohol  is  displaced  by  a  drop  or  two  of  oil  of  turpentine  or  oil 
of  cedar,  and  the  sections  are  then  permanently  mounted  in  Canada  balsam. 

There  are  other  methods  which  have  been  suggested  for  the  differential 
demonstration  of  the  tubercle-bacilli,  which  have  been  proved  to  be  more 
or  less  satisfactory ;  but,  as  this  is  not  the  proper  place  to  introduce  com- 
plete details  for  the  practice  of  bacteriological  researches,  they  will  not  be 
mentioned  here.     (For  Bacillus  tuberculosis,  see  Photo.  No.  3.) 

BaciUm  Leprse. — The  bacillus  of  leprosy  behaves  in  a  manner  quite 
similar  to  the  bacillus  of  tuberculosis,  with  respect  to  the  method  of  stain- 
ing the  latter,  above  described.  The  bacillus  leprse  differs,  however,  from 
the  bacillus  tuberculosis  in  this  respect, — viz.,  in  the  fact  that  the  former  is 
much  more  quickly  acted  upon  by  the  coloring  fluid ;  and,  besides,  it  is 
capable  of  staining  by  common  methods,  already  mentioned,  applicable  to 
most  of  the  bacteria.     It  is  capable  also  of  being  stained  brown. 

A  method  of  differentiating  between  the  bacillus  leprse  and  the  bacillus, 
tuberculosis  is  based  upon  the  readiness  with  which  the  former  absorbs  the 
special  coloring  matter.  If  the  cover-glass  film  containing  the  lepra-bacilli 
is  allowed  to  remain  from  six  to  seven  minutes  in  a  cold  dilute  alcohol 
solution  or  fuchsin  (five  to  six  drops  of  a  concentrated  alcoholic  solution  in 
a  watch-glass  full  of  distilled  water),  and  is  subsequently  decolored  for 
fifteen  seconds  in  acidulated  alcohol  (one  part  of  nitric  acid  to  ten  parts  of 
alcohol),  then  washed  in  acidulated  distilled  water,  and  afterwards  stained 
in  a  dilute  watery  solution  of  methylin-blue,  then  washed  and  examined  at 
once  in  water,  the  lepra-bacillus,  after  such  treatment,  appears  as  a  red  rod 
upon  a  blue  ground ;  whilst  the  tubercle-bacillus  treated  in  a  similar  manner 
has  not  yet  absorbed  any  of  the  coloring  matter.  Other  methods  of  differ- 
entiation have  been  proposed  which  are  more  or  less  satisfactory  and  of 
varying  readiness  of  application,  which  it  is  not  necessary  to  mention. 

Bacillus  of  Syphilis. — Lustgarteu  employs  the  following  method  for  the 
differential  demonstration  of  this  bacillus.  The  sections  are  first  stained 
from  twelve  to  twenty-foiu-  hours  at  the  ordinary  room  temperature  in  the 
following  solution  : 

Concentrated  alcoholic  solution  of  gentian  violet  .    .    .     11  parts; 
Saturated  solution  of  aniline  oil  in  water 100  parts. 

They  are  then  kept  in  the  same  solution  for  two  hours  at  a  temperature 
of  60°  C.  The  sections  are  now  washed  for  a  few  minutes  in  absolute 
alcohol,  then  for  ten  seconds  in  a  one-and-a-half-per-cent.  solution  of  per- 
manganate of  potash,  after  which  they  arc  immersed  an  instant  in  a  concen- 
trated solution  of  chemically  pure  sulphurous  acid.  If  the  section  is  not 
entirely  decolorized,  this  double  dccolorization  is  repeated  three  or  four  times, 
after  which  the  sections  are  dehydrated  in  alcohol,  cleared  in  essence  of 
girofle,  and  mounted  in  balsam. 

The  bacilli  of  Icpro.sy  can  be  colored  by  the  same  procedure,  and  those 
also  of  tuberculosis  :  while  all  the  other  bacilli   remain   uncolored.     The 


168  OUTLIXES    OF    PRACTICAL    BACTEEIOLOGY. 

bacilli  of  syphilis  are  readily  distinguished  from  those  of  tuberculosis 
because  the  former  are  not  colored  by  the  method  already  described  for  the 
demonstration  of  the  tubercle-bacillus. 

Alvarez  and  Tavel,  iu  1885,  published  an  account  of  the  discovery  of  a 
bacillus  in  the  smegma  and  desquamation  of  the  moist  parts  of  the  genital 
regions,  which  to  coloring  agents  behaves  in  a  similar  manner  to  that  of 
Lustgarten.  According  to  these  authors,  their  bacilli  are  stained  by  fuchsin, 
and  the  color  resists  the  action  of  hydrochloric  acid  like  the  bacilli  of  tuber- 
culosis, but  they  are  finally  decolored  by  alcohol.  Their  coloration  is  less 
resistant  than  that  of  the  tubercle-bacilli.  Cornil  and  others  have  confirmed 
the  existence  of  bacilli  in  the  smegma  closely  resembling  the  bacillus  of 
syphilis  described  by  Lustgarten,  but  Cornil  declares  that  it  does  not  abso- 
lutely correspond  to  the  Lustgarten  bacillus.  The  latter  does  not  stain  by 
simple  methods  of  coloring,  nor  by  the  method  of  Ehrlich  for  the  diiFeren- 
tiation  of  the  tubercle-bacillus ;  while,  on  the  contraiy,  the  bacillus  of 
Alvarez  does  color  by  this  latter  process,  as  Cornil  has  confirmed. 

Bacillus  of  Glanders. — This  bacillus  is  also  one  of  those  usually  difficult 
to  stain  satisfactorily.  The  method  proposed  by  Loeffler  is  perhaps  the  best. 
For  cover-glass  preparations,  a  strong  alkaline  aqueous  solution  of  methyl- 
blue,  already  described,  is  used,  the  film  being  subjected  to  its  action  for 
several  minutes  to  half  an  hour.  If  the  cover-glass  has  been  inverted  on 
a  glass  slide,  the  staining  fluid  is  removed  by  capillary  attraction  iu  the 
manner  already  mentioned,  but,  instead  of  pure  distilled  water,  that  slightly 
acidulated  with  acetic  acid  is  used,  and  this  is  immediately  in  turn  drawn  oif 
by  capillarity  and  washed  out  several  times  by  means  of  pure  distilled  water. 
If  the  bacilli  are  contained  in  the  tissues,  the  sections  must  be  made  and 
immersed  in  the  staining  fluid  from  twenty  to  forty  minutes.  They  are 
then  washed  in  distilled  water  slightly  acidulated  with  acetic  acid,  rapidly 
dehydrated  in  strong  alcohol,  and  mounted  in  dammar,  after  clearing  with 
cedar  oil  or  oil  of  turpentine. 

Gramas  method  of  staining  is  sometimes  useful  for  diiferential  demon- 
strations of  certain  bacteria.  It  is  thus  employed  :  the  cover-glass  prepara- 
tions of  bacteria  or  the  sections  containing  the  latter  are  stained  for  ten 
minutes  to  a  half-hour  or  longer  in  a  strong  solution  of  gentian-violet  in  satu- 
rated aniline  water.  They  are  then  removed,  without  washing,  to  a  solution 
of  iodine  in  potassium  iodide,  in  which  they  are  allowed  to  remain  until  they 
become  dark  brown  or  nearly  black.  They  are  now  decolored  in  alcohol 
until  they  become  quite  gray.  For  those  bacteria  which  can  be  stained  by 
this  method,  it  will  be  found  that  they  remain  intensely  colored,  whilst  the 
ground  is  unstained.  If  it  be  desirable,  the  latter  may  be  tinged  with  a 
contrast  stain,  a  watery  or  a  weak  alkaline  solution  being  employed  for  this 
purpose. 

Methods  of  Staining  Spore^s. — The  spores  of  bacteria  are  exceedingly 
resistant  to  the  action  of  coloring  fluids.  They  appear  to  be  enveloped  in 
a  thin,  dense,  more  or  less  impenetrable  membrane,  which  greatly  opposes 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY.  169 

absorption  of  the  coloring  matter,  and  in  order  to  overcome  this  impediment 
and  secure  the  staining  of  these  objects  it  is  necessary  to  resort  to  special 
methods.  One  commonly  used,  and  which  has  been  found  to  be  quite 
satisfactory,  is  as  follows  : 

It  has  been  learned  by  experiment  that  high  heat  or  the  more  or  less 
prolonged  action  of  strong  mineral  acids  or  of  strong  alkalies  destroys  this 
resistance  of  the  spore-envelope.  Many  kinds  of  spores  can  be  stained  if 
the  cover-glass  preparation,  instead  of  being  drawn  three  times  through  the 
flame,  is  drawn  through  it  ten  or  more  times ;  so  likewise  if  the  cover-glass 
preparation  be  exposed,  in  the  sterilizing  oven,  for  a  half-hour  to  an  hour, 
to  a  temperature  of  150°  to  180°  C.  Furthermore,  many  species  can  be 
stained,  if  the  cover-glass  preparation  be,  as  usual,  fixed  by  heat  and  then 
immersed  for  twelve  to  twenty-four  hours  in  a  strong  alkaline  solution  of 
the  color-material ;  or,  better  still,  if  it  be  floated  for  ten  to  twenty  minutes 
upon  the  surface  of  a  heated  strong  aniline  wateiy  solution  of  the  color  se- 
lected. A  contrast-stain  for  the  protoplasm  of  the  bacteria  should  in  this 
case  be  subsequently  used.  The  double  staining  in  these  cases  is  more  cer- 
tain if  before  using  the  second  color  solution  the  first  is  washed  in  distilled 
water  and  then  subjected  for  a  few  seconds  to  the  action  of  absolute  alcohol. 
If  instead  of  alcohol  a  diluted  mineral  acid  is  used,  the  boundary  between 
the  spore  and  the  adjacent  protoplasm  is  more  sharply  defined.  If  the  bac- 
teria containing  spores  are  in  sections  of  tissues  or  are  associated  with  cellular 
bodies,  the  histological  elements  may  be  stained  with  still  a  third  color,  such 
as  hsematoxylin,  carmine,  or  picro-carmine. 

METHODS   OF   ISOLATION   OF   SPECIES   OF   BACTEKIA  AND   MODES   OF 

CULTUKE. 

Customarily,  it  is  only  in  the  tissues  of  internal  organs  that  it  is  possible 
to  encounter  pure  natural  cultures  of  the  specific  pathogenic  micro-organ- 
isms. Even  in  such  cases  it  is  not  uncommon  to  find  the  sjjecific  microbe 
associated  with  one  or  more  different  species  extraneous  to  the  disease.  It 
is  not  seldom  that  secondary  aflectious  are  grafted  upon,  or  become  the 
sequel  of,  the  primary  disease.  Even  when  this  is  not  the  case,  saprophytic 
bacteria  may  in  various  ways  find  entrance  into  the  tissues.  Different 
species  of  bacteria  are  so  frequently  associated  together  in  substances  that 
afford  them  nourishment  that  some  method  of  separation  of  different  species 
is  essential  for  an  intelligent  study  of  their  peculiarities  of  form,  develop- 
ment, and  physiological  or  pathological  characters. 

AVithout  going  into  the  history  of  the  development  of  these  methods,  it 
is  sufficient  to  remark  that  until  Koch  in  1881  proposed  a  method  of  culture 
upon  a  solid  medium  having  for  its  solidifying  substance  animal  gelatin,  tlie 
only  methods  of  obtaining  pure  cultures  of  individual  species  in  practical 
use  had  been  that  of  fractional  culture  proposed  by  Klebs,  and  that  of 
dilution  proposed  by  Lister,  botli  making  use  of  fluids  for  this  purpose, 
the  object  aimed  at  in  each  of  these  two  methods  being  the  separation 


170  OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 

and  equal  distribution  throughout  the  fluid  used  of  single  bacteria  to  such 
a  degree  that  a  single  drop  of  the  fluid  should  contain,  as  a  rule,  no  more 
than  a  single  micro-organism.  When  this  degree  of  separation  was  believed 
to  be  attained, — usually  from  calculation,  oftentimes  based  upon  actual  ob- 
servation under  the  microscope, — a  large  series  of  test-tubes  or  small  flasks, 
containing  the  fluid  culture  medium  previously  prepared,  were  inoculated 
each  with  a  single  drop  from  the  diluted  fluid  suspending  the  isolated  micro- 
organisms, and  were  then  set  aside  for  further  observation.  After  a  few 
days  it  was  found  that  a  certain  number  of  the  tubes  or  flasks,  thus  inocu- 
lated, had  become  more  or  less  cloudy  or  shown  in  other  ways  that  a  growth 
had  occurred.  If  the  separation  of  the  bacteria  had  been  made  with  suffi- 
cient care,  the  non-occurrence  of  growth  in  a  small  number  of  the  tubes 
furnished  the  proof  that  the  drop  with  which  they  had  been  inoculated 
<?ontained  not  even  one  germ  capable  of  development. 

If  in  a  fluid  containing  two  or  more  species  of  bacteria — one,  however, 
predominating — the  majority  of  the  tubes  would  be  found  to  contain  growths 
of  this  latter  species,  and  a  certain,  although  perhaps  limited,  number  of 
such  tubes  contain  absolutely  pure  cultures. 

This  method  of  procedure  required  such  extreme  care,  consumed  such  an 
enormous  amount  of  time,  and  produced  results  which  were  so  frequently 
uncertain,  and  therefore  unsatisfactory^,  that,  until  better  methods  were 
devised,  progress  in  the  knowledge  of  the  specific  nature  of  bacteria  ad- 
vanced with  slow  steps,  the  enormous  labor  involved  deterring  most  of  the 
best  observers  from  undertaking  it. 

After  pure  cultures  of  species  had  been  obtained  in  this  troublesome 
manner,  Klebs  made  use  of  another  method  for  the  purpose  of  directly 
studying  under  the  microscope  the  development  of  a  colony  from  a  single 
microbe.  For  this  purpose  he  proceeded  in  the  following  manner,  the 
minute  details  of  which  will  be  omitted  here.  Instead  of  a  fluid  culture 
medium,  he  used  one  which  at  the  ordinary  temperature  is  solid  but  trans- 
parent. To  the  ordinary  fluid  culture  medium  (such  as  meat  broth)  he 
added  a  sufficient  amount  of  gelatin  to  render  the  whole  solid  when  cool. 
In  preparation  for  the  examination,  this  solid  culture  medium  was  rendered 
fluid  by  gentle  heat.  It  was  then  inoculated  with  such  a  Cjuantity  of  a 
pure  fluid  culture  as  that  each  individual  germ  should  be  sufficiently  sepa- 
rated from  the  others.  This  was  secured  by  the  employment  of  his  method 
of  dilution.  A  drop  -from  this  fluid  gelatin-medium  containing  the  indi- 
vidual germs  evenly  dispersed  was  now  placed  in  a  capillary  cell,  the  top 
of  which  consisted  of  glass  so  thin  that  a  high  microscopic  objective  could 
easily  work  through  it.  AVhen  the  drop  had  solidified,  the  cell  was  placed 
under  the  microscope  and  a  germ  brought  distinctly  into  the  field.  This 
germ  now  became  the  object  of  observation,  and  was  carefully  watched, 
being  kept  in  view  for  hours  at  a  time  without  interruption.  In  this  man- 
ner Klebs  succeeded  in  following  the  process  of  multiplication  of  a  single 
germ,  and  the  development  of  a  colony  of  similar  individuals  therefrom. 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 


171 


This  method  of  eultivatiug  colonies  from  single  individuals  in  a  solid 
medium  became  the  basis  of  the  celebrated  method  proposed  by  Koch  for 
isolating  single  sjaecies  from  mixtures  thereof,  following  them  in  pure  cul- 
tures through  their  cvcles  of  development  and  studying  their  vital  and  other 
characters. 

Previous  to  the  introduction  of  this  new  method  of  Koch,  however, 
Brefeld  had  already  made  use  of  solid  culture  media  for  obtaining  pure 
cultures  of  bacteria.  His  method  essentially  consisted  in  pouring  melted 
arelatin  containing:  nutritive  substances  over  a  flat  level  surface.  After  it 
had  solidified,  the  point  of  a  needle  was  dipped  in  the  fluid  containing  the 
bacteria  and  numerous  separate  scratches  with  the  point  were  made  through 
the  surface  of  the  gelatin.  The  layer  was  then  set  aside  protected  from  the 
dust.  After  a  short  time  it  was  found  that  bacteria  began  to  groAV  along 
the  course  of  the  scratches,  and  it  was  observed  that  in  those  later  made  the 
development  occurred  usually  at  interrupted  points  and  consisted  of  colonies 
of  individuals  which  had  sprung  from  a  single  germ  which  had  been  rubbed 
off  and  left  behind  at  that  point.  In  this  way  it  was  possible  with  some 
rapidity  and  exactness  to  obtain  pure  cultures  of  different  species.  The 
method  of  Koch,  however,  has  been  found  by  experience  to  be  of  far 
more  general,  wider,  and  certain  application,  and  it  is  now  most  fre- 
quently employed.     It  will  be  described  later  in  some  detail. 


INSTKUMENTS   AND   APPARATUS    EEQUIRED   FOR   BACTERIOLOGICAL 

INVESTIGATIONS. 

Instruments. — All  instruments  and  all  vessels  containing  culture  media 
for  such  investigations  must,  as  a  fundamental  principle,  be 
thoroughly  sterile ;  that  is  to  say,  absolutely  free  "when  in  use 
from  the  accidental  contact  of  living  germs. 

Besides  the  instruments  employed  in  ordinaiy  histological 
examinations,  the  following  are  deemed  essential  for  bacterio- 
logical researches : 

Plain  glass  rods.    Glass  rods  into  one  end  of  which  a  fine 
stiff  platinum  wire  is  fused  (Fig.  8) :  several  of  these  should 
l)e  at  hand,  one  or  two  with  the  wire 
habitually  straight  (B) ;  as  many  with 
the  end  turned  at  right  angles  to  the 
length  ( C) ;  as  many  more  with  the' 
end  made  into  a  small  loop  (A).    Num- 
bers  of  test-tubes   of  ordinary   size, 
three-quarters  of  an  inch  in  diameter  ; 
fewer   an    inch    in    diameter.      Small 
shallow  glass  cups  two  inches  in  diam- 
eter, with  plain  flat  bottoms  and  a  plain 
cap.     Square  or  round  wire  cases  of  stiff  galvanized  wii'o,  for  holding  small 
collections  of  test-tubes  in  a  vertical  position  (Fig.  9).    Flat-bottomed,  long- 


FiG.  9. 


1         #cs. 

kV 

*t-^t 

-t=,'-1 

f;    i_T 

:  't^^ 

V'      ^ 

/ 

LV-^- 

\   \_ 

/       / 

[V 

./ 

!  ■  ,' 

'     r 

_\ 

-L-  \  J. 

_ -i  .-. 

\     ■■  1 

i 

\       ' 

/ 

\ 

,-I-V 

' 

:"3: 

■>      \. 



'^ 

> 

172 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 


Fig.  10. 


Fig.  11. 


necked,  thiu,  globular  flasks,  well  annealed,  of  capacity  from  an  ounce  to  a 
half-gallon.  Long  glass  pipettes  (Fig.  10)  with  a  globular  expansion  in 
their  course,  of  a  capacity 
of  an  ounce,  and  the  lower 
end  sufficiently  long  to  reach 
from  the  top  of  the  neck 
of  a  flask  to  the  bottom. 
Shallow  glass  dishes  (Fig. 
11)  with  flat  bottoms  and 
vertical  sides,  two  inches 
high  and  eight  or  nine  inches 
in    diameter    (A);    shallow 

bell-glasses  (B)  to  fit  within  these ;  glass  benches  to  be  placed 
within  them,  upon  which  oblong  square  plates  (C)  three  inches 
broad  and  five  inches  long  are  to  rest, — the  whole  to  serve  as 
raoist  chambers.  A¥hen  the  moist  chamber  is  in  use,  it  should  be 
sterilized  and  a  layer  of  bibulous  paper  moistened  with  corrosive 
sublimate  solution  should  cover  the  bottom  of  the  shallow  glass 
dish.  Two  or  three  thin  copper  cases  of  the  proper  dimensions 
for  holding  within  them  a  dozen  or  so  of  the  oblong  glass  plates 
above  mentioned.  These  copper  cases  should  be  fitted  with  a 
suitable,  closely-fitting,  metallic  cap  having  a  convenient  handle. 
A  cooling  apparatus  of  t\\e  following  construction  (Fig.  12):  a 
glass  or  metallic  cylinder  (A)  three  or  four  inches  high  and  six 
or  seven  inches  in  diameter  filled  with  water  to  the  brim ;  upon 
the  top  of  this  rests  a  square  plate  of  rather  thick  glass  twelve  inches  square 
(B),  with  the  surfaces  ground ;  upon  the  top  of  this  rests  a  bell-glass  (C) 

eight  or  ten  inches  in  diameter, 
with  a  ground  edge ;  under  the 
bottom  of  the  cylinder  contain- 
ing water  are  necessary  three 
long  thin  wedges  (F)  at  equal 
distance  around  the  circumfer- 
ence ;  a  small  circular  spirit- 
level  (E)  rests  upon  one  corner 
of  the  glass  plate ;  when  in  use 
a  block  of  ice  is  placed  in  the 
water,  the  surface  of  the  latter 
being  in  contact  with  the  bottom  of  the  glass  plate,  free  from  bubbles,  and 
the  surface  of  the  ground-glass  plate  is  perfectly  levelled  by  means  of  the 
wedges.  This  apparatus  is  to  be  used  iii  the  preparation  of  the  gelatin  pjlates. 
Quantities  of  bibulous  paper  and  quantities  of  washed  absorbent  cotton, 
as  well  as  vessels  containing  chemical  germicides,  should  be  at  hand,  such  as 
carbolic  acid  in  five-per-cent.  solution,  bichloride  of  mercury  1  part  to  1000 
parts  of  water. 


Fig.  1-2. 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY. 


173 


Fig.  13. 


STEKILIZING   APPARATUS. 

Sterilization  is  best  accomplislied  by  dry  heat  or  by  steam. 

Dry  Heat  Steiilizer  (Fig.  13). — In  order  to  apply  dry  heat  for  sterilizing, 
an  oven  of  sufficient  inner  capacity,  capable  of  standing  at  least  150°  C,  is 
required.  One  of  the  best 
ovens  of  this  kind  is  con- 
structed in  the  following  man- 
ner. An  oblong  square  box 
of  strong  thin  sheets  of  gal- 
vanized iron  is  constructed 
with  a  double  wall  (A),  in 
order  to  allow  the  passage  of 
a  flame,  and  the  heated  air 
therefrom,  around  the  whole 
exterior  of  the  inner  case. 
The  inner  dimensions  of  the 
box  should  be,  conveniently, 
eighteen  to  twenty-four  inches 
high,  a  foot  wide,  and  a  foot 
deep.  Supporting  cleats  should 
be  fastened  on  the  two  sides  at 
convenient  heights  for  the  pur- 
pose of  supporting  a  perforated 
or  wire  shelf  (G)  in  a  horizon- 
tal position  about  the  middle 
of  the  box,  in  order  to  divide 
it  into  two  compartments. 
Outside  of  this  inner  case  is 
built    another    at   a    distance 

therefrom  of  an  inch  in  every  direction.  A  hole  is  made  in  the  top 
through  both  cases,  and  a  short  tube  cemented  therein  which  places  the 
interior  in  communication  with  the  external  air.  In  this  tube  is  inserted 
a  cork  carrying  a  Centigrade  thermometer  (B)  with  a  scale  indicating  200 
degrees  C,  in  such  a  manner  that  the  bull)  shall  penetrate  an  inch  or 
two  below  the  top  of  the  inner  case.  Besides,  a  row  of  half-inch  holes  an 
inch  apart  should  be  cut  through  the  top  of  the  outer  case.  A  band  of 
metal  of  somewhat  greater  length  and  breadtli  sliould  be  jiunched  by  a 
like  number  of  similar  holes  at  equal  distance.  Tiiis  l)and  should  be  fast- 
ened in  cleats  (C)  in  such  a  manner  that  it  can  slide  backward  and  forward 
over  the  holes  in  the  outer  case  in  order  to  close  the  openings  in  the  lattei- 
or  to  open  them  at  will.  In  the  centre  of  the  bottom  of  the  outer  case  a 
hole  some  two  inches  in  diameter  should  be  cut,  and  under  this  a  triple 
Bunsen  burner  (E)  is  placed,  connected  with  the  gas-pipe,  in  order  to  supply 
th.e  necessary  heat.     The  top  of  the  burners  sh(»uld  be  two  inclies  below 


174 


OUTLINES    OP^    PRACTICAL    BACTERIOLOGY. 


Fig.  14. 


B    f-^ 


the  level  of  the  bottom  of  the  outer  case.  A  hollow  door  with  an  air 
cushion  between  the  two  sheets  is  hinged  at  the  front  (D)  in  such  a  manner 
that  the  inner  box  can  be  well  closed  from  the  external  air. 

Test-tubes  previous  to  sterilization  should  be  washed  perfectly  clean 
with  distilled  water.  Their  mouths  should  be  stopped  with  plugs  of  washed 
cotton  extending  at  least  an  inch  into  the  tube.  The  desired  number  of 
test-tubes  thus  prepared  are  placed  in  one  of  the  wire  cases  already  men- 
tioned, and  the  whole  placed  within  the  chamber  of  the  sterilizing  oven. 
Flasks  intended  for  holding  culture  media  are  to  be  cleaned  and  stopped 
with  cotton  in  an  analogous  manner.     Pipettes  are  also  washed  and  placed 

within  the  oven,  as  also  the  copper  cases  con- 
taining the  glass  plates,  and  any  other  apparatus 
which  is  desired  to  be  thoroughly  sterilized  and 
w^hich  will  not  be  injured  by  high  heat.  The 
Bunsen  burner  is  now  lighted  and  the  tempera- 
ture of  the  oven  raised  to  150°  C.  and  kept  at 
that  height  for  at  least  three-quarters  of  an  hour. 
At  such  a  prolonged  temperature  all  living  or- 
ganisms die,  and  even  the  white  plugs  of  cotton 
become  more  or  less  singed.  The  flame  is  then 
turned  ofP,  and  the  oven  allowed  to  gradually 
cool  with  the  door  kept  closed. 

Steam  Sterilizer  (Fig.  14). — A  steam  boiler 
of  the  following  dimensions  and  construction 
should  be  made.  A  tin  or  other  metallic  cylin- 
der (A)  fourteen  to  sixteen  inches  in  diameter, 
and  twenty-four  to  thirty  inches  high,  with  a 
tightly-fitting  top  (B),  in  the  centre  of  which  is 
a  perforation  for  a  cork  carrying  a  Centigrade 
thermometer  (C)  registering  100°  C,  the  bulb 
of  which  should  extend  two  or  three  inches  below 
the  top,  which  latter  should  also  be  furnished  with 
two  convenient  handles  and  should  be  covered 
with  thick  felt  or  thick  asbestos-paper.  Attached 
to  the  side  of  the  cylinder  near  the  bottom  should  be  a  water-gauge  (D),  for 
the  purpose  of  constantly  indicating  the  height  of  the  water.  Six  or  eight 
inches  above  the  bottom  of  the  cylinder  should  be  fastened  on  the  inside 
three  or  four  small  arms  for  the  support  of  a  removable  metallic  grate 
closely  fitting  the  diameter  of  the  cylinder,  and  best  made  of  stiff  wire. 
The  cylinder  is  completely  covered  with  an  external  envelope  of  heavy  felt 
or  thick  asbestos-paper,  to  impede  radiation.  Of  course  the  bottom  itself 
is  uncovered.  This  apparatus  is  furnished  with  heat  by  a  triple  Bunsen 
burner  (E)  attached  to  the  gas-pipe.  Previous  to  use,  it  should  be  seen 
that  there  are  at  least  three  to  four  inches  of  water  in  the  cylinder ;  and 
this  water  should  be  raised  to  the  boiling-point  and  kept  there.     Vessels, 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY.  175 

such  as  flasks,  test-tubes,  etc.,  containing  culture  media,  both  fluids  and  solids 
of  various  kinds,  are  placed  within  the  cylinder  for  sterilization  and  sub- 
jected to  the  action  of  steam  at  the  boiling-point  for  at  least  an  hour, 

Stenlization  by  Interrupted  Lower  Temperatures. — For  the  purpose  of 
sterilizing  blood  serum  and  some  other  culture  media  which  coagulate  and 
become  more  or  less  opac^ue  at  temperatures  below  the  boiling-point,  it  is 
necessary  to  use  another  apparatus,  which  consists  of  a  cylinder  with  a 
double  wall  for  the  purpose  of  providing  a  layer  of  water  about  an  inch 
thick  all  around  the  cylinder.  From  the  bottom  of  the  inner  cylinder  is 
a  hollow  tube  an  inch  in  diameter  in  communication  with  the  water-cavity 
at  the  bottom ;  the  cap  of  the  cylinder  is  also  double,  so  as  to  carry  a  layer 
of  water  an  inch  thick,  and  at  one  edge  projects  outward  and  slightly 
downward  a  hollow  tube  four  inches  long  and  an  inch  in  diameter,  closed 
at  the  outer  end,  the  inner  end  being  in  communication  with  the  cavity  of 
the  cap  and  likewise  filled  with  water.  The  ^vhole  of  this  apparatus,  except 
the  bottom,  is  covered  with  a  thick  layer  of  felt  or  asbestos-paper,  and  the 
lid  is  perforated  in  the  centre  in  such  a  manner  that  a  cork  and  Centigrade- 
thermometer  reach  downward  into  the  water  contained  in  the  tube  extend- 
ing up  from  the  bottom  of  the  inner  cylinder.  The  temperature  is  to  be 
raised  to  57°  C.  and  kept  at  that  point  when  the  apparatus  is  in  use.  Blood 
serum  to  be  sterilized,  contained  in  test-tubes  or  flasks,  should  be  placed 
within  the  inner  cylinder  containing  air  and  kept  at  a  temperature  of  57°  C. 
for  half  an  hour.  The  vessels  containing  it  are  then  removed  and  placed  in 
the  culture-oven,  where  they  are  kept  at  a  temperature  of  37°  C.  until  the 
next  day.  Again  they  are  placed  in  this  sterilizing  apparatus  and  subjected 
for  half  an  hour  to  57°  C.  They  are  again  removed  and  placed  in  the 
culture-oven  for  another  day ;  and  so  again  this  operation  of  sterilization  is 
repeated  in  the  same  manner  at  least  six  or  eight  times.  Afterwards  these 
vessels  are  kept  for  several  days  in  the  culture-oven  at  a  temperature  of 
37°  C,  by  which  time,  if  sterilization  has  not  been  perfect,  this  will  become- 
apparent  by  a  development  of  bacteria  in  the  serum.  In  the  great  majority 
of  cases,  however,  it  will  be  found  that  the  fluid  remains  perfectly  sterile. 

Blood  serum  is  used  for  culture-purposes  either  fluid  or  solid.  In  order 
to  solidify  the  serum,  an  apparatus  should  be  provided  in  which  the  tubes 
can  be  kept  in  a  nearly  horizontal  position,  with  the  top  end  of  the  tube 
raised  about  an  inch.  For  this  purpose  the  following  apparatus  has  been 
devised.  It  consists  of  a  square  metallic  box  with  double  walls  so  con- 
structed that  its  irmer  cavity  is  surrounded  l)y  heated  water.  The  bottom 
of  the  inner  box  is  so  inclined  that  the  liighcr  edge  is  an  inch  above  tlie 
height  of  the  lower  edge.  The  box  is  provided  with  a  glass  lid,  and  the 
whole  is  covered,  except  the  bottom,  with  thick  felt  or  asbestos-paper.  \ 
thermometer  is  attached  to  t!iis  box  in  such  a  manner  that  the  bulb  enters 
the  water  surrounding  the  box  and  registers  the  temperature.  The  tempera- 
ture should  be  gradually  raised  to  62°  C.  and  kept  for  a  short  time  at  this 
height  until  coagulation  takes  place,  and  the  tubes  should  be  watched  care- 


176 


OUTLINES   OF    PRACTICAL    BACTERIOLOGY. 


fully  and  removed  as  soon  as  this  occurs.     In  this  manner  blood  serum  can 
be  solidified  without  much  loss  of  transparency  of  the  medium. 

Culture-Oven  (Fig.  15). — One  or  more  culture-  or  brood-ovens  should  be 
made,  in  the  following  style.     A  double  box  of  thin  metal  should  be  made 


Fig.  15. 


with  an  interior  height  of  two  feet  and  a  breadth  and  depth  of  fourteen 
inches  or  more.  This  should  be  encased  in  an  outer  box  so  as  to  leave 
a  space  of  an  inch  (B)  between  the  walls.  The  box  should  be  provided 
with  a  Centigrade  thermometer  (E)  of  100  degrees  extending  through 
the  top  in  such  a  manner  that  the  bulb  projects  an  inch  or  two  into  the 
interior  of  the  inner  box.  A  hole  should  be  perforated  also  in  the  top  of 
the  outer  box  at  one  of  the  corners,  so  that  a  cork  carrying  a  thermostat 
(G,  F,  H)  can  be  inserted  into  it  and  the  bulb  containing  the  mercury  extend 
some  inches  into  the  space  between  the  walls  of  the  outer  and  the  inner  box. 
This  space  is  to  be  filled  completely  with  water,  so  that  the  whole  box,  sides, 
top,  and  bottom,  is  surrounded  with  a  layer  of  this  fluid  an  inch  thick.  The 
whole  apparatus  is  to  be  covered,  except  on  the  bottom,  with  thick  felt  or 
asbestos-paper  (A),  and  the  box  is  to  be  provided  with  t^vo  doors, — an  inner 
glass  door  (D)  fitting  tightly  and  an  outer  hollow  metallic  door  (C)  carrying 
a  layer  of  air  an  inch  thick.  This  should  also  be  capable  of  being  tightly 
closed,  and  should  likewise  be  covered  externally  with  felt  or  asbestos-paper. 


OUTLINES   OF   PRACTICAL   BACTERIOLOGY.  177 

The  temperature  of  the  oveu  is  regulated  in  the  following  manner.  The 
tube  from  the  gas-pipe  is  connected  with  one  arm  (F)  of  the  thermostat ;  the 
other  arm  (G)  of  this  instrument  is  also  connected  with  rubber  tubing  which 
is  attached  at  the  other  extremity  to  a  small  burner  (I)  capable  of  furnish- 
ing a  small  round  gas-jet.  The  latter  is  to  be  protected  from  side-move- 
ments of  the  air  by  means  of  a  mica  or  glass  cylinder  suitably  supported. 
This  burner  is  placed  under  the  centre  of  the  bottom  of  the  oven,  and  tlie 
desired  degree  of  temperature,  recorded  by  the  Centigrade  thermometer, 
with  30  degrees  and  upwards  of  its  scale  projecting  above  the  top  of  the 
oven,  is  obtained  by  regulating  the  thermostat  by  means  of  the  fine  screw 
(H).  An  exceedingly  regular  temperature  is  obtained  by  this  means,  espe- 
cially if  the  gas-supply  from  the  pipe  be  equalized  by  a  proper  regulator. 

In  hot  climates,  and  in  hot  weather  in  temperate  climates,  the  gelatin 
media  commonly  used  solid  become  fluid  from  the  high  heat,  and  the  great 
advantages  offered  by  this  culture  medium  are  lost  if  there  is  no  means  of 
keeping  it  solid  at  temperatures  sufficiently  high  to  permit  development 
therein.  The  culture-oven  above  described  is  capable  of  being  used  for  this 
purpose,  but  its  mode  of  preparation  must  in  that  case  be  modified,  A  cur- 
rent of  water  cooled  by  ice  is  made  to  pass  through  the  cavity  bet\\^een  the 
inner  and  the  outer  box,  and  the  desired  temperature  of  the  air  in  the  inner 
box  is  to  be  secured  by  regulating  the  rapidity  of  the  flow  of  the  current 
of  ice-cold  ^yater. 

CULTUKE   MEDIA. 

Fluid  Culture  Ifedia. — Most  of  the  bacteria  grow  with  exuberance  in 
fluids  containing  various  organic  substances,  especially  animal.  The  most 
commonly  used  culture  fluids  are  broths  made  from  flesh  of  various  kinds, 
— chicken,  beef,  mutton,  veal.  These  broths  are  usually  made  in  the  pro- 
portion of  one  pound  of  flesh  to  a  litre  of  distilled  water.  The  flesh  is 
chopped  fine,  the  fatty  portions  having  been  removed,  and  is  allowed  to 
soak  for  a  few  hours  in  distilled  water  kept  cold  during  that  period  by 
keeping  in  an  ice-box.  The  water  may  then  be  poured  off,  and  the  juice 
squeezed  out  of  the  flesh  by  means  of  a  meat-press  is  added  to  it.  The 
mixture,  which  has  an  acid  reaction,  is  then  neutralized  and  thoroughly 
boiled  for  forty  to  sixty  minutes,  until  all  the  coagulable  albuminous  sub- 
stance is  precipitated.  It  is  then  filtered  into  large  sterilized  flasks,  a  stock 
of  the  latter  being  constantly  kept  on  hand.  In  the  ]>rocess  of  filtration 
it  is  possible  that  some  living  germs  may  have  entered  tlie  fluid,  which 
makes  it  necessary  to  sterilize  completely.  This  is  done  by  boiling  for  ten 
to  fifteen  minutes  on  five  or  six  successive  days ;  in  the  interim  the  flasks 
are  kept  in  the  culture-oven  at  a  tem])erature  of  35°  C. 

It  is  often  desirable  to  add  other  substances  to  these  broths,  for  the  cul- 
tivation of  certain  species  of  bacteria.  One  to  two  per  cent,  of  peptonum 
siccum  and  a  half  per  cent,  of  chloride  of  sodium  may  be  added.  These 
are  best  added  subsequent  to  the  first  boiling,  for  the  presence  of  pejitone 
in  the  broth  darkens  the  color  considerably,  the  intensity  of  the  latter  being 
Vol.  I.— 12 


178  OUTLINES   OF   PRACTICAL   BACTERIOLOGY. 

increased  by  prolonged  boiling.  After  the  addition  of  the  peptone  and  salt, 
it  is  necessary  again  to  neutralize,  boil,  and  filter,  and  the  subsequent  re- 
peated boilings  should  not  in  this  case  extend  over  ten  minutes  at  a  time. 
Whenever  any  of  this  stock  material  is  withdrawn  it  is  necessary  again 
to  sterilize  the  remainder,  for,  however  carefully  the  fliuid  may  be  with- 
drawn by  means  of  sterilized  pipettes,  it  is  possible  that  a  few  bacteria 
may  enter  the  flask  accidentally  from  the  air ;  and  it  is  also  advisable  to 
boil  the  fluid  at  least  once  or  twice  after  it  has  been  transferred  to  the  small 
sterilized  vessels  in  which  it  is  to  be  used. 

For  culture-purposes,  the  fluid  may  be  placed  in  sterilized  test-tubes,  or 
small  one-ounce  sterilized  flasks,  and  it  is  advisable  to  keep  constantly  ready 
for  use  a  number  of  such  vessels.  The  fluid  should  not  more  than  half  fill 
the  flask,  and  the  test-tubes  should  not  contain  more  than  one  and  a  half 
inches  of  it. 

Frequent  use  of  this  fluid  is  made  for  hanging  drop  cultures,  and  for 
this  purpose  it  is  necessary  to  have  a  number  of  object-glasses  with  a  con- 
cavity ground  out  of  one  of  the  surfaces.  Such  cultures  are  to  be  made  in 
the  following  manner.  The  object-glass  and  an  ordinary  thin,  perfectly 
flat  cover-glass  are  sterilized,  best  in  the  sterilizer  by  dry  heat ;  a  ring  of 
vaseline  is  placed  around  the  edge  of  the  cavity,  by  means  of  a  camel's- 
hair  brush ;  the  cover-glass  is  seized  with  the  points  of  a  delicate  pair  of 
sterilized  forceps  ;  a  drop  of  the  fluid  is  removed  with  the  loop  of  platinum 
wire,  previously  heated  to  redness  in  the  flame  of  the  Bunsen  burner  or  spirit- 
lamp,  and  is  placed  upon  the  centre  of  one  surface  of  the  cover-glass ;  the 
drop  is  now  inoculated  with  the  desired  bacteria  by  touching  it  with  the 
point  of  platinum  wire  upon  which  they  have  been  removed  from  the 
material  for  observation.  The  cover-glass  is  immediately  turned  down- 
ward and  placed  upon  the  ring  of  vaseline  in  such  a  manner  that  the  drop 
shall  hang  over  the  centre  of  the  concavity  in  the  object-slide.  It  is  then 
gently  pressed  down  until  the  vaseline  forms  an  uninterrupted  layer  around 
the  edge,  entirely  excluding  communication  between  the  surrounding  air 
and  that  contained  in  the  concavity.  This  hanging  drop  culture  is  now 
ready  for  observation,  and  can  be  studied  constantly  under  the  microscope 
at  the  ordinary  temperature  of  the  room,  or  upon  a  warm  stage,  or  it 
can  be  set  aside  for  development  at  the  ordinary  room  temperature,  or  placed 
in  the  culture-oven  and  examined  from  time  to  time.  After  such  drop 
cultures  have  been  sufficiently  studied  in  the  fresh  state,  the  cover-glass 
may  be  carefully  removed  and  the  fluid  allowed  to  dry;  the  film  thus 
formed  may  be  fixed  and  artificially  stained  and  mounted  permanently  in 
the  manner  previously  described. 

fiolid  Calture  3fedia. — Solid  culture  media  may  be  either  transparent  or 
opaque. 

Of  the  transparent  culture  media,  that  containing  animal  gelatin  is  most 
generally  used,  and  a  stock  of  it  is  best  prepared  in  the  following  man- 
ner.    A  sufficient  quantity  of  meat  juice  has  already  been  strongly  boiled 


OUTLINES   OF   PEACTICAL   BACTERIOLOGY.  179 

until  the  albumen  is  thoroughly  coagulated.  The  best  gelatin  obtainable  is 
added  in  the  proportion  of  five  to  ten  per  cent.  (The  stronger  percentage 
should  be  employed  in  mild  weather.)  Before  adding  to  the  fluid,  which 
should  be  cold,  the  gelatin  is  to  be  chopped  into  fine  pieces;  it  is  then 
soaked  in  the  cold  fluid  for  half  an  hour  or  more  until  it  has  become  well 
swollen ;  the  whole  is  then  heated  until  the  gelatin  becomes  thoroughly 
melted.  The  peptone  and  salt  are  then  added  in  the  proportion  already 
mentioned,  and  the  mixture  is  neutralized  with  a  strong  solution  of  sodium 
bicarbonate.  Care  should  be  taken  to  have  the  reaction  faintly  alkaline 
rather  than  at  all  acid,  as  many  forms  of  bacteria  will  not  grow  w^ell  or 
develop  at  all  in  acid  culture  media.  It  is  well,  however,  for  the  cultiva- 
tion of  certain  germs,  to  provide  a  stock  of  slightly  acid  culture  media,  both 
fluid  and  solid.  This  mixture  is  now  well  boiled  for  thirty  minutes  and 
filtrated  through  strong  filter-paper  previously  well  sterilized  in  the  steril- 
izing-oven,  the  funnel  supporting  the  filter  having  been  also  thoroughly 
sterilized.  Before  the  mixture  is  poured  upon  the  filter,  the  latter  should 
be  moistened  with  a  small  quantity  of  sterilized  distilled  water,  and  it  is 
necessary  that  the  filtering  should  be  done  Avhile  the  fluid  is  very  hot.  In 
fact,  in  filtering  through  filter-paper  it  is  advisable  that  the  funnel  should 
be  surrounded  by  boiling  water  in  a  vessel  properly  formed  to  receive  the 
funnel.  The  filtration,  however,  can  usually  be  satisfactorily  performed 
without  such  an  apparatus,  if  instead  of  the  filter-paper  fine  sterilized 
absorbent  cotton  is  used.  In  this  case  the  funnel  must  be  kept  quite  warm, 
by  throwing  the  flame  of  a  Bunsen  burner  around  it  frequently.  The 
filtered  fluid  is  to  be  directly  collected  in  a  number  of  large  sterilized  flasks, 
and  a  stock  of  it  constantly  kept  on  hand.  For  immediate  use,  a  convenient 
number  of  test-tubes  are  one-fourth  filled  by  means  of  a  sterilized  pipette. 
It  is  sometimes  found  that  the  mixture  thus  obtained  is  not  quite  clear , 
and  this  can  be  determined  from  the  first  flow  of  the  fluid  through  the 
filter.  In  this  case  it  is  necessary  to  stop  the  filtration  and  clarify  the  mix- 
ture by  the  addition  of  the  white  and  shell  of  an  egg.  This  albumen  should 
not  be  added  until  the  fluid  has  become  cool.  It  is  to  be  thoroughly  dis- 
seminated throughout  the  mixture  by  shaking  well,  and  the  w^hole  again 
subjected  to  hard  boiling.  It  should  be  stated  here  that  these  boilings  are 
best  done  in  the  steam  cylinder.  After  the  egg-albumen  has  completely 
coagulated,  the  mixture  is  again  filtered  in  the  manner  just  described. 

It  is  finally  necessary  to  sterilize  the  filtered  fluid ;  and  this  is  done  by 
placing  the  various  vessels  containing  it  in  the  steam  cylinder  for  ten  to 
fifteen  minutes  on  five  or  six  successive  days.  In  the  interim  the  vessels 
should  be  kept  in  the  culture-oven  at  a  temperature  of  35°  C.  The  remark 
previously  made  should  be  repeated  here,  that  Avhcnever  any  of  the  stock 
material  is  removed  from  the  flasks  containing  it,  it  is  necessary  to  steril- 
ize again  that  which  remains,  in  order  to  prevent  development  of  bacteria 
which  may  accidentally  have  found  access  while  the  cotton  plug  has  been 
removed. 


180 


OUTLINES   OF   PEACTICAL   BACTERIOLOGY. 


Fig.  16. 


Test-tubes  containing  flesh-peptone-gelatin  thus  prepared  are  used  for 
culture  in  various  ways.  The  most  common  use  is  to  inoculate  them  with 
pure  cultures  of  bacteria  by  means  of  a  puncture  with  the  point  of  a  plati- 
num wire  extending  into  the  depth  of  the  gelatin. 

Another,  and  the  most  important,  use  of  this  gelatin  culture  medium  is 
that  introduced  by  Koch  for  obtaining  pure  cultures  from  mixtures  of  various 
species.  The  procedure  is  as  follows.  Three  gelatin  tubes  are  taken  and  the 
contents  rendered  fluid  by  gentle  heat ;  after  the  fluid  gelatin  has  descended 
to  the  temperature  of  body-heat,  one  tube  is  inoculated,  by  means  of  a  pre- 
viously sterilized  platinum  needle,  with  the  material  containing  the  various 
bacteria  in  question ;  after  the  inoculation,  the  tube  is  again  immediately 
plugged  and  the  fluid  well  but  gently  shaken,  in  order  to  diffuse  the  germs 
thoroughly  and  evenly  throughout  the  fluid  mass ;  from  this,  while  still 
fluid  (a),  another  tube  (c)  of  the  three  is  inoculated  by  transferring  into  it 
with  the  platinum  wire  loop  (e)  three  drops  in  the  manner  indicated  in  Fig. 
16  ;  the  second  tube  is  then  immediately  plugged  and  well  shaken,  after  the 

manner  of  the  first.  The  third  tube  is  in- 
oculated from  the  second  in  the  same  man- 
ner. A  sterilized  glass  plate  is  now  care- 
fully withdrawn  from  the  metallic  case 
enclosing  it,  care  being  taken  to  seize  it  by 
the  edges  between  the  thumb  and  finger; 
this  is  placed  upon  the  ground-glass  plate 
of  the  cooling  apparatus  already  described 
(Fig.  12,  D),  and  immediately  covered  Avith 
the  bell-glass ;  in  a  few  moments  the  glass 
plate  has  become  sufficiently  cold,  and  the 
gelatin  from  the  first  test-tube  is  now 
poured  upon  it  and  spread  out,  either  by 
means  of  the  lip  of  the  tube  or  a  sterilized 
glass  rod,  in  an  even  layer  in  the  form  of 
an  oblong  square,  care  being  taken  that  the 
fluid  does  not  extend  to  the  edge  of  the  plate,  and  the  latter  is  again  quickly 
covered  with  the  bell-glass.  In  pouring  the  fluid  from  the  test-tube,  care 
should  be  taken  that  upon  removing  the  cotton  plug  the  inner  surface  of 
the  lip  is  well  wiped.  The  external  surface  of  the  lip  should  be  exposed 
for  an  instant  to  the  flame  of  the  Bunsen  burner,  but  the  fluid  should  not 
be  poured  out  until  the  lips  have  become  sufficiently  cool,  otherwise  many 
of  the  germs  contained  in  the  inoculated  tube  may  be  killed  by  the  action 
of  the  heat  as  the  fluid  flows  out.  In  a  few  moments  the  layer  of  gelatin 
has  become  solid.  The  fluid  contained  in  the  other  test-tubes  is  spread 
upon  glass  plates  in  a  similar  manner.  The  plates  in  regular  succession  are 
placed  upon  the  benches  in  the  moist  chamber  (Fig.  11)  and  set  aside  for 
development. 

This  flesh-peptone-gelatin  becomes  fluid  below  the  body-temperature 


OUTLINES   OF   PRACTICAL,   BACTERIOLOGY.  ■        181 

(at  about  80°  F.),  and  if  it  is  desired  to  be  kept  solid  during  the  growth  oi" 
bacteria,  it  cannot  be  subjected  to  the  heat  of  the  culture-oven.  The  sur- 
rounding room  temperature  is  sufficient  for  the  development  of  most  of 
the  germs  which  will  grow  in  this  medium.  High  summer  heat  is  fre- 
quently sufficient  to  melt  the  gelatin,  and  at  these  times  this  medium  is  not 
usually  available  for  solid  cultures,  unless  the  culture-oven  be  used  as  a 
cooling-box. 

In  solidifying,  the  germs  dispersed  throughout  the  layer  of  gelatin  upon 
the  plate  are  fixed  in  the  position  in  which  they  may  happen  to  be  caught 
at  the  time,  and  from  each  one  capable  of  development  a  colony  will  be 
formed.  It  will  be  found  that  these  colonies,  visible  under  a  low  power  of 
the  microscope  (fifty  diameters)  or  to  the  naked  eye,  will  have  developed  in 
thirty-six  to  forty-eight  hours,  or  more,  and  it  will  be  seen  that  in  one  of 
the  gelatin  plates  the  colonies  are  sufficiently  distant  from  each  other  to 
permit  of  inoculations  from  individuals,  by  means  of  the  point  of  the  plati- 
num wire,  without  danger  of  accidental  contact  with  any  of  the  others. 
This  plate  is  now  used  for  making  pure  cultures.  A  number  of  solid  gel- 
atin tubes  at  hand  are  inoculated  from  the  different  colonies  and  set  aside  for 
development,  and,  if  sufficient  care  has  been  exercised  in  the  procedure,  it 
will  be  found  that  each  tube  contains  a  perfectly  pure  culture. 

Instead  of  pouring  the  inoculated  fluid  gelatin  from  the  tube  upon  a 
large  glass  plate  in  the  manner  described,  a  small  quantity  of  it  may  be 
withdrawn  by  means  of  a  sterilized  pipette  and  spread  upon  an  ordinary 
object-glass  which  has  been  previously  sterilized.  The  layer  thus  formed, 
after  solidification,  may  be  placed  in  the  moist  chamber  for  development, 
and  the  growth  of  isolated  colonies  may  thus  be  watched  under  the  micro- 
scope from  time  to  time. 

A  device  which  is  now  frequently  used  for  plate  cultures  is  even  better 
than  that  just  described.  After  the  gelatin  has  been  poured  upon  the  plate, 
a  mat  with  a  large  perforated  centre  is  cut  out  of  stiff  paper  one-eighth 
of  an  inch  thick,  the  outer  edge  of  the  mat  having  the  same  dimensions 
as  the  plate.  This  mat,  which  has  also  been  sterilized,  is  placed  upon  the 
plate,  and  another  plate  is  clamped  upon  it.  Thus  we  have  a  closed 
shallow  chamber  formed  capable  of  being  placed  upon  the  stand  of  the 
microscope. 

Anaerobic  bacteria  will  not  grow  Avhen  exposed  to  free  air.  The  sur- 
face of  the  gelatin  upon  the  glass  slide  or  upon  the  glass  plate  may  be 
covered  in  whole  or  in  part  by  extremely  thin  sterilized  mica  plates  and 
thus  protected  from  the  air,  when  such  bacteria  may  liave  an  opportunity 
for  development,  in  which  case  the  colonies  can  be  satisfactorily  examined 
under  the  microscope,  or  used  for  obtaining  pure  cultui-es  in  tlie  usual 
manner. 

Another  use  of  the  gelatin  layer  ujion  the  glass  slide  has  already  been 
alluded  to,  and  is  as  follows.  A  sufficient  quantity  of  sterilized  flcsli-]icp- 
tone-gelatin  is  removed  with  a  sterilized  pipette  and  poured  upon  the  surface 


182  OUTLINES    OF   PRACTICAL   BACTERIOLOGY. 

of  the  glass  slide  and  allowed  to  solidify.  The  gelatin  is  then  inoculated 
bv  scratches  with  a  platinum  wire  carrying  the  desired  microbes,  after  the 
method  of  Brefeld  ak'eady  described.  The  slide  is  then  placed  in  the  moist 
chamber  for  development  and  subsequent  examination. 

Agar- Agar- Flesh- Peptone. — A^Tien  it  is  desired  to  employ  transparent 
culture  media  which  remain  solid  at  the  body-heat,  or  at  the  ordinary  tem- 
perature of  the  culture-oven,  agar-agar  is  used,  in  the  proportion  of  one  to 
two  per  cent.,  instead  of  gelatin,  in  the  following  manner.  The  agar  is 
obtained  already  ground,  or  is  chopped  up  into  fine  pieces.  The  required 
quantity  is  added  to  the  meat  juice  or  broth,  wherein  it  is  allowed  to  soak 
until  thoroughly  swollen.  After  neutralization  the  whole  is  then  well 
boiled  for  at  least  an  hour,  and  the  mixture  is  filtrated,  through  steril- 
ized washed  cotton,  or  through  sterilized  fine  flannel,  into  two  or  three 
sterilized  receiving-flasks  of  sufficient  capacity.  To  one  of  the  flasks  is 
added  sterilized  glycerin  in  the  proportion  of  six  to  eight  per  cent.  To 
another  of  the  flasks  a  similar  quantity  of  glycerin  is  added  with  peptone 
and  salt  in  the  usual  proportions.  It  is  necessary"  again  to  boil  the  mixture 
in  these  flasks,  and  filter.  The  process  of  filtration  is  far  more  difficult 
in  this  case  than  in  that  of  the  gelatin  mixture.  The  filtration  should  pro- 
ceed while  the  vessels  are  subjected  to  the  action  of  steam  in  the  steam 
sterilizer.  It  is  to  be  remarked  that  care  should  be  taken  to  have  the  final 
fluids  in  each  of  these  cases  neutral  or  faintly  alkaline.  These  mixtures 
solidify  at  40'^  C,  and  become  slightly  opalescent ;  they  are  never  so  trans- 
parent as  flesh-peptone-gelatin.  After  the  filtration  has  been  satisfactorily 
performed,  the  fluid  should  be  distributed,  as  in  the  case  of  the  gelatin 
mixture,  in  stock  flasks  of  convenient  size  and  in  test-tubes  for  ready  use. 
The  sterilization  of  this  material  must  be  accomplished  in  the  manner 
already  described  for  the  gelatin  mixture.  This  material  may  be  used  for 
cultures  in  the  same  manner  as  the  gelatin  mixture,  and,  besides,  the  cul- 
tures may  be  made  in  the  culture-oven  and  at  temperatures  even  as  high  as 
the  highest  fever-heat. 

The  agar  mixture,  besides  as  in  the  ordinary  plate  culture  method,  is 
employed  for  the  isolation  of  mixtures  of  various  species  of  bacteria  in  the 
following;  manner,  after  Esmarch.  Three  sterilized  as^ar  tubes  are  taken 
and  the  contents  rendered  fluid.  After  cooling  down  to  about  42°  or  43° 
C,  these  tubes  are  inoculated  in  the  manner  already  described  for  the  gelatin 
plates.  A  block  of  ice  at  hand,  having  a  smooth  upper  surface  wliich 
should  be  horizontal,  is  so  grooved  by  scraping  with  a  knife  that  a  gutter  six 
inches  long  and  three-quarters  of  an  inch  wide  and  as  much  deep  runs 
across  the  surface.  The  inoculated  tubes  in  succession  are  now  held  hori- 
zontally and  slowly  rotated  on  tlieir  axes,  in  order  that  the  fluid  may  spread 
evenly  over  the  whole  of  the  inner  surface  of  the  tube  as  far  up  as  the 
stopper.  This  being  done,  the  tube  is  placed  horizontally  in  the  ice  gutter, 
where  it  is  immediately  set  in  rapid  axial  rotation  by  the  liand.  In  this 
manner  the  film  of  agar  lining  the  tube  becomes  quickly  solid.     The  tubes 


Photo.  No.  1. 


/■     • 


<     . 


I.. 


Micro-  and  ^tkiumdcocci.    X  1200. 
Photo.  No.  2. 


./' 


Typhoid  Bacilli.    X  1200.    Pure  culture  from  the 
spleen. 

Photo.  No.  5. 


Photo.  No.  3. 


~  I'i         \ 


Tubercle-Bacilli  ix  Sputum.    X  600. 


^'        ♦• 


s*    7^*'": 


♦  '? 


I-'' 


^•■ 


Bacteria  of  Intestinal  Contents,  showing 
Two  Comma  Bacilli.— Case  of  cholera  Asiatica. 
X  1200. 


Photo.  No.  {\. 


Liquefying  Colony  in  (Jriatin  Plate  of  Cholera         Non-liquefying  Colony  in  Gelatin  Plate 
Nostras  (FiNKLER).—T\venty-ri)ur  hours' growth.  X  30.      of  an  Air  Micrococcus.    X  30. 


OUTLINES    OF    PRACTICAL    BACTERIOLOGY.  183 

are  now  placed  aside  in  a  horizontal  position  for  a  half-hour ;  they  can 
then  be  kept  in  the  vertical  position  at  the  ordinary  temperature  of  the 
surrounding  air,  or  placed  in  the  culture-oven  if  so  desired,  for  development 
of  the  germs  scattered  throughout  the  layer  of  agar.  From  time  to  time 
the  development  of  colonies  in  these  tubes  can  be  watched  under  the  micro- 
scope by  having  an  attachment  upon  the  stage  which  will  hold  the  tube  in 
proper  horizontal  position  and  allow  of  its  rotation  and  a  to-aud-fro  move- 
ment, so  that  any  desired  colony  may  be  brought  into  the  field.  After  a 
sufficient  time  it  will  be  found,  as  in  the  case  of  flat  gelatin  plates,  that  one 
of  the  Esmarch  tubes  sliows  the  colonies  sufficiently  separate  from  one 
another  to  allow  of  one  being  touched  with  the  bent  point  of  a  platinum 
needle  and  a  portion  of  it  removed  and  inoculated  into  any  other  desired 
medium,  thus  securing  a  pure  culture  therefrom.  It  should  be  stated  that 
this  method  of  cylindrical  plate  cultures  is  also  applicable  to  the  gelatin 
mixtures.  The  use  of  the  Esmarch  tubes  for  this  purpose  has  several 
advantages,  chief  of  which  is  the  security  against  accidental  inoculation  of 
the  culture  medium  from  the  germs  suspended  in  the  surrounding  air.  The 
colonies  growing  in  such  tubes  can  be  observed  for  a  much  longer  time  than 
those  upon  glass  plates  in  the  ordinary  moist  chamber,  for  the  capacity  of 
the  covering  bell-glass  is  such  that  ordinarily  there  are  always  a  certain 
number  of  germs  suspended  in  the  included  air,  and  in  the  course  of  hours 
they  will  settle  upon  the  surface  of  the  gelatin  plate  and  give  origin  to  the 
growth  of  colonies  starting  therefrom.  For  isolating  different  species  and 
obtaining  pure  cultures  therefrom,  the  Esmarch  tubes  are  now  generally 
preferred  to  the  former  plate  method. 

Plate  cultures  are,  however,  used  for  other  purposes,  chief  among  which 
is  the  differentiation  between  colonies  of  different  species  by  means  of  certain 
characteristics  of  growth.  (Photos.  Nos.  5  to  8.)  For  this  purpose  the. 
gelatin  plates  are  much  more  useful  than  those  of  cylindrical  form.  It  was 
soon  found  by  Koch  in  using  this  method  of  isolation  of  bacteria  that  many 
of  the  different  species  presented  certain  distinguishing  characteristics  in  the 
asjject  of  colonies  developed  in  the  gelatin.  As  an  example,  some  species 
while  developing  in  such  a  medium  render  the  gelatin  fluid,  others  do  not 
possess  such  an  influence.  Furthermore,  certain  species  spread  more  or  less 
widely  over  the  surface  of  the  gelatin,  while  others  are  heaped  up  upon  it 
within  narrow  limits.  Again,  some  of  the  colonies  present  regular  circular 
outlines,  others  irregular.  Some  of  tliem  are  more  or  less  coarsely  gran- 
ular, others  finely  granular,  still  others  more  or  less  glairy,  others  pow- 
dery. Some  present  one  color,  some  another.  Some  have  the  power  of 
rendering  the  neighboring  gelatin  fluid,  Avhile  developing  evenly  throughout 
the  fluid  mass,  thus  rendering  it  cloudy ;  others  arc  limited  more  or  less  to 
the  centre  of  the  fluid  portion,  being  surrounded  by  a  fluid  border  entirely 
limpid.  Some  possess  the  poAver  of  disseminating  a  characteristic  color  in  a 
narrow  zone  surrounding  the  developing  colony,  and  so  on.  Thus  tlie  differ- 
ences between  many  species  are  more  or  less  marked  and  cliaractcristic,  so 


184 


OUTLIXES   OF   PRACTICAL   BACTERIOLOGY. 


that  for  the  recognition  and  differential  diagnosis  of  nnmerous  species  of 
bacteria  the  gelatin  plates  furnish  most  valuable  means.  The  aspects  of 
pure  cultures  of  these  species  are  frequently  characteristic  also  in  gelatin 
tube  cultures.     (Photos.  Nos.  9,  10.) 

Whilst  many  of  the  species  of  bacteria  present  certain  distinguishing 
characteristics  when  cultivated  in  agar-agar,  in  this  medium  they  are  usually 
far  less  marked  than  in  the  case  of  gelatin  cultures,  and  in  it  the  number 
of  species  possessing  special  characteristics  is  far  more  limited. 

The  agar-agar  tubes  for  ordinary  culture  are  usually  prepared  in  sucli 
a  manner  that  the  surface  of  the  agar  is  increased  by  inclining  the  tubes 

(Fig.  17,  i,  B)  before  solidifica- 

F-G-  !"■  tion  in  the  same  manner  as  that 

„,inmsfflm-^.         described  for  the  blood  serum, 

0''    ^      &  A  A    ;■■;;,     and,  instead  of  punctured  inocu- 

"^  \  lations,  scratches  along  the  sur- 
face are  usually  made  with  the 
point  of  a  needle. 

Opaque  Culture  Media. — 
Culture  media  of  this  kind  have 
been  long  used.  Perhaps  the 
most  common  consists  of  ster- 
ilized bread-pap  contained  in 
small  sterilized  globular  flasks. 
Potatoes  either  sliced  or  mashed 
and  kept  in  similar  vessels  have 
also  been  more  or  less  exten- 
sively used.  The  most  frequent 
use  of  potato  for  this  pur^jose 
has  been  as  follows.  Firm  pota- 
toes are  selected,  free  from  specks, 
their  skins  well  scrubbed  with  a 
stiff  brush,  the  eyes  containing 
particles  of  earth  are  picked 
out,  the  potato  is  immersed  for 
twenty  minutes  to  half  an  hour  in  a  solution  of  corrosive  sublimate,  1 
])art  to  1000,  taken  therefrom  and  placed  in  a  colander  M-ith  freely-per- 
forated bottom,  subjected  for  an  hour  to  the  action  of  steam  in  the  steam 
sterilizer,  then  allowed  to  cool ;  afler  which  blades  of  common  knives  (a 
sharp  table-knife  with  a  wooden  handle  answers  the  purpose  well)  are 
thoroughly  sterilized  by  holding  in  the  flame  of  the  Bunsen  burner,  and 
allowed  to  cool.  The  hands  are  now  well  washed  and  dipped  for  a  few 
moments  in  a  solution  of  corrosive  sublimate,  1  part  to  1000.  The  potato 
is  now  firmly  grasped  between  the  first  two  fingers  and  thumb  of  the  left 
hand  and  evenly  divided  with  the  sterilized  blade  of  one  of  the  knives. 
Each  half  is  placed  in  the  moist  chamber  with  the  cut  surface  up,  care  being 


Photo.  No.  7. 


Colony  in  Gelatin  Plate  of  Comma  Bacillus  of  Koch.— Forty-eighi 
hours  old.    X  30. 

Photo.  No.  8. 


Non-liquefying  Colonies  in  Gelatin  Plate  of  a  Curved  Bacillus, 
resembling  that  of  koch,  but  not  identical  with  it.    x  30. 


Photo.  No.  10. 


Photo.  No.  9. 


Comparison  of  Tube-Cultures  in  Gelatin  of  Comma 
Bacillus  of  Koch  (the  Two  to  Left)  with  the  Curved 
Bacillus  of  Finklf.r  (the  Two  to  Right).— Half  natunil 
size.    (Copy  after  KocJi.; 


Culture  in  Gelatin  Tube  of  Comma 
Bacillus  of  Koch  f  Fifty-two  Hours 
old),  showing  Appearance  of  Air-Bub- 
ble AT  Top,  the  Surface  of  the  Solid 
Gelaiix  being  inclined.— Natural  size. 


OUTLINES   OF   PRACTICAL,   BACTERIOLOGY.  185 

taken  in  this  manoeuvre  that  nothing  shall  come  in  contact  with  the  surface. 
The  potatoes  thus  prepared  are  covered  as  quickly  as  possible  with  the  bell- 
glass,  in  order  to  limit  exposure  to  the  surrounding  air.  The  middle  of  the 
cut  surface  of  the  potato  thus  prepared  may  now  be  inoculated  with  the  plati- 
num wire  and  set  aside  for  development.  The  latter  may  take  place  at  the 
ordinary  surrounding  temperature,  or  in  the  culture-oven,  as  may  be  desired. 
Many  of  the  bacteria  will  be  found  to  have  a  more  or  less-  characteristic 
growth  upon  this  culture  medium,  and  for  a  few  of  them  indeed  it  offers  the 
only  known  ready  means  of  making  a  differential  diagnosis.  After  some 
days,  ho'wever,  growths  of  fungi  wdiich  have  fallen  from  the  air  are  apt  to 
appear  uj)on  the  surface  of  the  potato  and  thus  frequently  interfere  with 
the  observation.  In  order  to  obviate  this,  a  modification  of  the  potato  cul- 
ture method  has  recently  been  introduced  by  Meade  Bolton.  A  number  of 
large  test-tubes  an  inch  in  diameter  are  required.  A  long  cylindrical  punch 
of  an  inner  diameter  slightly  less  than  that  of  the  test-tube  is  needed ;  this 
also  should  be  sterilized.  A  number  of  fresh  potatoes  are  carefully  selected, 
the  two  ends  cut  off  with  a  sterilized  knife.  A  plug  is  now  punched  out 
from  the  centre  by  means  of  the  punch.  This  plug  is  divided  by  a  sterilized 
knife  in  such  a  manner  that  the  knife  passes  from  one  corner  at  the  top 
obliquely  downward  to  the  opposite  corner  at  the  bottom.  Each  of  these 
halves  is  placed  in  a  test-tube  with  the  thick  end  at  the  bottom  (Fig.  17, 
3,  B).  After  a  sufficient  number  of  test-tubes  have  been  thus  filled,  they 
are  sterilized  by  subjecting  them  for  an  hour  to  the  action  of  steam  in  the 
steam  sterilizer.  This  may  be  repeated  once  or  twice  on  successive  days. 
The  potatoes  are  then  ready  for  culture,  and  the  inoculations  are  to  be  made 
upon  the  middle  of  the  inclined  surface  by  means  of  a  platinum  needle.  It 
is  found  that  this  method  of  potato  culture  not  only  secures  greater  protec- 
tion from  accidental  contamination  of  the  culture  medium,  but  the  growtli 
of  the  inoculated  bacteria  can  be  closely  watched  from  time  to  time  directly 
through  the  walls  of  the  tube. 

Other  vegeta])les  and  even  animal  substances  of  various  kinds  may  be 
used  for  cultures  in  a  similar  manner.  For  the  cultivation  of  bacteria  which 
grow  preferably,  or  better,  in  acid  media,  either  fluid  or  solid,  various  sub- 
stances have  been  used,  such  as  prunes,  quinces,  apples,  carrots,  etc.  Many 
of  the  natural  animal  fluids  have  also  been  employed,  such  as  aqueous  humor, 
lymph,  pleuritic,  pericardial,  or  abdominal  fluids,  urine,  milk,  etc.  The 
agar  medium  to  which  five  to  eight  per  cent,  of  neutral  glycerin  has  l)een 
added  is  a  good  substitute  for  blood  serum. 

For  long  preservation  free  from  possible  destruction  by  the  accidental 
development  of  bacteria,  the  necks  of  the  stock  flasks  and  the  tops  of  test- 
tubes  can  be  hermetically  closed  by  melting  them  in  the  flame  of  a  powerful 
Bunsen  burner,  as  suggested  by  Sternberg.  This  is  a  con\'enient  means  of 
providing  one's  self  with  requisite  media  to  be  transported  long  distances 
and  used  in  distant  sr-icntific  expeditions.  But  the  most  convenient  menus 
of  accomplishing  the  same  object — in  fiict,  it  is  well  to  use  it  habitually, 


186  OUTLINES   OF   PRACTICAL   BACTEEIOLOGY. 

because  of  its  simplicity — is  that  used  at  the  Agricultural  Department  by 
Dr.  Theobald  Smith,  and  at  the  Army  Museum  by  Dr.  Wm.  M.  Gray- 
After  the  vessel  containing  the  culture  medium  (flask  or  test-tube)  is  filled 
or  inoculated,  before  stopping  the  vessel  the  end  of  the  cotton  stopper  is 
dipped  into  very  hot  melted  paraffine.  The  plug  of  cotton  with  its  end 
saturated  with  the  hot  paraffine  is  now  replaced  immediately  in  the  mouth  of 
the  vessel,  which  when  cold  is  found  to  be  hermetically  sealed.  When  it  is 
desired  to  withdraw  the  plug  from  such  a  closed  tube,  it  is  only  necessary  to 
heat  the  neck  gently  in  the  flame  in  order  to  melt  the  superficial  portion 
of  the  paraffine. 

METHOD   OF   ENUMEEATION   OF   BACTEEIA. 

The  most  frequently  employed  method  of  counting  the  bacteria  contained 
in  a  given  specimen  of  waier  is  based  upon  Koch's  method  of  isolation  of 
microbes  by  resort  to  gelatin  plate  cultures.  A  certain  small  quantity  of 
the  water,  freshly  obtained,  is  without  delay  (for  bacteria  will  multiply  even 
in  distilled  water)  well  mixed  with  a  certain  considerably  larger  quantity 
of  sterilized  flesh-peptone-gelatin  rendered  fluid  in  a  sterilized  test-tube, 
and  the  mixture  is  poured  upon  a  sterilized  glass  plate  after  the  method 
already  described  for  making  gelatin  plate  cultures.  After  the  layer  of 
mixed  gelatin  becomes  solid,  the  plate  is  set  aside  in  the  moist  chamber 
for  twenty-four  to  thirty-six  or  more  hours  to  develop.  After  the  colo- 
nies have  sufficiently  developed,  the  plate  is  placed  upon  a  black  sheet 
of  pasteboard  or  of  metal  which  is  distinctly  and  regularly  divided  by  a 
series  of  parallel  cross-lines  into  small  squares,  and  is  then  placed  upon  the 
stage  of  the  microscope  furnished  with  a  low-power  lens  (twenty  to  thirty 
diameters),  or  upon  the  stage  of  a  dissecting  microscope.  The  number  of 
colonies  within  a  square  can  be  counted  without  difficulty.  When  a  number 
of  the  squares  are  thus  examined  and  the  average  in  each  square  ascertained, 
the  data  for  a  very  close  approximation  of  the  number  of  bacteria  con- 
tained in  a  cubic  centimetre  of  the  water  in  question  are  obtained ;  for  each 
colony  has  developed  from  a.  single  germ.  It  is  unnecessary  to  remark 
that  the  number  of  bacteria  in  other  fluids  may  be  estimated  in  a  similar 
manner.  Enumeration  of  the  bacteria  in  air  and  earth  may  be  approxi- 
mated by  suitable  modifications  of  this  method. 

CULTIVATIONS   FKOM   ANIMAL   TISSUES. 

In  seeking  to  obtain  pure  cultures  of  bacteria  existing  upon  exterior 
surfaces  or  upon  the  surface  of  alimentary  or  other  passages  or  open  canals, 
which  are  constantly  lined  with  numerous  varieties  of  microbes,  resort  must 
be  had  to  the  method  of  plate  culture,  and  the  labor  is  usually  great.  In 
the  case  of  search  for  bacteria  in  internal  abscesses  or  solid  lesions,  the  work 
of  isolation  is  far  less  tedious,  for  the  number  of  associated  organisms  is 
then  much  less. 


Pure  Culture  of  Deneke,  or  Curved  Bacillus  of  Old  Cheese,    x  1200. 


Photo.  I^To.  12. 


Pure  Culture  of  Finkler,  m;  cholera  Nostras,  Curved  Bacillus, 
showing  a  .Spirillum.    X  1200. 


Photo.  No.  13. 

x'r 

y^ 

0 

»?.       ^ir 

*           y»      "^    "^ 

V^  :\^  v?.^*^  *'■'  »^  '"'v  V  '> 


Pure  Culture  of  Comma  Bacillus  of  Koch,  or  of  Asiatic  Ciioli.ra.    x  1200.- 
Obtaiiied  by  plate  culture  from  intestinal  contents  of  same  case  ns  No,  4, 


OUTLINES   OF   PRACTICAL   BACTERIOLOGY.  187 

In  the  case  of  abscesses  or  enclosed  fluids,  a  small  quantity  is  with- 
drawn by  means  of  a  sterilized  hypodermic  syringe  after  previous  steril- 
ization of  the  surface  through  which  the  puncture  is  to  be  made.  Such 
sterilization  is  secured  in  the  following  manner.  The  selected  surface  is 
thoroughly  well  washed  and  scrubbed  with  soap  and  water.  It  is  next  well 
washed  with  alcohol.  Then  it  is  washed  with  a  solution  of  corrosive  sub- 
limate in  sixty  per  cent,  alcohol  (1  part  to  500),  and,  if  possible,  a  wad  of 
absorbent  cotton  moistened  in  the  same  fluid  should  be  strapped  closely 
upon  the  surface  and  kept  there  covered  with  oiled  silk  for  several  hours. 
If,  however,  more  expedition  is  necessary,  after  the  surface  has  been  well 
washed  first  with  the  soap  and  water  and  the  alcohol,  and  then  with  the 
germicide,  the  latter  is  washed  oif  again  with  strong  alcohol.  The  puncture 
with  the  sterilized  hypodermic  syringe  may  now  be  made  and  the  desired 
fluid  withdrawn.  Three  agar  tubes  should  be  at  hand,  and  cylindrical  roll 
cultures  made  after  the  manner  of  Esmarch  already  described.  After  the 
colonies  have  sufficiently  developed,  pure  cultures  of  the  various  species 
included  should  be  made  in  gelatin  or  other  desired  tubes  in  the  usual 
manner. 

To  obtain  cultures  from  solid  lesions  the  following  method  should  be 
pursued.  The  organ  containing  them  should  be  removed  entirely  if  post 
mortem,  this  being  done  with  sterilized  instruments  and  hands,  care  being 
taken  that  the  organ  in  question  shall  be  the  first  one  removed.  If 
transportation  is  necessary,  it  should  be  immediately  enveloped  in  cloth 
soaked  with  a  watery  solution  of  corrosive  sublimate,  1  part  to  1000,  and 
the  culture  should  be  made  at  the  earliest  possible  moment.  When  ready 
to  do  this,  a  number  of  dissecting-knives  with  wooden  handles,  of  small 
scissors,  and  of  forceps  large  and  small,  should  be  thoroughly  sterilized  by 
heating  in  the  Bunsen  flame  and  subsequently  allowed  to  cool.  The  hands 
should  be  sterilized,  and  the  cultures  now  made  as  rapidly  as  possible  in  a 
still  air.  Three  agar  tubes  should  be  at  hand  ready  to  make  Esmarch  plate 
cultures  in  the  manner  described.  The  organ  is  incised  through  the  lesion 
by  means  of  one  of  the  sterilized  knives  by  a  long  deep  cut  vertical  to  the 
surface  of  the  organ.  The  cut  surfaces  are  separated,  and  another  cut 
through  the  lesion  is  made  vertically  to  this  surface  with  another  steril- 
ized knife.  These  new  surfaces  are  separated,  and,  if  possible,  a  third  cut 
Vertical  thereto  is  again  made  with  another  sterilized  knife.  The  first  tube 
is  now  to  be  inoculated  by  means  of  tlie  platinum  needle  from  a  desired 
point  in  the  last  surface,  and  the  two  other  tubes  are  to  be  inoculated  succes- 
sively from  the  first  in  the  manner  already  described ;  the  tubes,  after 
spreading  the  layer  of  agar  over  the  entire  surface  and  fixing  it  there  by 
means  of  the  block  of  ice,  are  set  aside  for  the  development  of  the  colonies. 
Pure  cultures  are  to  be  obtained  from  these  in  the  usual  manner.  It  is 
well  to  char  the  surface  of  the  organ  with  a  red-hot  spatula,  before  puncture, 
when  possible. 


188  OUTLINES   OF   PRACTICAL   BACTERIOLOGY. 

PATHOLOGICAL   PKOPERTIES   OF   BACTERIA. 

The  bacteria  are  now  admitted  to  belong  to  the  vegetable  kingdom  and 
to  constitute  the  lowest  forms  thereof.  Like  the  higher  vegetables,  a  few 
species  are  noxious,  most  are  harmless.  The  recognition  of  the  noxious 
qualities  of  bacteria  is  to  be  made  by  actual  experiment.  This  is  done 
through  contact,  feeding,  inhalation,  and  inoculation  experiments.  It 
should  be  unnecessary  to  remark  that  in  performing  these  exjjeriments 
two  fundamental  principles  must  be  always  kept  in  view  :  first,  that  the 
experiments  be  performed  with  absolutely  pure  cultures  of  the  selected 
species,  and,  secondly,  that  they  be  performed  in  such  a  manner  that  no 
accidental  contamination  by  other  extraneous  bacteria  can  occur.  These 
two  fundamental  principles  can  be  with  considerable  facility  and  perfection 
applied  in  the  case  of  inoculation  experiments.  In  the  case  of  contact, 
feeding,  and  inhalation  experiments,  however,  there  is  often  unavoidably 
some  association  with  other  bacteria  which  naturally  infest  the  surfaces 
in  question  and  to  some  extent  interfere  with  the  purity  of  the  experi- 
ments. 

In  inoculation  experiments  the  bacteria  may  be  inserted  into  the  cutis, 
into  the  subcutaneous  connective  tissue,  into  the  muscular  or  intermuscular 
tissue,  into  the  depths  of  internal  organs,  etc.,  with  comparatively  little  risk 
of  accidental  contamination.  The  preliminary  jDrocedure  is  very  similar 
to  that  already  described  for  obtaining  material  for  culture  from  enclosed 
abscesses.  The  hair  is  to  be  first  thoroughly  removed  from  the  surface,  and 
the  latter  then  sterilized  in  the  manner  mentioned,  and  in  the  case  of  experi- 
ments upon  the  lower  animals  it  is  well  also  to  go  a  step  further,  in  securing 
the  absolute  destruction  of  surface-germs  by  charring  the  point  of  the  in- 
tended puncture  by  means  of  a  hot  plate  of  metal.  Of  course  it  is  essential 
that  all  instruments  used  in  the  operation  should  be  thoroughly  sterilized  by 
heat.  The  inoculation  material  may  be  introduced  either  by  means  of  a 
hypodermic  syringe  or  by  means  of  the  platinum  wire  loop  inserted  through 
the  incision.  After  the  operation  is  complete,  the  point  of  puncture  or 
incision,  including  the  charred  surface  if  one  be  made,  should  be  thoroughly 
protected  by  means  of  an  imj)ervious  antiseptic  covering. 

After  a  varying  period  of  development  or  incubation,  lesions  corre- 
sponding to  the  affection  in  question  should  be  produced  in  the  animal 
experimented  upon,  if  the  latter  be  susceptible  to  the  disease,  and  if  the 
powers  of  the  bacteria  have  not  become  attenuated  :  in  these  lesions  the  bac- 
teria experimented  with  should  be  again  recoverable  by  the  usual  methods. 

ARTIFICIAL   IMMUNITY   FROM   INFECTIOUS   DISEASES. 

With  the  knowledge  of  the  characteristics  of  chicken-cholera,  Pasteur 
also  made  known  the  important  fact  that  in  the  microbe  which  was  demon- 
strated to  be  the  cause  of  the  disease  a  means  of  artificial  protection  against 
subsequent  attacks  was  furnished.    Since  this  important  practical  discovery, 


OUTLINES    OF    PEACTICAL    BACTERIOLOGY. 


189 


Fig.  18. 


the  knowledge  of  analogous  properties  of  a  number  of  other  specific  microbes 
seems  to  indicate  the  existence  of  a  law  more  or  less  general  governing  im- 
munity from  recurrent  attacks  of  many,  if  not  all,  of  the  so-called  infectious 
or  contagious  diseases  which  are  known  to  leave  behind  them  a  greater  or 
less,  a  longer  or  shorter  immunity. 

Whether  this  immunity  is  secured  by  direct  and  more  or  less  mechanical 
action  of  the  microbes  themselves,  or  indirectly  through  the  agency  of  a 
specific  product  of  the  specific  microbe  elaborated  in  the  process  of  its 
growth  or  decay,  was  for  a  time  a  matter  of  purely  theoretical  dispute ;  but 
recent  chemical  examinations  of  the  contents  of  pure  cultures  of  various 
pathogenic  and  a  few  other  bacteria  have  shown  the  existence  therein  of 
certain  peculiar  poisons  not  only  possessing  specific  physiological  action,  but 
also  having  peculiar  chemical  properties  and  constitutions  which  ally  them 
more  or  less  closely  to  certain  well-known  poisonous  vegetable  alkaloids. 
These  chemical  bodies  have  been  named  ptomaines.  Experiments  demon- 
strating the  activity  of  these  bodies  have  been  performed  by  numerous  in- 
vestigators in  conjunction  with  those  intended  simply  to  demonstrate  the 
pathogenic  qualities  of  the  specific  microbes.  Pathogenic  bacteria  proved  to 
be  the  cause  of  the  specific  infectious  disease  to  which  they  belong  have  been 
killed  in  their  pure  cultures  by  the  action  of  heat.  The  culture  medium 
then  injected  under  all  due  precautious  in  certain 
instances  likewise  produces  a  series  of  symptoms 
characterizing  the  disease  in  question.  Again,  these 
pathogenic  bacteria  have  been  removed  from  the 
fluids  of  their  pure  cultures  by  means  of  filtration. 
This  has  been  most  perfectly  done  by  means  of  the 
unglazed  porcelain  filter  of  Chamberland  (Fig.  18). 
The  filtered  fluid,  the  sterility  of  w^hich  has  been 
tested  by  culture  experiments,  lias  been  inoculated 
with  similar  results.  Furthermore,  the  chemical 
substances,  or  ptomaines,  obtained  from  these  culture 
fluids,  when  injected  also  cause  analogous  results. 
From  these  experiences  it  would  seem  probable  that 
it  is  the  alkaloid  developed  by  the  growth  of  the 
bacterium  which  is  the  specific  active  agent  in  the 
production  of  the  disease. 

In  a  certain  number  of  specific  infectious  dis- 
eases it  has  been  already  demonstrated  that  artificial 
immunity  can  be  produced  by  inoculations  with  cul- 
tures of  the  pathogenic  microbe.  Furthermore,  the 
same  end  has  been  accomplished  in  a  number  of 

cases  by  using,  instead,  the  products  of  pure  cultures  after  the  bacteria  had 
been  killed  or  removed  by  filtration.  Again,  the  .same  effect  has  been 
accompli.shed  for  a  number  of  diseases  by  the  use  of  tlic  ptomaines  alone. 

The  value  and  the  utility  of  this  knowledge  of  the  means  of  securing 


190  OUTLINES   OF   PRACTICAL   BACTERIOLOGY. 

artificial  immunity  from  certain  infectious  diseases  are  scarcely  to  be  calcu- 
lated at  this  moment,  whilst  we  have  hardly  begun  investigations  in  this 
direction. 

The  knowledge  of  the  means  of  preventing  infectious  disease  by  inocu- 
lation of  the  active  living  agency  which  causes  it  is  already  considerable : 
in  several  countries  that  knowledge  has  been  given  a  more  or  less  wide 
practical  application,  especially  in  guarding  against  the  destruction  by  in- 
fectious or  contagious  diseases  of  cattle  and  smaller  domestic  animals.  But 
objection  to  the  use  of  such  preventive  measures  has  been  found  by  practi- 
cal experience  to  be  serious :  with  the  artificial  production  of  the  disease 
a  centre  of  infection  is  established  which  may  be  the  starting-point  of  a 
devastating  epidemic. 

It  is  clear  that  this  great  danger  disappears  and  the  objection  based 
thereon  is  removed  when  instead  of  the  active  living  germ — the  essential 
agency  of  the  infection  or  contagion — is  substituted  the  employment  of  its 
chemical  product,  the  specific  jptomaine,  which  recent  experimentation  indi- 
cates will  ultimately  prove  equally  efficacious  for  the  production  of  artificial 
immunity. 

It  seems  probable  from  knowledge  already  gained  that  the  immunity 
acquired  by  surviving  a  natural  attack  or  an  artificial  production  of  the 
disease  is  secured  by  the  action  in  the  tissues  of  the  specific  microbe  through 
its  jjtomahies  ;  and  this  action  is  probably  due  both  to  the  restraining  effect 
of  the  ptomaine  itself  upon  the  development  of  the  specific  bacterium  which 
generates  it,  in  a  manner  quite  analogous  to  the  effect  of  alcohol,  generated 
in  the  process  of  fermentation,  in  arresting  at  a  certain  stage  the  growth  of 
the  microbe  which  produces  it,  and  to  the  establishment  of  a  tolerance  by 
the  animal  organism  for  the  poisonous  alkaloid.  When  these  properties 
of  the  various  specific  ptomaines  shall  become  thoroughly  known  and  well 
demonstrated,  the  successful  and  safe  control  of  epidemic  diseases  will  prob- 
ably become  a  matter  of  certainty. 

The  vast  importance  of  the  future  applications  of  the  products  of  bacteria 
in  clinical  medicine  and  in  demography  is  scarcely  now  conceived,  for  most 
recent  investigations  seem  to  indicate  that  the  time  may  not  be  far  distant 
when  the  practitioner  at  the  bedside  will  be  enabled  to  control  or  cut  short 
the  cause  of  an  infectious  or  contagious  disease  already  started,  through  the 
administration  of  the  ptomaine  elaborated  by  the  growth  of  the  specific 
bacterium  which  causes  it,  or  of  its  direct  physiological  antidote,  and  the 
public  health  officer  or  veterinarian  stop  or  prevent  an  epidemic,  without 
any  danger  of  creating  infectious  centres,  by  inoculations  of  the  chemical 
products, — the  ptomaines  of  the  specific  bacteria. 


MATERNAL  IMPRESSIONS. 

By  \YILLIAM   C.   DABNEY,  M.D. 


From  time  immemorial  there  has  been  a  popular  belief  that  impressions 
made  upon  the  mind  of  a  pregnant  woman  would  cause  defects  in  the  child 
witli  which  she  was  pregnant  at  the  time. 

In  the  well-known  instance  related  in  Holy  Writ  there  seems  to  have 
been  no  expectation  on  Jacob's  part  that  the  Almighty  would  interfere 
directly  to  cause  the  flocks  of  Laban  to  bring  forth  young  "  ringstraked, 
speckled,  and  spotted/'  but  the  device  to  which  Jacob  resorted  is  men- 
tioned in  such  a  way  as  to  show  a  belief  in  maternal  impressions  at  that 
time. 

It  was  onh'  comparatively  recently,  as  the  present  age  of  scej)ticism 
approached  and  thinking  men  came  to  doubt  the  truth  of  those  things 
which  they  could  not  understand,  that  the  power  of  these  maternal  impres- 
sions began  to  be  questioned.  Whether  maternal  impressions  bear  a  causa- 
tive relation  to  foetal  defects  is  one  question  :  hoiv  such  impressions  act  in 
producing  the  effect  is  another  and  a  totally  different  question. 

I  propose  in  this  article  to  review  the  evidence  upon  which  the 
theory  of  "Maternal  Impressions"  rests,  and  to  see  what  grounds  there 
are  for  the  popular  belief  which  is  common  to  "  all  nations  and  kindred 
and  people." 

Much  of  the  testimony  upon  which  the  theory  is  based  is  worthless ; 
some  because  it  is  "  hearsay,"  and  some  because  the  "  witnesses"  Avere  not 
competent  to  form  an  opinion  and  to  give  an  exact  account  of  wliat  they 
saw.  All  of  this  character  I  have  endeavored  to  omit,  and  to  take  into 
consideration  only  that  which  we  have  from  reliable  sources. 

Much  confusion  exists  also  as  to  the  nature  of  the  defects  attributable 
to  maternal  impressions,  as  well  as  to  the  nature  of  the  impressions  them- 
selves. It  is  important,  therefore,  that  the  subject  should  be  systematically 
studied  before  auy  definite  conclusions  can  be  reached. 

There  are  two  classes  of  defects  which  liave  been  attributed  to  Maternal 
Impressions, — mental  defects,  and  bodily  defects.  These  sliould  be  con- 
sidered so])arately. 

Mental  Defects. — That  mental  defects  in  the  child  may  be  due  to 
violent   emotional  disturbances  of  the   mother  during   her  pregnancy  is 

191 


192  MATEEXAL    IMPEESSIOXS. 

generally  acknowledged  by  those  who  have  given  most  attention  to  the 
subject ;  and  yet  the  cases  of  this  character  which  have  been  recorded  are 
few  in  number.  History  and  tradition,  it  is  true,  furnish  a  number  of 
instances  of  the  kind,  but  they  lack  the  w^eight  which  is  given  by  careful 
scrutiny  of  all  the  attendant  circumstances. 

Sir  Walter  Scott,  for  instance,  mentions  that  James  I.  could  not  stand 
the  sight  of  a  drawn  sword,  and  a  gallant  gentleman  who  was  knighted  by 
James  makes  the  same  statement,  and  acknowledged  aftenvards  that  he  was 
apprehensive  at  the  time  lest  the  king  should  let  the  sword  fall  upon  his 
shoulders  Avith  the  wrong  side  down.  The  monarch's  apprehension  was 
attributed  to  the  fact  that  prior  to  his  birth  his  mother  had  seen  Rizzio  cut 
down  in  her  presence. 

Dr.  E.  S^guin,  well  known  as  an  authority  on  the  subject  of  mental 
affections,  stated^  that  it  was  a  well-known  fact  that  an  officer  of  the  First 
jS'apoleon,  as  to  whose  courage  there  could  be  no  question,  became  pale 
when  he  saw  a  naked  parlor  sword,  the  explanation  being  that  his  father  in 
a  fit  of  jealousy  had  nearly  killed  his  mother  Avith  such  a  weapon  during 
her  pregnancy  Avith  Napoleon's  future  officer. 

Dr.  S6guin  reported  at  the  same  time  another  case  Avhicli  came  unde; 
his  OAvn  obserA^ation  and  care.  A  girl,  aa^Iio  at  the  time  he  kncAV  her  AA'as 
twelve  or  thirteen  years  old,  Avas  a  congenital  idiot ;  the  other  members  of 
the  family,  which  was  a  large  one,  AA^ere  aboA^e  the  aA^erage  in  point  of 
intelligence.  The  mother  Avas  pregnant  Avith  this  idiotic  child  during  the 
civil  AA^ars  of  Paris,  and  Avas  harassed  Avith  anxiety  for  the  safety  of  her 
husband. 

In  a  paper  read  before  the  Obstetrical  Society  of  London,  May  7,  1884, 
Dr.  Arthur  Mitchell,  Commissioner  in  Lunacy  for  Scotland,  stated  that  in 
6  cases  out  of  443  in  Avhich  an  effort  was  made  to  establish  a  cause  for 
idiocy,  the  influence  of  maternal  impressions  Avas  clearly  traceable. 

The  Avell-knoAvu  statement  of  Baron  Larrey  with  respect  to  the  siege  of 
Landau  in  1793  is  most  striking,  and  yet  it  is  by  no  means  certain  that  the 
results  Avere  attributable  solely  to  the  fear  and  distress  of  the  Avomen,  for  the 
privation  and  suffering  Avere  also  extreme.  Of  92  children  born  in  the  dis- 
trict soon  aftenvards,  16  died  at  birth,  33  died  Avithin  ten  months,  8  became 
idiotic  (or  rather  it  should  have  been  stated,  perhaps,  were  idiotic),  and  2 
Avere  born  with  several  bones  broken. 

So  far  as  we  are  able  to  judge  from  the  limited  data  at  hand,  it  Avould 
appear  that  a  prolonged  impression  is  far  more  liable  to  influence  the  foetus 
than  a  short  one,  even  though  the  latter  may  be  more  violent :  it  is  espe- 
cially difficult  to  reach  any  conclusion  on  this  point,  hoAvever,  because  iu 
many  instances. a  sudden  and  violent  shock  Avas  folloAved  by  a  long  period 
of  distress.  In  Mitchell's  cases,  for  example,  it  is  to  be  observed  that  in 
four  of  the  six  the  Avomen  suffered  from  prolonged  distress  in  consequence 


1  Phila.  Med.  Times,  December  23,  1876. 


MATERNAL    IMPRESSIONS.  193 

of  the  death  of  a  near  relative,  and  in  one  of  the  other  two,  while  the  fright 
Avas  but  temporary,  the  impression  was  very  enduring. 

The  character  of  the  impression  is  of  great  importance.  Anxiety  and 
grief  seem  to  hold  the  first  place,  and  fear  the  second,  ^vith  respect  to  the 
frequency  with  which  maternal  impressions  influence  the  mental  character- 
istics of  the  child.  So  far  as  I  can  learn,  no  case  of  sudden  or  excessive 
joy  has  produced  any  appreciable  effect. 

The  data  are  insufficient  also  to  establish  the  j^^'^^d  of  pregnancy  at 
which  maternal  impressions  are  most  liable  to  cause  mental  defects  in  the 
child  ;  and  additional  difficulty  is  placed  in  our  way  here  by  the  circum- 
stance that  the  impressions  are  usually  prolonged.  It  M'ould  seem  most 
probable,  however,  that  the  mind  of  the  child  A^ould  be  most  readily  affected 
in  the  later  months  of  pregnancy.  "  The  permanent  cerebral  convolutions 
are  formed  from  the  seventh  month  onward"  (Landois). 

It  is  useless  to  speculate  upon  the  manner  in  which  maternal  impressions 
influence  the  mental  development  and  characteristics  of  the  child.  Upon 
this  point  we  hiow  absolutely  nothing,  and  mere  speculations  would  be  out 
of  place  here. 

We  know  but  little  also  as  to  the  frequency  with  which  mental  defects 
in  the  child  are  to  be  attributed  to  impressions  made  upon  the  mother  during 
her  pregnancy.  IMitchell  found  but  6  cases  in  443  in  w^hich  the  connection 
was  clearly  manifest.  Certain  it  is  that  in  proportion  to  the  number  of 
cases  in  w^hich  women  receive  violent  mental  shocks  or  are  subjected  to 
great  grief  and  anxiety  during  pregnancy,  the  number  of  cases  in  which  the 
mental  faculties  of  their  children  are  impaired  is  exceedingly  small.  During 
our  late  civil  war,  for  example,  the  anxiety  and  grief  of  the  women  whose 
male  relatives  were  in  the  field  were  beyond  description,  yet,  so  far  as  I 
can  learn,  there  was  no  perceptible  increase  in  the  proportion  of  idiotic  or 
otherwise  mentally  defective  children  among  those  who  were  born  in  those 
troublous  times. 

Bodily  Defects. — Far  more  cases  of  bodily  than  of  mental  defect  have 
been  attributed  to  maternal  impressions ;  and  the  reason  for  this  is  obvious. 
The  bodily  defect  is  apparent  at  the  birth  of  the  child ;  the  mental  defect  is 
obvious  only  at  a  later  period,  Avhen  the  child's  mind  should  have  under- 
gone development ;  and  by  that  time  the  various  causes  of  anxiety  or  mental 
distress  during  pregnancy  have  probably  been  forgotten. 

As  has  been  mentioned  heretofore,  the  doctrine  of  maternal  impressions, 
so  far  as  the  production  of  bodily  defects  is  concerned,  has  met  with  vigorous 
opposition.  Some  of  those  who  have  been  most  strenuous  in  tlieir  oppo- 
sition have,  however,  acknowledged  that  malformations  may  be  caused 
by  psychical  impressions,  such  as  "  unaccustomed  agitation  and  fright" 
(Foerster).^ 

Rokitansky,  whose  vast  experience  and  sound  judgment  give  weight 


'  Die  Missbildungen  dcs  Menschen,  p.  4. 
Vol.  I.— 13 


194  MATERNAL,   IMPRESSIONS. 

to  all  his  statements,  says,  "  The  question  whether  mental  emotions  do  in- 
fluence the  development  of  the  embn^o  must  be  answered  in  the  affirma- 
tive. Instances  undoubtedly  have  occurred  of  such  maternal  imjjressions — 
fright  more  particularly — when  violent  giving  rise  to  malformations."  ^  He 
goes  on  to  state  that  it  is  just  conceivable  that  the  connection  may  be  acci- 
dental. He  refers  also  to  a  fact  with  which  all  anatomists  are  familiar,  that 
anomalies  of  the  vascular  system  are  more  common  than  those  of  any  other 
part  of  the  body.  But  the  heart  and  blood-vessels  are  so  far  shut  in  from 
direct  observation,  that  the  influence  of  maternal  impressions  in  the  produc- 
tion of  these  anomalies  has  scarcely  been  noticed.  Peacock  alone  of  all  the 
writers  on  the  subject  calls  attention  to  the  probable  connection  between 
impressions  made  upon  the  pregnant  woman  and  congenital  defects  of  the 
heart.^ 

One  of  the  strongest  arguments  against  the  influence  of  maternal  im- 
pressions on  the  child  in  utero,  in  the  opinion  of  the  opponents  of  the 
doctrine  at  least,  is  that  all  deformities  are  due  to  errors  of  development. 
Now,  there  are  two  difficulties  in  the  way  of  this  objection.  It  presupposes 
that  all  defects  which  have  been  attributed  to  maternal  impressions  were 
"  errors  of  development"  or  deformities  in  the  common  acceptance  of  the 
term,  which  is  not  the  case ;  we  shall  see  that  in  a  considerable  proportion 
of  the  cases  which  have  been  reported  by  reliable  physicians  there  was  no 
error  of  development,  but  a  mark  or  marks  which  evidently  occurred  late 
in  pregnancy,  when  the  development  of  the  child  was  practically  complete. 
But  the  fact  that  in  a  very  large  proportion — a  large  majority,  indeed — of 
the  cases  the  defects  were  plainly  due  to  errors  of  development  does  not  in 
the  least  militate  against  the  doctrine  of  maternal  impressions,  provided  it 
can  be  shown  that  the  impression  was  made  at  a  period  of  pregnancy  when 
the  development  of  the  deformed  part  of  the  body  was  not  complete.  It  is 
not  a  question  as  to  how  maternal  impressions  produce  deformities,  but 
whether  they  actually  do  produce  them. 

The  whole  subject  has  to  be  considered  from  a  number  of  diffisrent 
points  before  any  definite  conclusions  can  be  reached ;  and  it  will  be  well  to 
state,  before  proceeding  farther,  what  those  different  points  are. 

They  are  as  follows  : . 

1.  The  period  of  pregnancy  at  Avhich  the  impression  was  made.  This 
is  important,  in  order  to  determine  whether  the  impression  was  made  at  a 
time  when  an  error  in  development  was  possible. 

2.  The  similarity  of  the  defect  in  the  child  to  the  object  making  the 
impression  upon  the  mother. 

3.  Whether  or  not  it  is  necessary  for  the  A\omau  to  be  conscious  of  the 
impression  for  the  defect  to  result. 

4.  The  value  of  a  statement  of  the  character  of  the  impression  made 


'  Pathological  Anatomy,  vol.  i.  p.  11. 

^  Malformations  of  the  Heart,  pp.  165,  166. 


MATERNAL    IMPRESSIONS.  195 

before  the  birth  of  the  child,  and  the  proportion  of  cases  in  which  such  ante- 
partum statement  has  been  made. 

5.  The  channels  through  which  impressions  are  received  by  the  mother. 

6.  Th'e  duration  of  the  impression  necessary  to  produce  the  effect. 

7.  The  character  of  the  impressions  which  are  most  liable  to  produce 
results. 

8.  A  brief  consideration  of  the  objections  which  have  been  urged  against 
the  doctrine  of  maternal  impressions. 

9.  The  practical  deductions  to  be  drawn  from  a  consideration  of  the 
subject. 

For  convenience  of  reference  I  shall  tabulate  the  90  cases  which  have  been 
collected  from  various  sources,  and  which  seem  to  me  worthy  of  credence. 
I  have  already  stated  that  many  were  excluded  from  the  list  because  the\- 
did  not  seem  to  me  to  be  reported  with  sufficient  clearness  to  be  worthy  of 
belief. 

The  table  will  show  (1)  the  name  of  the  reporter,  (2)  the  journal  or  work 
in  which  the  report  may  be  found,  (3)  the  period  of  pregnancy  at  M'hich 
the  impression  was  made,  (4)  the  cause  or  nature  of  the  impression,  and  (5) 
the  nature  of  the  defect  in  the  child. 

It  will  be  observed  that  nearly  all  the  cases  included  in  the  General 
Table  have  been  reported  within  the  past  twenty  years.  This  is  not  due  to 
the  absence  of  reports  of  cases  prior  to  that  time,  but  to  the  greater  accu- 
racy and  care  with  which  cases  of  every  character  have  been  reported  during 
the  past  quarter  of  a  century.  Those  who  are  in  the  habit  of  really  study- 
ing the  reports  of  cases  have  doubtless  been  struck  with  the  fact  that  the 
character  of  these  reports  is  very  different  now  from  M'hat  it  formerly  was. 
Of  late  the  facts  connected  with  cases  have  been  reported  without  being 
obscured  by  theories  and  conjectures :  hence  these  cases  are  far  more  valu- 
able, for  purposes  of  study  and  comparison,  than  those  reported  in  former 
times. 

During  the  latter  half  of  the  eighteenth  and  the  first  half  of  the  nine- 
teenth century  there  appeared  quite  a  number  of  works  on  Maternal  Im 
pressions:  the  object  of  nearly  all  was  to  show  that  there  was  no  ground 
for  the  belief  in  the  doctrine  which  was  evidently  prevalent  at  that  tim(\ 
These  works  are  valueless  at  the  present  day,  because  the  arguments  whicli 
they  contain  are  based  not  upon  facts,  but  upon  theories,  many  of  which  are 
now  known  to  be  false. 

I  desire  to  state  with  reference  to  the  cases  reported  in  the  General  Table 
tliat  as  far  as  possible  I  have  examined  the  reports  in  the  journals  or  period- 
icals where  they  were  originally  published,  and  I  wisli  to  acknowledge  my 
obligations  to  the  officers  and  employees  of  the  "  Libi-;irv  of  the  Surgeon- 
General's  Office"  for  courtesies  shown  me  while  prosecuting  my  studies 
there.  In  a  few  instances  it  was  impossible  to  get  access  to  the  original 
reports,  and  I  was  compelled  to  take  such  information  as  A\-as  furnishcxl 
in  abstracts  of  those  reports,  published  in  other  journals. 


196 


MATERNAL   IMPRESSIONS. 


'CD      a 


^    CO 


—  %-. 
■?    O 

S 


•n    ^ 


=1=1  S  o 


CD    (V 


P-^        A 


.im'  ^  r-; 


rC      ^   r^ 


^    'S  ^  -^ 


C5 


C3 


;  oj  S  ■!>  r 

)  rj^     O  03     o 


O 


S-5 


W 


.Si 


=S    cS 


OS    O 

:2  o 


03    O)    O) 

n3  '+3  o 


'Ph^ 


«3  ^     .   cs 


O) 


s  a  o 

H  i 


^H        "S 


S^ 


?«  ; 


P-.  o  o  o 


5    P= 


OS  "J  cs  :t^  <u 


oS  ^    OS  ^ 

^      ^      m 


TJ    ^    OS 

03     H     uj 

'  -2  3  OS 

; -r  o  ^° 
l5      ^ 


OS     « 


::  rr!        o 


o 

II 

> 

rC     03 


c     • 

■5'B 

oa 


!  -^  f,r,  ^  «  '-' 

I     •  ojj  '^  S  Q 

I    OS  C     03  =«  ^ 

'    r'  ^  ^  0^ 


;  ^  3 


C     ^     03 


C 

o 


•^   OS   iXJ  ■-'   ^ 

brj^  ,22: "  a 

C    ,     r;  OS    '-" 

'>  S^  ^% 

^  f;  oj  OS  OS 

OS 


G    O    CO  '^    O 


^ 


.^  "23  jz; 
!  4J  S  o  'G 


9^ 


.a  ^o 

a  §^ 
gag 


U  CD 

^  CO 

S  00 

S  CO 

0  CO 

0  00 

HS^ 

l-S    T-l 

ts  t^ 

•73  0 

03  1-< 

03  (M 

^     >. 

^^ 

■  s 

•    OJ 

■r '-s 

=r.^ 

M 


pq 


^  GO  3 


CO     °  ■-! 


r-H'-S^ 


•^        T3  to"  173 
■  03    rj    03  03 

.   OS 


cj  S  :^  5! 
03     .    Ph    . 

m    P5    m 


CO 
CO 

3 
0 

CO 

S 

0 

i-s 

'-s 

r^. 

^ 

n3  CO  r3 

03 

03 

r^ 

!>-.r^ 

P 

OS 

< 

g 

•r 

pq 

P5 

T— I       ^ 

CO    O  CO    O  00 


CO  i-d  ' 

oS 


j;00  fl  O 
CD  oS  O 
00      . 

2.S  3 


oso 


^3  ^ 

C     03 

osp 


^  J  ^ 


ce    3  cc    P  tB    ;3 

go     .  '3   P     •  '3   O     • 
1-s^  0'"='-^  ©'"'r;::'  oi-sr^ 

00    ^  00  J  CO  J  CO 

•  COM       .  00  I— I       •  00  H       .CO 

f/2r-l       .OirH       .COrH       .COr-l 


cc- 


CO 


CC 


"5    r 

.02 

m 


pq 


pq      pq 


o    pq 


•ft 


f^ 


>;      k     t:     K      G      M      >< 


><! 


Xi 


M 


M 


MATERNAL    IMPRESSIONS. 


197 


II      1 


<V         ,<D 


(^■^  O 


B  ^ 


W 


w 


=3 

5 

3 

c3 

!-i     CO 

CO 

.  o 

t; 

3 

i 

c 

o 

cu 

cS 

'tS 

a; 

S^ 

rfi    -i^ 

ho 

<D 

^  ^ 

■  ^ 

^ 

be 

cS 

o 

;^ 

<s  o 

rO 

OS     fl 

tfl 

a 
o 

o 

c; 

tC 

fcjj 

a> 

nS 

^ 

C  o 

<U 

>> 

^^ 

•5 

rg 

o 

^c 

cO'T3 
03  ,_ 

o 

^1 

^ 

n3 

rfl 

.SIS 

-^1 

03    o 

O 

■73 

r-] 

3 

o  o 

)S 

)S 

3 

13 

3 

;5^ 

o 

o 

o 

O 

o 

O 

O 

o 

^ 

K 

o 

O 

o 

S3 

>i 

xin-; 

i 

1 

n3 

o 

it- 

t; 

a; 
1 

OS 

•^1 

PL, 
CO 

o 

3 

03 
ra    CO 

O  j3 

rG 

a 
o 

o 

s 

III 

C3 
S3 

CO 

i 

o 

s 

r-.     CO 

^    C3 

O 

s 

OS 

r^ 

oS 
OS 

03 

g 

bJD 

Is; 

ll 

OP    C 

a-- 

03  ."S 

C 

o 

cS 

o 

1 

OS 

03 

fl    O 

12 

bJ)-^ 

3 

'% 

03 
OS 
OS 

r^      to 
^^ 

a  ^ 

•r '5 

fl    CI 
03    ^ 

OS  a;  a 

r— 1      CO      "^ 

_aj  ,3  t(-i 

2 

btfa 

ca  CO 

9 

■5  ^ 

-^  bb 

S   ^    bt 
OJ    ■"    C 

^ 

b/) 

^  o 

rT) 

s^ 

!-i,a 

o 

,i3 

-dss 

rTS 

a  -s 

^^ 

O 

CJ 

o 

O    CO 

-t-A 

OrS 

o 

rQ     O     C 

g 

^ 

^ 

^ 

^ 

^ 

^ 

§ 

s 

^1 


osp 


r^ 


oSp 


03    S 


s;  o 


03  00 
c3    "^ 


03  CO 


03 -g 


^!^ 


??co 


co^  (O^Oco^Oco^Oco^Oco 

oi-sr:!  o>-s2  o^-sS  oi-sS  oi-sES  o^^  o>-s«3  ohS!:::!'^  G'*'^  g'*'^  c=^t3  S^ 

"g-'co/^         '-'j         '-'j         --^j         '-'^         Q0"3         GOj'^OOo3St-oSGr--3CODoSfi      " 

M     .  GO  I— I     •     -*— I     •     -•— I     •     -M     •     -t— I     .cot— I     .001— I     .00— ■;.'"00'— ';--"cD  —  ;.'^00'— '^'^'— I 
.COr-H     .GQvO     .02  0     .GQO     .rCiO     .CKrH      .OGt-h     .a2rt;gH--H^Hrt2Hr-i;5HT-i 


^         CO 
03    C      .- 


S      O      S      2      O      grg^ 

"g  ^3'g  ^  3  I* 

H     H     ;^ 


<^ 


Ph 


M 


X 


s      >^ 


^r<! 


C       P.       « 


198 


MATERNAL    IMPEESSIONS. 


O    « 


'd 

S 

r^ 


2  '^   ^  ^ 


S  o  § 

%  ^^ 
Q      S 


CO 


O   ^   'ciC  s 


^  a>   ^  '-*-•        j^^ 

■t:  -  o)  f^  -^  3 
'$  o  ^  ^  ^  If 


§  s  s 


s^ 


^-s  ^^ 


«  o  ^  S 

b 


a  S  ^^"'^ 


S  rJ3 


=3     ;:::         rP 


>-i  CD    aj    O 

^_^  03     r-i     ^   " 

•c  J  ^  -g 


05  - 

3     '=*     S^ 
CS     ^     ^ 

g^.  3 


.2.t;       ^ 


t-.'C 


-^  g 

«    rS 


%-¥. 


looked 
on  her 
dressec 

.s  » 

S  cc 

fe    OJ 

-^  ^  a 

Sea 

a  m 

<u  ^  ^ 

thigl 

Worn  a 

viole 

SS 

o 

OS 

o3  -S  r; 


c3    O) 


.O    f^ 


^-^ 


a  =3 


a  o 


rQ    oj 

^3  b 


•g^r 

-a 

be 

05 

>- 

^:a  s 

rQ 

a>     &Cr^ 

^•s  =3 

a  oj  2 

S  ra  a> 

"r 

!^ 

t^^  ^ 

&, 

«^     CO 

S 

t^ 

P. 

I^Oh 

^, 

bIJo>, 

1 

•^§1 

iq 

S   i^'H 

P       :i 

H 


pl^ 


^^ 


oj;^ 


r—    ■  -    LO    — I 


Ph 


P^ 


Ph 


O    ci 


CO 

Ah 


rd  a 

O    03 


173    <U 


^  a 


N-H    gr^rH   §^>-H    SPhco   cdPhcm 


a  -e  00  a 

03    rl  "^   c3 


'SPh 


)  P-i  CO 


a  § 

'^  -§00 
S  feoo 


'sp^;:: 


w 


o 

p 


><l 


t> 


^     b 

X       >< 

M        ><! 

MATEENAL   IMPRESSIONS. 


199 


a 


w 


&< 


w 


^    CO 


Ph  jj 


bfj 


bX)  ' 


^    ^ 


2-2 


0) 

^ 

o 

-4^ 

3 

o 

a 

>. 

CO 

■^ 

W)^ 


O     C     r<  '^     M 


a; 

—T3  T3 

efS 

.hr«i:^ 

^ 

^  i;   " 

IS ;    hare 
ng  one 
similar 

bJ) 

H 

ts  e 

3  "o 

2  S  S 

Ol 

bJDg 

lO    9    0)    <D 

^^o 

be    . 

Sc 

g  «^ 

.S  -2 

l-iHO) 

r^      S 

<D    cj 

S-P 

O  'C 

O      ^      Q 


O 


w 


•c2     -s^ 


o  ^ 
bfj.-  ^Td 


bJD;^ 
j2    OJD 


;:5  '^    c3  _S 


>  a 


1  '^  ^ 


n3  ^ 

g  t; 


o3    33 


b:t2 

CD     ^ 

beg 


ri  p;  tP 
3  fl  "" 


>5 

a; 

fi   be 


3   bp^ 


y ; 


s  S  s's 


Oh' 


■  g  -g   g    ?   OJ   S 


>^    OJ     ^  ?- 


^    S    tH    c; 
T3    o    CD    ^ 


-^  5  5  p.?i 


biJ:^: 


a.  g^ 
TS  .1-  a; 

<D  -u    tc 


S-a;t3  ^-3 


O    CO    ^    O    Ph 


O  ^    O  cS    O    CO    O 
^         %         % 


.2  '^  3        Ph  ''^ 

^  3  '^  .a  g^2 

,^  '"^  -^  'rf      -^ 

CO      CO      O    r^      OJ 

a  a  ^  s^  fl 

o  cO  o'y  fi 


t^% 


03 


i  C3 


-co  rrt 

^    "    O    a  'TS        'Z 


>  a^ 

•-~'co    OJ 

p,    -p 

•,       ^     CO 

9   <^-   '% 

3^^ 
fe  2  S 


oi 


b/j2  S 


be^ 


jj    OJ    CO    H  c3    =3 

o  ,x:  d  C  o      g 
cS  o  .2  =2  ;^  5  bb 


fH  aj       ^  , 


^S:':^      ^ 


^i 


H 


,^         ,^         A 


P3 


W 


W 


MS        ^  ^ 

-li-rP 

-S^^ 

.^3   c 

a;  oi 
0  CO 

■J^     IJ 

^^  1^ 

t^f=^ 

sp^ 

>-.-5 

cS 

03 

PM 

03  A 

-^  sve> 

Ct5 

o 

to 

O      r-i 

S^S5.2^. 

_o  ,^ 

_CJ  ^ 

h-s      ., 

"   g^^  X3  d  oJ 

-£3  a  c» 

*3  d  05 

^'^cQ 

12  '^ 

5^ 

-gM^^I^S 

■§boo 

■jgO  00 

00 

;=3      o 

o 

O 

O' 

h-1 

M 

iA 

M 

Lancet 

1877. 
Obstet- 
y,1871 
Obstet- 
an.     8 

•^  bfi 

•x:  be 

OJ    P< 

FM 

PM 

- 

~ 

ondon 
Nov.  3, 
mer.  J. 
rics,  Ma 
mer.  J. 
rics,     J 

CO 

.•  S  oo 

CO 

CO 

S.2S 

S    20D 

a^ 

CO 

a^; 

^      <      < 

-< 

<;• 

< 

<{ 

200 


MATERNAL   IMPRESSIONS. 


_^ 

1 

> 

1 

£3 

! 

0 

E^ 

,a 

i          ^ 

1^ 

O 

53 

Oi 

o 

OJ 

03 

c 

OJ    03- 

w 

o 

o 

"^  0 

i   g 

o 

^ 

>-, 

.SJz; 

H 

-t< 

s 

r^ 

c 

c  '~' 

5zi 

rJ2 

n3 

O 

o 

9^ 

23 

tc5 

a 

C3 

"o;  P 

',2 

_d, 

3 

3 

_p. 

3 

d. 

.&■ 

!2 

2 

2 

0    03 

S 

<u 

S" 

03 

03 

i 

03 

?^ 

^ 

r-i 

6 

5 

Q 

5-  "^ 

'Ph 

02 

W 

K 

a 

w 

s 

03 

w 

, 

^ 

o 

o 

^ 

3 

0) 

fl 

'- 

■? 

nd 

"o 

Ph 

Ph 

o 

to 

-2 
g 

S 

2 

2 

2 

fe| 

f 

0 

o 

«4-l 

o 

"o 

o 

03     0 

0 

"p 

ZJ 

P 

p 

o 

CP 

03 
O 

03 

^ 

K* 

b 

£ 

^ 

b 

o 

o 

i       w 

S 
2 

c3 

s 

3 

s 

o 

s 

03 
P- 

03 

0)    r^. 

1 

.2 

03 

.2 
2 

'ri" 

.2 

03 

'5" 

03 

0 
i3 

c 
'p 

■? 

'2 

-id 

o 
o 

0 

03  -7 

.§ 

Ph 

ri 

& 

P. 

g" 

'0 

0 

03 

b 

g. 

p 

3 

r^ 

^ 

^^ 

^ 

0^ 

^ 

_^ 

ri 

c 

rQ 

q; 

CO 

03 

CO 

"c3 
0 

ri^ 

~ 

:: 

-_ 

^ 

^ 

03 
03 

.2 

.2 

OS 

rf 

O 

03    =3 

"1 

HI 

3 

3 

3 

3 

> 

2 

Ph 

a 

1— 1 

p 

ri 
M 

=  _ 

. 

^ 

rri 

^3 

f^H 

0 

P3 

c 

©y 

0 

n^ 

cc 

03 

^ 

^" 

^ 

^ 

r^ 

^ 

s 

ri 

22; 
OS  S 

■^ 

S 

3 

o 

!z; 

ri 

0 

ri 
0 

3 

3 

g 

■73 
CO 

CO 

O 

g 

^ 
H 

n3 

^ 

ri 

'a 

g 

3 

0 

^ 

= 

CO 

CO 

iM 

CO 

CO 

CO 

(M 

(M 

^ 

-^ 

- 

, 

1 

, 

, 

1 

, 

, 

^' 

<P 

o 

TJ 
OJ 
WH 

T3 
03 

03     " 

■^■^ 

-<1 

J3  'S 

<1    X 

< 

0 

^ 
-< 

0 
X 

^1 

^1 

M 

^ 

^ 

s 

1^  0 

n3 

'^ 

2 

2 

-^ 

"^ 

nS 

'^ 

ri 

ri 

r^ 

ri 

ri 

p 

<x* 

o 

r^      03 

CO    C3 

CO    c3 

1/3    S 

to    l3 

rj2 

C3 

■x 

C3 

CO   03 

CO     OJ 

tf 

03 

g 

m 

. 

Sp^ 

>eq 

CO  'feiW 

00  >w 

co>W 

CO  '^^ 

23 

CO  "fc; 

33 

co>m 

CO  "^P^co 

H 

t^ 

^? 

T 

^ 

■> 

P 

^    ;? 

2  > 

=sJ.> 

^  2  > 

03  r^  •■— 

4i  2  > 

^i 

>" 

«e  2 

;^ 

=s  2  > 

=s  2  >^ 

a 

ri  '^ 

03 

Qi) 

^    ■—  'X. 

03  '^  •'- 

C;  1-^ 

§^ 

'5 

o 

z; 

"3 

0 

2; 

fe    c3  X 

03     0.- 

M 

«.§-§ 

l-ij     C3     '2 

w.§^ 

w.^ 

0 

w.g 

-C 
C3 

hH  P-ri 

HH  .3    0 

W.g-gK 

^ 

o 
^s 

1-^ 

hq 

!?; 

> 

^ 

^ 

^ 

>- 

K^ 

;> 

^ 

a 
o 

ik 

"3 

rt 

bfi 

c 

C 

^ 

rd 

-d 

-ri 

r; 

^ 

_  r) 

-C 

-C 

k3 

a» 

03 

rt 

^ 

^ 

^ 

0 
P3 

"0 

w 

P3 

^ 

0 

Pi 

0 
P3 

H 

1— J 
1— 1 

> 

►> 

KH 

(—1 

'k^ 

'r^ 

ty^ 

»— i 

1— 1 

7j 

l-q 

^q 

^q 

h^; 

1^ 

H-l 

1— 1 

h1 

h^ 

Hi 

fe. 

h^l 

hi 

o 

d 

^ 

MATEENAL    i:SIPEESSIONS. 


201 


B 


^■>  s  = 

p  "^  o  c 

■^  (^  'c, 

^  >  o  S 

C    O  iH  "T 


P  ?i       ^"o  o  'c  -e 


W     Hi 


O 


,  --  .^  c    '-'"'';      '-c    ^    ^ 


.-    <z> 


£      CI 


■t-       oj  .•a 


CO     5S 


":  -5  i€  •-    ?  -2  "^  £  s  c. 

2      5  I  .=  S    .  J  •"  _o  J  ^  £ 

^     ^  ^  '5  ^  -i:  ^  5"  &,^  '5  o 

5    55  5    5       5 


£      £      J     .S." 

1— I         r-         CC         OJ 


0.2     ^     .5 


03    (D 

ji, 

•oJD^ 

o 

C   p 

r^ 

cfi    ? 

j; 

2  &. 

5  =3 

"? 

S    >- 

--? 

""■ 

3    "S 

7^  iii 

ij 

~    o 

o 

c  fr> 

'3 

n 

c  ^ 

!^    •" 

,,j 

■si 

£  i" 

^ 

.:£  ':d  5  '^  ^  "^ 


5 

^ 

"o 

^ 

S 

c 

? 

o 

2 

Q 

^  ^ 


bJ-j  f'^  iJ".  t:  s 
=(=  ,_g  -5  J  ^. 

^  -S  .£  '^  ^ 

^  ^  T3 .2  i:' 
5  3  ~  3  rP 


" 

T3 

cS 

IC 

c 

E 

OJ 

■£ 

S^-e 

C3 

-^ 

"^ 

•"  o 

t3 
C 

"^ 

1-^ 

5r^':^^^s 


13  £-3 


5  '=J2^> 


r-?  r- 


^=f 


a   ■-  o 

—   o 

"^  +3  -"^ 

^       c 
«=  c  ^ 


'=^-  c  ^ 

!2  ^  o 
SS  o 


=;      -^      'TS 


Ph  ^'       ^ 


1^     !zi 


H 


P^ 


t3      ^sq 


CO  >  CO  03  "^      t; 

.-^  •"  .*^  ^  ^'      ":::  S  ^ 

^       ^                2  _  5  CO 

i>  CO  ci  '-' 

a  '=^  J 

H-»  nn  '^ 


^  5  "^  !5  ^  .^  ^  ^-  ^  ^  ^  ^-  J^ 
*E>      '3      *3      "      '3      "3  f^    '- 
_  X    .«    .X    .X     .X    ,  y.  ^  c^ 


CO 


if  o   'op 


o^   o    - 


1^    .  .  ^ 

o  S  ?  :=  c  ? 


W  '^ 


5  oc  O '"' 

O  CO  o 

.     -  ^    3 

'SCO    r^h-. 


^  a.  .•  ^  ^      .ti  o  <"  i  -J 

00  M      O  J^i 


:2     ^     «     fl     p3     « 


£•5 


1^     ^ 


2  K 

'"     ^ 


>^ 

>^ 

X 

>^ 

H^ 

^ 

202 


MATERNAL   IMPRESSIONS. 


t«   o 

bJj-S 

i  S 

'^    rG 
rfl    -^ 

Ph  O) 
rC  -G 


fe/j 

c 
o 


,    '^  oi  fe   £  I  i" 

J    C  O    c/i  Oj  ^ 

;  c  5^  t-  oj  >  :72 

I  §  ^'1  ^  S  s 
&J1  o 


^  o 


„      bb  ip  .  "i^ 

g  nd  .S  ^  '5    ^'J 

CO     5S  .S  ^    O  'Jo 

^3    cc    C    cs   S  -S 

to  ~  * ' — '  ii  ^ 


53 


ia  o  -  r   T   &rj 


n3  f»  „*   ,     ^   r*   ^   zi   ,  • 
rS   bfj'^   M  c  .^   o   S   bJ 

r^  '-  X!  •-  _:   t::L^   P.-" 


bjjf 


bn 

<1) 

bj. 

■73 

« 

fi 

h-1 

o 

oj    Ol 

O    o 

c 

rO«l-l 

;:: 

l^H 


r^    _S    .-  - 

'^  rrt  TS  crns 

rrt     r-     Ci  to     OJ    ,1) 

^  ^^  oi  o  3 

o  o 


^■7.2 


r:i       -^  ?.''S 


O       P3       O 


<u 


Cl> 


b£ 


O  C 

CJ  ^  ; 
^     CD     =S     !-,  '^J     . 

fj    O    g^  O    O    s 


bC 


r^      bJTj   S      O 


•S      bCS 


^     OJ      CD   ^   '^   r£ 


P^      ==  c 


.a 


,a    S    CD  ^  '^  ' 

5     (D   -^   r=   ^H 
-t^     „     05    "-     t^  'W 
pQ    2    ?"    >-.  QJ    - 

bJj  -   p;  rs  rC   S 

^    03    ,      CD  1^    2 

cS    b€^rC 

CD    S    >*    .  ^  ^    j-, 

■t.'S  s^  s^ 
fe     ^     !> 


,    C  ^-*    OS  oj    '^ 

■^    u:    V  ,^  ^  "^  cd,£h 

j3  brj  S  .^  "^  ^M  bjo  ^  "2 


5  r^      OJ 

P.^  =*^ 

o   c  brj  "--     .  p         a 

p:    03  g    br^  g        ^ 

1—    Qj  i-H    L,    f--  "^  —    '^  rt-i    o    ^  ^ 

^  ^  ^      g      ^ 


"  id  s  "' 

.  o  S  c 

-'  c  ■;<  o 

^  o 

pHpr::    ■ 
n^  ^  ^  w 


2S 


CD           ^'  ^' 

P-        .S  .S 

'?   I  .s 

bXi  bJD 

CD  Oi 

PC  pq 


f^ 


C  Jai 

O    CD 

.^    <D 

a 

*  is 

OJ 

JTl 

^^  a> 

Ph 

;^ 

^   ^ 


o     .  o     .  c     . 

o     .  o     . 

1^ 

O  CD    O  CC    O  ?0 

u  ^  o  1:0 

« 

S  00  8  00  8  CO 

SB  CO  a  00 

« 

j3  CO    c  <^    C  00 

C  CO    s  '^ 

w 

>-.'-'  1^.'-'  >-.'"' 

K^    I— 1        f^    I— I 

^ 

o    o    o 

0    0 

O  CO    O  CO 

8ii  00  S  » 
c  00  c  00 


So    SCO 
S  k-i    C  CO 


^-  ^  *"=  ^ 
0.0.       ""s 

CJ  CD  <;j  CD  •  - 
ffi  00  a  CO  35  .--• 
r;  CO    C  00    ^     >^ 


pq     pq     ffi 


[ii      fe      f^ 


P5 


I— I  ^n  L>. 


1— 1 

0 
>1 

MATERNAL    IMPEESSIOXS. 


203 


An  examination  of  the  table  will  show  that  these  90  cases  may  be 
divided  into  several  diiferent  classes  according  to  the  part  of  the  body  in- 
volved ;  and  with  a  view  of  studying  the  defects,  with  especial  reference  to 
the  development  of  the  different  parts  of  the  body,  I  shall  make  the  follow- 
ing classification : 

Cases. 

1.  Hare-lip  or  cleft  palate 21 

2.  Defects  of  the  upper  extremities 21 

3.  ''  "  lower         "              8 

4.  "  "  ears 8 

5.  "  ••  eyes 4 

6.  '•  ••  head,  neck,  and  trunk •    .    .  20 

7.  "  "  skin  and  hair 15 

In  several  instances  there  was  more  than  one  defect,  and  in  such  cases, 
as  a  rule,  each  defect  has  been  placed  in  its  appropriate  class,  so  that  it  will 
be  observed  that  the  sum  of  the  different  defects  is  97,  while  the  total  number 
of  cases  is  but  90. 

I  shall  arrange  these  different  classes  of  cases  in  tabular  form,  for  greater 
convenience  of  reference  and  study. 


CASES 

OF   HAKE-LIP 

AND   GLEET   PALATE. 

Case. 

Period  of 

Pregnancy. 

Case. 

Period  of  Pregnancy. 

I. 

4  months. 

XII. 

3  months. 

II. 

4  months. 

XIII. 

2  months. 

III. 

3  months. 

XIV. 

3  months. 

IV. 

Early  period. 

XV. 

3  months. 

V. 

Early  period. 

XVI. 

3  months. 

YI. 

2  months. 

XVII. 

2  or  3  months. 

VII. 

2  months. 

XVIII. 

2  or  3  months. 

VIII. 

7  weeks. 

.  XIX. 

3  months. 

IX. 

Before  marriage. 

XX. 

3  months. 

X. 

Early  period. 

XXI. 

Commencement  of  pregnancy 

XI. 

Early  period.    (Occurred  in  two  suc- 
cessive pregnancies.) 

If  we  examine  now  these  cases  of  defects  of  structure  of  the  lips  and 
palate,  it  will  be  observed  that  in  all  but  2  of  the  21  cases  the  impression 
was  made  within  the  first  three  months  of  pregnancy,  and  in  the  other  two 
it  was  made  during  the  fourth  month.  This  is  a  point  of  great  importance ; 
for,  while  it  is  impossible  with  our  present  light  to  understand  how  these 
defects  can  be  produced  by  maternal  impressions,  it  has  been  justly  claimed 
by  the  opponents  of  the  doctrine  that  it  is  well-nigh,  if  not  altogether, 
impossible  to  conceive  how  a  defect  of  develoi)ment  could  occur  when  the 
development  itself  was  practically  completed.  That  a  "  retrograde"  process 
of  absorption  may  oc{>ur  is  within  the  bounds  of  possibility,  certainly,  but 
it  is  far  more  improbable  than  a  failure  of  proper  development. 

Roth  quotes  Meckel  with  respect  to  bodily  defects  brought  about  by 
maternal  impressions,  to  the  effect  tliat  "  it  is  impossible  that  such  a  causal 
connection  could  exist  later  than  the  first  months  of  intra-utcrine  life ;"  and 
Roth  himself,  who  is  a  pronounced  believer  in  the  power  of  maternal  im- 


204  MATERNAL    IMPRESSIONS. 

pressions,  says  that  the  most  probable  time  in  which  they  are  effective  is 
during  the  first  three  months,  or,  more  exactly,  from  the  second  to  the  third 
month,  for  after  the  third  month  the  plates  become  closer  to  each  other,  so 
that  a  separation  at  that  time  would  scarcely  be  possible. 

The  remarkable  experimental  investigations  of  Dareste  ^  on  the  artificial 
production  of  monsters  in  the  lower  animals  have  proved  beyond  a  reason- 
able doubt  that  these  monstrosities  have  their  origin  in  the  early  periods  of 
embryonic  life ;  and  it  is  an  interesting  and  suggestive  fact  that  the  two 
conditions  which  would  most  surely  affect  the  foetal  or  rather  the  embryonic 
blood-supply  were  just  those  which  always  modified  the  processes  of  evolu- 
tion,— namely,  (1)  contact  of  the  egg  with  a  source  of  heat  at  a  point  neaj; 
the  cicatricula  but  not  coinciding  with  it,  and  (2)  the  production  of  temper- 
atures slightly  above  or  below  that  of  normal  incubation. 

It  is  important  to  remember,  however,  what  has  already  been  remarked, 
that  there  is  a  great  difference  between  those  defects  of  development  which 
have  been  attributed  to  maternal  impressions  and  certain  defects  which  have 
been  attributed  to  the  same  cause,  such  as  scars,  defects  of  the  hair,  and 
certain  nervous  defects,  which  may  and  probably  do  have  their  origin  at  a 
much  later  period  of  intra-uterine  life.  The  hair,  as  we  shall  see  hereafter, 
is  developed  quite  late  at  any  rate,  and  it  is  entirely  possible,  and  probable 
even,  that  such  defects  as  facial  paralysis,  of  which  two  most  striking  cases 
are  given  in  the  General  Table,  w^ould  occur  at  a  late  period  of  pregnancy. 
Furthermore,  with  respect  to  scars  and  marks,  it  is  well-nigh  certain  that 
they  would  occur  late ;  for  not  only  is  the  skin  comparatively  late  in  -de- 
veloping (about  the  fourth  month),  but  w^e  shall  see  that  there  is  almost 
conclusive  proof  that  these  scars  are  or  may  he  the  result  of  disturbances  of 
an  inflammatory  character.  We  shall  see  also  farther  on  that  as  a  matter 
of  fact  the  scars,  etc.,  which  have  been  attributed  to  maternal  impressions 
have  had  their  supposed  cause  in  operation,  as  a  general  rule,  at  a  much 
later  period  of  pregnancy  than  the  "  deformities"  in  the  common  acceptation 
of  the  term;  such,  for  example,  as  hare-lip  and  cleft  palate.  Indeed,  this 
seems  to  me  an  argument  in  favor  of  the  truth  of  the  doctrine  of  mater- 
nal impressions ;  for  in  many  instances  the  persons  who  have  reported  these 
cases  have  been  manifestly  ignorant  of  the  details  of  embryology  and 
teratology,  and  yet  they  have,  as  a  rule,  attributed  defects  of  development 
to  impressions  made  at  an  early  period  of  pregnancy,  and  "scars"  and 
"  marks"  to  similar  impressions  made  at  a  much  later  period. 

With  respect  to  the  special  forms  of  deformity  or  defective  development 
which  we  are  considering  just  now, — hare-lip  and  cleft  palate, — we  are  told 
by  embryologists  that  the  superior  maxillary  processes  of  the  first  branchial 
arch  come  together  during  the  first  eight  or  ten  weeks  of  foetal  life,  and  at 
the  ninth  week  or  soon  afterwards  the  hard  palate  is  closed  and  on  it  rests 
the  septum  of  the  nose. 


Comptes-Eendus,  Nov.  3,  1873. 


MATERNAL   IMPRESSIONS. 


205 


A  glance  at  the  table  will  show  that  in  the  main  the  maternal  im- 
pressions which  produced  or  which  were  supposed  to  have  produced  these 
deformities  occurred  at  this  very  period. 

Roth  reports  a  case  Avhich  I  have  included  in  the  General  Table  which, 
viewed  from  a  developmental  stand-point,  would  find  its  appropriate  place 
here :  it  was  a  case  of  tracheal  cyst  of  the  neck ;  the  "  maternal  impres- 
sion" was  made  at  the  second  or  third  month  of  pregnancy,  and  was  due  to 
seeing  a  person  stabbed  in  the  neck.  It  is  scarcely  possible,  however,  to 
attribute  to  the  influence  of  a  maternal  impression  a  case  reported  by  Mr. 
Ashburton  Thompson  to  the  Obstetrical  Society  of  London  on  April  4, 
1877.  A  woman  seven  months  pregnant  went  to  the  door  to  answer  a 
knock  :  she  was  shocked  to  see  a  man  who  could  not  speak,  and  from  whose 
windpij^e  projected  a  tracheotomy-tube.  Two  months  afterwards  the  child 
was  born  with  a  tracheal  cyst  and  a  fistulous  opening  leading  into  it.  It 
seems  scarcely  possible  that  there  could  have  been  any  connection  between 
the  impression  and  the  defect  in  this  instance,  on  account  of  the  evident 
error  of  development  to  which  the  defect  was  due  and  the  late  stage  of 
pregnancy  at  which  the  impression  was  made. 


DEFECTS  OF  THE  UPPEK  EXTKEMITIES. 


Case. 

Period  of  Pregnancy. 

Nature  of  Defect. 

I. 

Kot  stated. 

Three  fingers  webhed  ;  nails  like  claws. 

II. 

From  marriage. 

Only  four  fingers  on  one  hand. 

III. 

3  months. 

Three  fingers  on  one  hand. 

IV. 

3  months. 

Marks  like  those  of  cog-wheel  on  shoulder. 

V. 

2  months. 

Claws  like  a  terrapin. 

VI. 

Not  stated. 

Kudimentary  fingers,  below  left  elbow. 

VII. 

Early  period. 

No  fingers  on  one  hand. 

VIII. 

Early  period. 

Only  two  long  fingers  and  thumb  on  each  hand. 

IX. 

Early  period. 

Thumb  attached  by  slender  pedicle. 

X. 

3  or  4  months. 

Plight  arm  and  forearm  absent ;  abortive  hand  attached 
to  scapula. 

XI. 

Not  stated. 

Fingers  of  one  hand  missing. 

XII. 

7  weeks. 

Fibrous  cord  connecting  the  hands. 

XIII. 

Early  period. 

One  arm  absent. 

XIV. 

Not  stated. 

One  arm  absent. 

XV. 

Not  stated. 

One  arm  absent. 

XVI. 

Early  period. 

No  fingers  (only  the  thumb)  on  one  hand. 

XVII. 

Early  period. 

One  finger  missing,  two  webbed. 

XVIII. 

Commencement. 

Phalanges  on  one  hand  missing 

XIX. 

6  or  8  weeks. 

Hand  missing  from  about  the  middle. 

XX. 

Not  stated. 

Supernumerary  fingers. 

XXI. 

Not  stated. 

One  metacarpal  bone  missing. 

In  the  table  of  cases  of  hare-lip  and  cleft  palate  it  was  unnecessary  to 
state  the  special  deformity  in  each  case,  but  in  the  other  tables  it  has  seemed 
best  that  this  should  be  done. 

There  are  21  cases  in  the  table  of  defects  of  the  upper  extremity,  but 
three  of  these  might  with  propriety  be  placed  in  a  different  categoiy, — 
namely,  Case  IV.,  in  which  tliere  were  marks  like  those  made  by  a  cog- 
wheel on  the  arm  and  shoulder,  which  should  probably  be  placed  more 


206  MATERNAL    IMPRESSIONS. 

correctly  with  the  "  defects  of  the  skin  and  hair ;"  Case  IX.,  in  which  the 
thumb  was  attached  by  a  slender  pedicle,  which  was  almost  certainly  a 
secondary  defect  and  not  due  to  an  error  of  development ;  and  Case  XII., 
in  which  there  were  fibrous  bands  uniting  the  two  hands  and  spreading  out 
over  one  so  as  to  bind  the  fingers  together.  A  case  somewhat  like  the  one 
just  mentioned  has  been  reported  by  Kidd,^  in  which  the  bands  were  cer- 
tainly of  secondary  origin  and  had  caused  amputation  of  one  leg.  Indeed, 
with  respect  to  the  absence  of  limbs  or  parts  of  limbs  much  caution  is  neces- 
sary before  arriving  at  a  positive  conclusion  as  to  the  cause.  In  many  cases 
the  presence  of  rudimentary  fingers  or  toes  leaves  no  doubt  that  the  de- 
formity is  due  to  a  defect  of  development,  but  in  other  instances  there  can 
be  just  as  little  doubt  that  the  defects  are  due  to  intra-uterine  amputation  by 
bands  or  by  the  umbilical  cord. 

Leaving  out,  then,  the  three  cases  which  I  have  already  mentioned,  there 
remain  eighteen  of  deformities  of  the  upper  extremity ;  of  these,  eight — 
namely,  I.,  Y.,  VI.,  VIII.,  X.,  XVIL,  XX.,  and  XXI.— are  clearly 
due  to  errors  of  development,  and  cannot  be  attributed  to  the  effects  of  con- 
striction by  bands  or  by  the  cord.  In  four  of  these  eight  cases  the  period 
of  pregnancy  at  which  the  impression  was  made  is  not  stated ;  in  two  others 
it  was  made  at  an  "  early  period"  of  pregnancy,  in  another  at  the  second 
month,  and  in  the  other  at  the  third  or  fourth  month. 

Of  the  ten  cases  in  which  a  part  or  the  whole  of  a  limb  was  missing, — 
and  which  it  is  best  to  consider  separately,  because  such  a  defect  may  have 
been  secondary, — the  period  of  pregnancy  at  which  the  impression  was  made 
is  not  stated  in  three ;  in  all  the  others  it  occurred  at  an  early  period,  in 
one  only  later  than  three  months,  and  in  five  it  is  distinctly  stated  to  have 
been  within  eight  weeks. 

If  we  turn  now  to  the  development  of  the  upper  extremity,  it  will  be 
found  that  the  limbs  are  apparent  at  a  very  early  stage, — from  the  thirty-fifth 
to  the  forty-second  day, — but  the  humerus  shows  its  first  centre  of  ossification 
(in  the  shaft)  at  the  eighth  or  ninth  week,  the  radius  and  ulna  at  the  third 
month,  the  metacarpal  bones  and  jDhalanges  at  the  end  of  the  third  month. 

These  facts  render  it  quite  evident  that  so  far  as  the  period  of  pregnancy 
is  concerned  there  is  nothing  to  justify  the  conclusion  tliat  the  deformities 
in  question  are  not  due  to  maternal  impressions.  On  the  contrary,  it  will 
be  well  to  reiterate  here  what  has  been  previously  stated,  that  the  connection 
is  rendered  more  probable  by  the  fact  that  the  observers  were  often  not 
aware  of  the  importance  of  the  correspondence  between  the  period  of  preg- 
nancy and  the  time  of  the  impression,  and  hence  were  not  biassed  by  this 
circumstance  at  least  in  arriving  at  the  conclusions  at  which  they  did. 

It  is  well  enough  to  state  here,  what  might  with  propriety  have  been 
stated  earlier,  that  there  may  be  an  excess  as  well  as  an  arrest  of  develop- 
ment.    Supernumerary  fingers  furnish  an  illustration  of  the  former. 


1  Obst.  Jour,  of  Great  Britain,  vol.  ii.  p.  737. 


MATERNAL   IMPRESSIONS. 
DEFECTS  OF  THE   LOWER   EXTREMITIES. 


207 


Case. 

Pekiod  of  Pregnancy. 

Nature  of  Defect. 

I.      .    . 
II.      .    . 

III.  .    !- 

IV.  .    . 
V.      .    . 

VI.     .    . 

VII.     .    . 

VIII.     .    . 

3  months. 

Before  and  dui'ing  pregnancy. 

Not  stated. 

Not  stated. 

Not  stated. 

7  weeks. 

Commencement. 

Paternal  impression  ? 

Big  toe  missing. 

One  leg  shoiter  than  the  other. 

Both  legs  absent. 

Leg  absent  from  middle  of  thigh. 

One  leg,  from  knee  down,  absent.                  | 

Fibrous  cord  uniting  feet. 

One  foot  absent. 

Both  legs  missing  from  middle  of  thighs. 

The  same  remarks  are  applicable  to  defects  of  the  lower  extremities  as  to 
defects  of  the  upper. 

Of  the  eight  cases  in  the  table  it  is  possible — from  the  entire  absence  of 
rudimentary  parts — that  the  defect  in  all  except  one  (Case  II.)  is  attributable 
to  an  amputation  of  the  member  by  the  cord  or  by  bands. 

In  Case  II.  one  leg  was  much  shorter  than  the  other,  a  common  enough 
defect  in  a  slight  degree,  but  the  singular  features  of  this  case  were  that  in 
addition  to  this  shortness  of  one  leg  the  child  had  one  blue  and  one  brown 
eye,  precisely  similar  peculiarities  to  those  of  the  lady  by  whom  its  mother 
had  been  so  much  impressed. 

In  three  of  the  cases  the  period  of  pregnancy  when  the  impression  was 
made  is  not  mentioned,  but  in  all  the  others  it  was  early,  only  one  being  as 
late  as  three  months.  One  of  these  cases  is  most  remarkable,  and  suggests, 
what  reflection  will  show  is  not  so  improbable  as  would  appear  at  first  sight, 
that  the  impression  was  made  upon  the  father  and  by  him  communicated  to 
the  child  through  the  spermatozoa.  It  is  equally  probable,  however,  that  the 
second  wife  dwelt  upon  the  tragic  end  of  her  predecessor,  and  that  the  impres- 
sion was  made  in  this  way.  (See  Case  LXXXIV.  of  the  General  Table.) 
■  The  period  of  development  of  the  lower  limbs  is  nearly  the  same  as  that 
of  the  upper,  and  requires  no  comment. 

DEFECTS   OF  THE   EARS. 


Case. 

Period  of  Pregnancy. 

Nature  of  Defect. 

T 

II 

Not  stated. 

Holes  in  the  lobules  of  the  ears. 

Ear  like  an  opossum. 

Ear  like  a  jackass. 

One  ear  absent. 

Part  of  one  ear  absent. 

III 

IV 

V 

VI 

2  or  3  months. 
2  months. 
Not  stated. 

VII 

VIII 

4  months. 
Early  period. 

One  ear  absent. 

Holes  in  the  lobules  of  the  eaiN. 

It  will  be  observed  that  in  tv-n  of  the  eight  cases  of  defect  of  the  ears  the 
period  of  pregnancy  at  which  the  im})ression  was  made  is  not  stated ;  in  one 
it  was  at  three  or  four  months  ;  in  one,  four  months ;  in  one  it  was  stated  to 
have  been  at  an  early  period,  and  in  the  other  three  it  was  three  months  or 
less.     In  two  in.stances  in  which  tlie  cars  were  like  those  of  tlic  animal 


208  MATEENAL    IMPRESSIONS. 

causing  the  impression,  the  period  of  pregnancy  was  three  months  in  one 
and  two  or  three  months  in  the  other.  Of  two  cases  in  which  there  were 
holes  in  the  ears,  the  period  is  not  stated  in  one,  and  in  the  other  it  is  said 
to  have  been  early  in  pregnancy.  In  all  the  other  cases,  four  in  number, 
the  ears  were  absent  in  whole  or  in  part.  ^ 

Embryology  teaches  that,  as  a  rule,  the  outer  ear  appears  as  a  low  pro- 
jection at  the  seventh  week,  and  at  the  third  month  the  external  ear  is 
usually  well  formed.  It  is  evident,  therefore,  that  if  the  impression  in 
these  cases  was  effective  at  all,  it  must  have  been  in  the  stage  when  the  ears 
were  just  forming  or  had  just  formed,  when  they  were  in  such  a  soft  and 
plastic  state  that  any  interference  with  their  further  development  would  lead 
to  their  atrophy  and  disappearance. 

The  possibility  of  the  removal  of  the  ears  by  intra-uterine  amputation 
must  be  exceedingly  remote ;  for  their  close  approximation  to  the  head  of 
the  fcetus  would  render  their  inclusion  in  bands  or  in  a  loop  of  the  cord 
well-nigh  impossible. 

Of  the  two  cases  in  which  there  were  holes  in  the  lobules  of  the  ear  at 
birth,  the  period  of  pregnancy  at  which  the  impression  was  made  was  not 
stated  in  one,  and  in  the  other  it  was  merely  stated  to  have  been  early.  How 
these  holes  were  produced  it  is  impossible  to  understand. 

DEFECTS   OF   THE    EYES. 


Case. 

Period  of  Pregnancy. 

Nature  of  Defect. 

I 

II 

Ill 

IV.    .... 

Before  and  during  pregnancy. 

3  or  4  months. 

4  months. 
2  months. 

One  hlue  and  one  dark  eye. 

Right  eye  absent. 

Eyes  large  and  round  "  like  a  sheep's." 

Eyes  very  large. 

There  were,  it  will  be  noticed,  but  few  cases  in  which  there  was  any  defect 
of  the  eyes.  Two  of  the  four  cases,  however,  are  very  striking  when  taken 
in  connection  with  the  other  defects  which  were  present  in  the  same  cases,  and 
compared  with  the  objects  giving  rise  to  the  impression  in  each  instance. 

Case  I.  has  already  been  described  sufficiently  in  detail  when  speaking 
of  defects  of  the  lower  extremities. 

It  is  worthy  of  note  with  respect  to  Case  II.  that  the  child  was  not  a 
Cyclops,  for  the  left  eye  was  well  developed,  and  the  orbit  of  the  right  was 
indicated  by  a  slight  depression. 

Case  III.  was  probably  one  of  intra-uterine  hydrocephalus,  for,  in 
addition  to  the  "  very  large  eyes,"  the  head  was  large,  but  the  bones  were 
absent  for  about  two  inches  all  around.. 

So  far  as  defects  of  development  are  concerned,  none  of  the  four  eye- 
cases  are  of  especial  interest ;  in  two  the  eyes  were  large  and  round,  but  a 
peculiarity  of  this  character  taken  by  itself  would  have  no  significance. 

In  one  (Case  II.)  there  was  a  very  evident  and  singular  defect  of  devel- 
opment.    The  impression  was  made  during  the  first  three  or  four  months, 


MATERNAL    IMPRESSIONS. 


209 


wlieu  the  woman  was  attempting  to  rear  b}'  hand  a  calf  which  presented 
defects  siugidarly  like  those  which  her  child  presented  at  its  birth  some 
months  afterwards.  There  is  nothing  in  the  period  of  pregnancy  at  which 
the  impression  was  made  in  this  case  which  militates  against  the  view  that 
the  defect  was  due  to  the  impression. 

DEFECTS   OF   THE   HEAD,    NECK,    AND   TKUNK. 


Case. 

Period  op  Pregnancy. 

Nature  of  Defect. 

I. 

2  months. 

No  nock. 

II. 

5  or  6  months. 

Facial  paralysis. 

III. 

5  or  6  months. 

Facial  paralysis. 

IV. 

2  or  3  months. 

Head  like  a  jackass. 

V. 

Early  period. 

Large  nsevus  between  the  eyes. 

1 

YI. 

Earljr  period. 

Large  nasvus  on  the  buttock. 

VII. 

4  months. 

Long  head  (with  black  wool). 

VIII. 

3  months. 

Face  like  a  monkey's. 

IX. 

2  months. 

Immense  head  ;  bones  wanting  for  space  of  two 
above  eyebrows  and  ears. 

inches 

X. 

First  3  months. 

No  neck  ;  no  face ;  long  snout  like  a  rat. 

XI. 

2  months. 

Spina  bifida. 

XII. 

1  month. 

Hydrocephalus. 

XIII. 

17  weeks. 

Four  mammae. 

XIV. 

Commencement. 

Children  united  from  neck  to  hips  in  front. 

XV. 

Commencement. 

Children  united  from  neck  to  hips  in  front. 

XVI. 

2  or  3  months. 

Large  and  protruding  tongue. 

XVII. 

3  months. 

Anterior  abdominal  wall  a  thin  film. 

XVIII. 

2  months. 

Like  the  "  frog-faced  woman." 

XIX. 

4  weeks. 

Hermaiahrodite. 

XX. 

2  or  3  months. 

Cystic  tumor  of  the  neck. 

For  the  sake  of  convenience,  the  head,  neck,  and  trunk  have  been 
grouped  together,  though  they  include  organs  which  are  developed  at 
different  stages  of  intra-uterine  life.  Of  the  twenty  cases,  there  was  facial 
paralysis  in  two,  the  period  of  pregnancy  being  the  same  in  each.  The 
cases  are  exceedingly  striking  ones :  two  women  at  about  the  same  period 
of  pregnancy  were  assisting  their  mother,  who  was  an  invalid,  to  the  night- 
stool,  when  she  was  suddenly  paralyzed  on  one  side ;  the  daughters  were  of 
course  greatly  shocked,  and  at  full  term  each  gave  birth  to  a  child  with 
facial  paralysis.  In  another  case  (VII.)  the  child  was  born  with  a  long 
head  and  black  wool ;  the  period  of  pregnancy  at  which  the  impression  was 
made  in  this  in.stance  was  four  months.  In  yet  another  case  (XIII.)  the 
child  was  born  with  four  mamma? ;  the  impression  in  this  case  was  made  at 
the  seventeenth  week.  In  all  the  other  cases  the  imj)rcssion  was  made 
at  an  early  period  of  pregnancy ;  in  fourteen  of  them  certainly  it  was  not 
later  than  three  months ;  in  the  other  two  the  reporters  merely  state  that  it 
was  at  an  early  period.  It  is  unnecessary  to  study  in  detail  the  develop- 
ment of  the  foetus  in  the  class  of  cases  now  under  consideration  ;  it  is  suffi- 
cient to  observe  that  in  every  instance,  except  the  four  mentioned  above, 
the  period  of  pregnancy  at  which  the  impression  was  made  was  early, 
when  the  embryo  was  in  a  plastic  state  and  when  the  different  organs  and 
parts  of  the  body  were  as  yet  undeveloped.  It  is  especially  to  be  remarked, 
Vol.  T.— 14 


210 


MATERNAL    IMPRESSIONS. 


furthermore,  that  in  three  at  least  of  the  other  four  cases^  if  not  in  all  of 
them,  the  defects  were  of  such  a  character  as  might  very  probably  occur  at  a 
late  stage  of  pregnancy.  The  case  which  seems  most  doubtful  in  this  respect 
was  the  one  of  supernumerary  mammae  :  the  impression  here  was  definitely 
fixed  at  the  seventeenth  week ;  "  the  development  of  the  human  mamma 
begins  in  both  sexes  during  the  third  month ;  at  the  fourth  and  fifth  months 
a  few  simple  tubular  glands  are  arranged  radially  around  the  position  of  the 
future  nipple,  which  is  devoid  of  hair"  (Landois).  It  may  be  well  to  call 
attention  here  to  a  fact  in  connection  with  the  case  that  has  just  been  men- 
tioned (LXXIV.  of  the  General  Table)  which  is  worthy  of  consideration. 
The  mother  in  this  instance  was  subjected  to  two  impressions,  one  at  the  sev- 
enteenth week  and  one  at  the  twentieth,  and  each  is  supposed  to  have  caused 
a  foetal  defect. 

DEFECTS   OF   THE   SKIN  AND   HAIR. 


Case. 

Peeiod  of  Pregnancy. 

Nature  of  Defect. 

I. 

4  months. 

Patch  of  white  hair  on  the  head. 

II. 

45-  months. 

Mark  on  the  forehead. 

III. 

During  whole  of  pregnancy. 

Bald  spot  on  the  head. 

IV. 

Early  period. 

Scars  on  the  thighs. 

V. 

Early  period. 

No  prepuce. 

VI. 

2  months. 

Eed  scar  on  the  face. 

VII. 

4  months. 

Black  wool  on  head,  hack  of  the  neck,  and  arms. 

VIII. 

2  months. 

No  prepuce. 

IX. 

3  months. 

Back  of  neck  and  body  covered  with  hair  one  or 
two  inches  long. 

X. 

20  weeks. 

Scar  on  the  head. 

XI. 

Last  few  days  of  pregnancy. 

Blebs  on  the  hands. 

XII. 

8  months. 

Thumb-nail  black  and  came  off  soon  after  birth. 

XIII. 

Few  weeks. 

Compact  mass  of  hair  extending  back  from  eye- 
brows over  head  and  neck. 

XIV. 

Not  stated. 

Bald  patch  on  the  head. 

XV. 

8|  months. 

Large  blebs  on  body  and  limbs. 

Of  the  fifteen  cases  of  defect  of  the  skin  and  hair,  nine  were  of  the 
former  and  six  of  the  latter.  I  have  placed  them  together  because  the  his- 
tory of  embryonic  development  would  lead  us  to  infer  that  these  defects 
would  occur  from  impressions  made  at  a  later  date  than  those  which  we 
have  considered  heretofore.  An  examination  of  the  table  will  show  that 
this  is  the  case.  In  seven  of  the  fifteen  cases  it  is  distinctly  stated  that  the 
impression  was  made  after  the  fourth  month  of  pregnancy,  in  one  it  con- 
tinued during  the  whole  of  pregnancy,  and  in  another  the  time  is  not  stated. 
In  the  other  six  cases  the  impression  was  made  at  an  early  period.  In 
two  cases  the  impression  was  made  during  the  last  few  days  of  pregnancy, 
and  in  each  instance  it  was  similar  in  character.  In  one  (Case  XI.)  a 
woman  during  "the  last  few  days"  of  her  pregnancy  received  several 
burns  upon  her  hand  :  her  child  was  born  with  blebs,  full  and  rounded  and 
fresh-looking,  at  the  corresponding  parts  of  one  of  its  hands.  In  the 
other  (Case  XV.) — one  of  the  most  remarkable  cases  on  record — a  woman 
was  severely  burnt  upon  her  body  and  limbs.     She  was  taken  to  the  Penn- 


MATEEXAL   IMPRESSIONS.  211 

sylvania  Hospital,  and  thirty-six  hours  after  her  admission  she  was  deliv- 
ered of  a  child  upon  Avhose  body  and  limbs  were  full  and  fresh-looking 
blebs  corresponding'  almost  exactly  in  situation  to  those  on  the  mother. 

With  respect  to  scars  and  marks  upon  the  skin,  it  is  impossible  to  form 
any  definite  opinion  as  to  their  mode  of  production.  Suffice  it  to  say  that 
they  are  almost  certainly  produced  by  some  disturbance  of  the  circulation, 
and  that  this  disturbance  may  and  most  probably  does  occur  usually  com- 
paratively late  in  the  pregnant  state,  and  may  induce  quite  rapidly  the 
changes  that  are  observed  at  birth.  This  view  is  rendered  highly  ^^robable, 
furthermore,  by  Case  XII.  in  the  table  of  defects  of  the  skin  and  hair.  A 
lady  eight  months  pregnant  was  greatly  shocked  by  seeing  her  little  boy 
brought  in  with  one  of  his  thumbs  severely  crushed ;  there  was  an  extrava- 
sation of  blood  under  the  nail,  and  it  soon  became  black :  her  child  was 
born  soon  afterwards,  and  the  corresponding  thumb-nail  on  its  hand  w^as 
black,  and  finally  came  off  on  the  same  day  with  that  of  its  elder  brother. 
In  each  of  these  cases  the  disturbance  leading  to  the  "  mark"  was  clearly 
of  an  inflammatory  character. 

In  those  cases  in  which  there  was  some  defect  in  connection  Avith  the 
development  of  the  hair  it  is  to  be  observed  that  in  three  of  the  six  cases 
the  period  of  pregnancy  was  four  mouths  or  over,  in  one  it  was  three 
months,  in  one  it  was  a  few  weeks,  in  one  it  is  not  stated.  jN^ow,  "  the  hair 
appears  upon  the  forehead  at  the  nineteenth  week ;  at  the  twenty-third  to 
twenty-fifth  week  the  lanugo  hairs  appear  free"  (Landois). 

In  order  to  determine  the  relationship  which  existed  between  the  time 
of  the  impression  and  the  stage  of  development,  it  was  necessary  to  divide 
the  cases  into  different  classes ;  but  this  will  be  unnecessary  in  investigating 
the  other  points  of  interest,  and  we  will  return  to  a  consideration  of  the 
General  Table. 

In  what  proportion  of  cases  is  the  defect  in  the  child  similar  to  the  object 
causing  the  impression  upon  the  mother  f 

It  has  been  urged  as  one  of  the  objections  to  the  doctrine  of  "  ]Maternal 
Impressions"  that  the  defect  in  the  child  does  not  usually  correspond  with 
the  object  producing  the  impression, — indeed,  that  it  but  seldom  does  so. 

An  examination  of  the  General  Table  will  show,  however,  quite  a  close 
correspondence  in  69  of  the  90  cases  which  I  have  collected.  In  some  of 
these  cases,  indeed,  the  correspondence  was  exceedingly  close, — for  example, 
in  Hunt's  case  of  extensive  burns  (No.  XC),  and  also  in  Wilson's  case 
(Xo.  LXXVII.),  in  which  there  were  blebs  corresponding  in  situation  to 
the  burns  on  the  mother's  hand.  Also  in  the  remarkable  case  reported  by 
Purefoy  (Xo.  XXXVII.)  the  correspondence  was  most  striking.  So  close, 
indeed,  is  the  correspondence  in  all  of  these  69  cases  that  any  argument 
against  maternal  impressions  based  on  a  want  of  correspondence  between 
the  impression  and  the  defect  would  seem  to  be  worthless. 

The  strength  of  the  argument  in  favor  of  maternal  impressions  drawn  from 
a  similarity  between  the  object  causing  the  impression  and  the  nature  of  the 


212  MATERNAL,   IMPEESSIONS. 

defect  is  greatly  increased  by  the  circumstance  that  in  some  cases  there  were 
several  different  defects  in  the  child,  corresponding  closely  with  a  number 
of  different  defects  in  the  object  causing  the  impression.  For  example,  in 
Case  XXXVII.  the  calf  which  produced  the  impression  had  no  right  ear, 
the  child  had  no  right  ear ;  the  calf  had  no  right  eye,  nor  had  the  child ; 
both  of  the  calf's  forelegs  were  missing,  the  arm  and  forearm  of  the  child 
on  the  right  side  were  missing,  but  there  was  an  abortive  hand  attached  to 
the  scapula.  It  may  be  objected  on  teratological  grounds  that  in  these  cases 
there  was  merely  a  defect  of  development  of  one  side  ;  but  such  defects,  to 
this  extent  at  least,  are  most  uncommon,  and  the  similarity  is  such  that  its 
being  a  mere  coincidence  is  inconceivable  to  my  mind.  So  in  the  case  of 
Hunt  and  in  that  of  Wilson  there  was  not  (in  each  of  them)  a  single  mark 
corresponding  to  a  like  mark  on  the  object  causing  the  impression,  but  a 
number  of  separate  and  distinct  marks  alike  in  character,  but  on  different 
parts  of  the  body, — each  of  which,  however,  corresponded  in  situation  to  an 
injury  on  the  mother's  body.  Also  in  a  case  reported  by  Mr.  Ashburton 
Thompson  (No.  LXXI V.)  there  were  two  separate  and  distinct  impressions, 
followed  by  two  separate  and  distinct  defects  in  the  child. 

Is  it  necessary  for  the  mother  to  be  conscious  of  an  impression  and  to 
EXPECT  a  defect,  for  such  a  result  to  ensue  f 

It  is  a  singular  fact,  about  which  there  can  be,  I  think,  no  doubt,  that  it 
is  not  necessary  for  a  mother  to  expect  a  defect  in  the  child  for  such  a  defect 
to  occur,  whether  this  defect  be  mental  or  bodily.  For  example,  in  the  case 
reported  by  Purefoy  the  woman  does  not  seem  to  have  expected  that  her 
child  would  present  defects  similar  to  those  of  the  calf  which  she  attempted 
to  rear  by  hand,  and  which  was,  of  course,  so  often  before  her  eyes  and  in 
her  thoughts. 

There  was  no  expectation  of  a  defect,  indeed,  in  Swift's  case  (Xo. 
LXXVIII.),  in  which  the  mother  saw  her  little  boy  with  his  thumb  in- 
jured and  the  child  was  born  with  the  corresponding  thumb  affected.  In 
Case  XC,  also,  it  is  impossible  that  the  woman  could  have  given  any 
thought  to  the  probable  influence  of  her  own  injuries  upon  the  bodily  for- 
mation of  her  child,  for  her  sufferings  were,  of  course,  intense,  and  death  was 
staring  her  in  the  face.  The  cases  might  be  multiplied  in  which  there  seems 
to  be  an  undoubted  connection  between  the  impression  and  the  defect,  but 
in  which  the  mother  was  either  entirely  unconscious  of  any  impression  at 
all,  or  at  any  rate  had  no  thought  that  it  would  influence  the  child  which 
she  was  carrying  in  her  womb. 

Of  what  value  is  a  statement  made  by  the  mother,  before  the  child  is  born, 
as  to  the  impression,  and  ilie  character  of  the  defect  which  she  anticipates  f 

In  not  a  few  instances  the  mother  has  stated  before  the  birth  of  the  child 
Avhat  the  impression  was,  and  what  she  believed  would  be  the  nature  of  the 
defect  in  the  child.  For  example,  in  Daly's  case  (Xo.  XLIV.)  a  woman 
during  the  first  three  months  of  her  pregnancy  lived  in  a  house  which  was 
infested  Avith  rats ;  she  was  greatly  annoyed  by  them,  and  at  the  birth  of 


MATERXAL    IMPRESSIONS.  213 

the  cliikl,  before  she  knew  of  any  defect,  she  asked  if  it  was  like  a  rat :  the 
child  had  no  neck,  and  no  face,  but  a  long  snout  projecting  from  between 
the  shoulders  and  in  a  line  with  the  body.  In  two  cases  also  (XX.  and 
XXIII.),  where  the  impression  was  due  to  a  dream,  the  nature  of  the  im- 
pression was  clearly  and  distinctly  stated  months  before  the  birth  of  the 
child,  and  in  each  instance  the  defect  corresponded  thereto  in  a  most  remark- 
able manner.  Evidence  of  this  sort,  however,  should  be  very  carefully 
weighed  before  acceptance,  unless  the  defect  corrresponds  very  closely  with 
the  impression,  for  it  is  a  notorious  fact  that  many  women  expect  defects  in 
their  children,  and  often  have  very  definite  conceptions  as  to  what  those 
defects  will  be,  and  yet  at  birth  the  children  are  normally  developed  in  all 
respects  and  are  free  from  any  "  marks"  whatsoever. 

Through  whcd  channels  are  impresdoivs  made  upon  the  mother  f 

The  channel  through  which  impressions  are  usually  received  by  the 
mother  is  that  of  sight ;  but  it  is  difficult  to  say  how  much  is  due  to  the 
simple  sight  of  the  object,  and  how  much  to  the  emotional  disturbance 
caused  by  viewing  it.  It  is  probable  that  the  latter  is  really  the  effective 
cause,  for  in  some  instances  the  impression  has  been  caused  in  other  ways 
and  yet  the  result  has  been  the  same.  For  example,  in  three  cases  (IV., 
XX.,  and  XXXIII.)  the  impression  was  caused  by  a  dream ;  in  another 
(XLVI.)  a  woman  was  greatly  excited  because  her  husband — a  physician 
— was  invited  to  assist  at  the  circumcision  of  a  neighboi-'s  child.  In  still 
another  case  (LXXXI.)  a  woman  had  her  hand  violently  pressed  by  her 
husband's  elbow,  the  pain  being  so  great  that  she  finally  fainted.  In  this 
case,  and  in  at  least  two  others, — those  of  Hunt  and  Wilson  (XC.  and 
LXXVII.), — the  impression  ^vas  evidently  caused  by  violent  pain. 

What  duration  of  the  impression  is  necessary  in  order  to  produce  a  resulf  ? 
'  There  seems  to  be  no  definite  rule  on  this  point,  nor  is  it  by  any  means 
easy  to  arrive  at  a  conclusion  with  regard  to  it. 

In  Case  XC.  the  period  of  time  which  elapsed  between  the  "  impression" 
and  the  "  effect"  could  not  have  been  more  than  twenty  hours,  for  the  woman 
^vas  delivered  of  the  child  about  thirty-six  hours  afler  her  injuries  Avere 
received,  and  the  foetal  heart-sounds  had  become  inaudible  some  hours  before. 

In  a  number  of  cases  the  shock  was  sudden,  but  the  mental  impression 
resulting  therefrom  was  far  more  enduring,  and  it  is  impossible  to  sjiy 
whether  the  defect  would  have  resulted  if  there  had  been  nothing  to  induce 
it  but  the  sudden  and  fleeting  shock.  Th(>re  seems  to  be  a  general  impres- 
sion among  writers  on  the  subject  that  the  impression  is  more  likely  to  pro- 
duce an  effect  if  it  is  of  considerable  duration ;  but  Case  XC.  shows  that 
this  is  not  invariably  true.  In  a  case  reported  by  Bolton  (XI  I.),  in  which 
an  opossum  was  thrown  into  the  lap  of  a  young  woman  three  months 
pregnant,  it  is  distinctly  stated  that,  while  she  was  startled  at  the  time, 
the  circumstance  was  .soon  forgotten. 

It  is  probal)le  that  either  a  sudden  and  violent  impression  or  one  whidi  is 
slighter  in  degree  but  operative  for  a  longer  time  may  produce  a  similar  effect. 


214  MATERIS'AL    IMPRESSIOJs^S. 

Jlliat  character  of  impressions  is  most  liable  to  produce  defects  f 

In  the  .vast  majority  of  cases  the  impression  is  due  to  some  emotional 
disturbance,  and  in  nearly  all  the  cases  included  in  the  table  the  emotion  was 
of  an  unpleasant  character.  Fright  and  the  mental  impressions  resulting 
therefrom  would  seem  to  be  by  far  the  most  common  of  all  causes.  Physi- 
cal suffering  must  have  been  the  cause  in  two  cases  (XC.  and  LXXVII.). 
It  was  pity,  doubtless,  that  led  the  woman  to  attempt  to  rear  a  deformed 
calf  by  hand,  and  it  is  probable  that  this  was  the  emotion  that  led  to  the 
defects  in  the  child  in  this  case  (XXXVII.).  In  a  few  instances  the  emo- 
tion was  of  an  agreeable  character :  for  example,  a  lady  was  in  the  habit 
during  her  pregnancy  of  looking  at  the  bald  head  of  her  father-in-law  with 
"  unaccountable  delight :"  her  child  was  born  with  a  bald  patch  on  its  head 
(Case  XXIX.).  In  the  case  (XIII.)  of  the  lady  whose  child  was  born 
with  one  leg  shorter  than  the  other  and  with  a  difference  in  the  color  of  the 
two  eyes,  the  emotion  causing  the  impression  was  one  of  great  affection. 

It  is  singular,  in  view  of  the  frequency  with  which  defects  are  attributed 
by  the  general  public  to  "  maternal  longings"  for  certain  articles  of  diet, 
that  so  few  cases  of  this  character  should  have  been  rej)orted  by  physicians ; 
and  I  have  been  able  to  find  none  which  it  seemed  proper  to  include  in  the 
table.  There  would  seem  to  be  no  good  reason,  however,  why  a  strong  im- 
pression should  not  be  produced  in  this  way.  A  friend  of  mine  has  told 
me  that  during  one  of  his  wife's  pregnancies  her  craving  for  oysters  was 
such  that  she  was  "  moved  to  tears"  when  she  found  they  could  not  be  had ; 
and  when  the  child  was  born  there  was  a  mark  upon  its  foot  which  to  the 
eyes  of  the  father  and  mother  was  precisely  like  an  oyster.  I  have  never 
seen  the  child  myself,  and  mention  the  case  here  only  to  show  how  strong 
such  "  cravings"  may  be,  even  in  the  case  of  sensible  women,  to  which  class 
this  lady  belongs. 

Before  bringing  this  chapter  to  a  close,  it  may  be  well  to  consider  very 
briefly  the  objections  which  have  been  urged  to  the  doctrine  of  "  Maternal 
Impressions."     They  are  as  follows  : 

1.  Abnormalities  may  occur  Math  out  fright. 

2.  Deformities  generally  occur  before  pregnancy  is  certain  or  before  the 
mother  is  conscious  that  she  is  pregnant. 

There  can  be  no  question  of  the  truth  of  both  of  these  propositions. 
We  have  already  seen  that  in  a  considerable  number  of  cases,  where  the 
similarity  between  the  object  causing  the  impression  and  the  defect  in  the 
child  was  most  striking,  there  had  been  no  conscious  impression  made  upon 
the  mother.  But,  aside  from  this,'  all  that  the  most  ardent  advocates  of 
maternal  impressions  claim  is  that  they  are  one  of  the  causes  of  defects  or 
deformities,  but  by  no  means  the  only  cause. 

3.  Abnormalities  may  occur  in  animals. 

This  is  not  a  valid  objection,  for  animals  possess  emotions  as  well  as 
mankind  :  what  boy  has  not  seen  a  cur  dog  with  a  tin  pan  tied  to  his  tail 
exhibit  the  most  abject  terror  ?     Nor  are  instances  wanting  in  which  abnor- 


MATERNAL    IMPRESSIOXS.  215 

malities  in  animals  appeared  to  be  due  to  maternal  impressions.  Furmau 
has  reported  ^  one  in  point  occurring  in  Henderson,  Kentucky  :  there  passed 
through  the  town  a  menagerie  with  which  was  an  elephant ;  a  sow  pregnant 
a  short  time  saw  this  elephant,  and  one  of  her  pigs  born  some  time  after- 
wards had  skin,  ears,  and  trunk  similar  to  those  of  an  elephant.  He  states 
that  a  similar  case  had  occurred  in  Shawneetown,  Illinois.  Xow,  unless  we 
deny  the  facts,  the  conviction  that  the  relationship  in  these  cases  is  that  of 
cause  and  effect  seems  almost  irresistible. 

4.  Several  children  of  the  same  parents  often  present  bodily  abnor- 
malities. 

In  a  number  of  cases  of  deformity  heredity  has  been  the  cause,  and  the 
deformity  may  differ  somewhat  from  that  of  the  parent.  For  instance,  ]\Ir. 
Lucas  reported  to  the  Clinical  Society  of  London  in  1887  three  cases  in 
which  the  absence  of  one  upper  lateral  incisor  tooth  in  the  parent  was 
followed  by  hare-lip  in  the  child,  and  at  a  meeting  of  the  same  Society  on 
April  1,  1887,  a  case  was  shown  by  Mr.  Parker  and  Dr.  Robinson  in  which 
the  two  inner  toes  were  united  and  the  three  outer  similarly  united;  the 
child's  grandmother  had  a  similar  defect,  and  sixteen  of  this  old  woman's 
descendants  were  deformed  in  precisely  the  same  way. 

The  late  Dr.  AY.  T.  Taylor,  of  Philadelphia,  reported^  a  very  curious 
case  which  had  been  related  to.  him  by  Dr.  Garretson,  in  which  a  lady  gave 
birth  to  five  children  in  succession,  each  of  whom  had  cleft  palate.  .In  the 
first  instance  the  defect  was  attributed  to  a  maternal  impression ;  and,  as  the 
defect  was  slighter  in  each  child  than  in  the  preceding  one,  Garretson  sup- 
poses that  the  impression  was  gradually  effaced.  This  view  of  an  "  over- 
lapping" impression — if  I  may  use  such  a  word — is  at  least  a  plausible  one. 

The  objection  that  deformities  are  due  to  defects  of  development  has 
already  been  considered. 

Why  in  the  case  of  twins  one  should  be  deformed  and  the  other  not,  in 
cases  of  supposed  maternal  impressions,  is  unknown ;  and  it  is  useless  to 
speculate  on  the  subject  just  now. 

The  fact  that  fright  and  emotional  disturbances  of  other  kinds  are  com- 
mon in  pregnant  women,  and  deformities  comparatively  rare,  is  not  a  just 
ground  for  unbelief  in  the  power  of  maternal  impressions.  It  would  be  as 
unreasonable  to  say  that  scarlet  fever  is  never  conveyed  by  milk,  because 
but  few  cases  of  the  kind  have  been  reported,  as  to  say  that  maternal  im- 
pressions never  cause  deformities,  because  such  a  connection  can  rarely  be 
established.  Thcfaet  that  scarlet  fever  is  sometimes  conveyed  in  milk  was 
well  established  long  before  the  nature  of  the  disease  was  definitely  under- 
stood, and  it  was  not  rejected  because  no  explanation  could  be  given  of  the 
manner  in  which  it  Avas  brouglit  about ;  nor  should  the  fact  that  maternal 
impressions  sometimes  produce  deformities  be  rejected  because  we  cannot 
understand  how  they  act. 

1  St.  Louis  M.  and  .S.  .Jour.,  Mav  5,  1880.  «  Phila.  Med.  Times,  Nov.  2-3,  1876. 


216  MATEEXAL   IMPEESSIOXS. 

There  remains,  finally,  the  practical  part  of  this  whole  subject  yet  to  be 
considered.  Is  it  advisable  that  a  woman  should  be  guarded  from  strong 
emotional  disturbances  of  every  kind  during  her  pregnancy,  for  fear  of  the 
effect  upon  her  unborn  child  ?  AYith  the  light  before  us,  there  can,  I  think, 
be  but  one  answer  to  this  question.  Few  as  are  the  instances,  relativ(^ly 
speaking,  in  which  deformities  are  traceable  to  maternal  impressions,  they 
are  yet  sufficiently  numerous,  and  sufficiently  distressing  when  they  occur, 
to  necessitate  care  on  the  part  of  every  pregnant  woman ;  and  I  cannot  but 
think  that  it  is  the  duty  of  ever}^  physician  to  warn  his  pregnant  patients 
of  the  necessity  for  avoiding  powerful  emotions  of  every  kind,  and  especially 
those  which  are  of  a  distressing  character. 

With  the  facts  before  us,  the  following  conclusions  with  respect  to 
"  Maternal  Impressions"  seem  to  me  to  be  warranted  : 

1.  Impressions  made  upon  a  pregnant  woman  are  capable  of  causing 
mental  and  bodily  defects  in  her  child. 

2.  jSTeither  mental  nor  bodily  defects  are  ofien  (comparatively  speaking) 
attributable  to  maternal  impressions. 

3.  The  defects  attributable  to  mental  impressions  may  be  either  errors 
of  development  or  "marks"  which  are  apparently  due  to  circulatory  or  in- 
flammatory disturbances. 

4.  The  defects  due  to  errors  of  development  have,  as  a  rule,  been  at- 
tributed to  impressions  made  at  a  period  of  pregnancy  when  such  errors  of 
development  are  known  to  occur. 

5.  The  other  defects  (marks,  etc.)  have,  as  a  rule,  been  attributed  to 
impressions  made  at  a  later  stage  of  pregnancy,  when  circulatory  and 
inflammatorv  disturbances  would  be  most  reasonably  expected. 

6.  In  a  veiw  large  proportion  of  the  cases  there  is  a  striking  similarity 
between  the  object  causing  the  impression  and  the  defect  in  the  child. 

7.  It  is  not  necessaiy  for  the  woman  to  be  conscious  of  the  impression, 
or  to  expect  a  defect,  for  such  a  defect  to  occur, 

8.  In  a  very  considerable  proportion  of  cases  the  woman  has  stated  the 
nature  of  the  impression  and  of  the  anticipatal  defect  before  the  birth  of 
the  child. 

9.  The  impressions  are  genemlly  due  to  emotional  disturbances  which 
are  nearly  always  of  an  unpleasant  character,  but  physical  paiu  is  capable 
of  producing  impressions  which  may  induce  defects. 

10.  An  impression  of  considerable  violence  may  produce  an  impression 
in  a  short  time, — even  a  few  hours, — but,  as  a  general  rule,  the  duration  is 
probably  much  longer  than  this. 

11.  Maternal  impressions  are  capable  of  producing  defects  in  the  lower 
animals. 

12.  Defects  traceable  to  maternal  impressions  are  sufficiently  numerous 
and  sufficiently  serious  in  character  to  necessitate  the  avoidance  by  any 
pregnant  woman  of  all  violent  emotional  disturbances,  especially  those  of 
an  unpleasant  character. 


DISEASES  OF  THE  FOETUS. 

By  barton   COOKE   HIRST,   M.D. 


In  the  brief  space  assigned  this  article  it  will  be  possible  to  give  only 
a  sketch  of  the  most  important  pathological  conditions  affecting  foetal  life. 

On  account  of  the  nature  of  the  work,  most  attention  will  be  paid  those 
intra-uteriue  diseases  which  more  especially  aifect  the  subsequent  extra- 
uterine existence. 

The  various  conditions  that  unfavorably  influence  the  foetus  in  utero 
will  be  considered  in  the  following  order : 

I.  Diseases  referable  to  maternal  influences. 
II.  Diseases  referable  to  abnormal  conditions  of  the  father. 

III.  Syphilis. 

IV.  Infectious  diseases. 

V.  Non-infectious  diseases. 
VI.  Traumatism. 
VII.  Diseases   of  the   foetal   appendages  which    react   injuriously   or 
fatally  upon  the  foetus  itself. 

Foetal  Diseases  referable  to  Maternal  Influences. — The  catalogue 
of  these  affections  is  a  long  one.  Nervous  disturbances,  high  temperature, 
defective  nutrition,  diseases  of  the  womb  and  of  its  adnexa  and  lining  mem- 
brane, alteration  in  the  blood-pressure,  the  presence  within  the  blood  of 
soluble  poisons,  or  that  subtle  influence  which  we  call  heredity,  may  all  be 
accountable  for  foetal  disease  or  foetal  deatli. 

The  Influence  upon  the  Foetus  of  Nervous  Disturbance  in  the  Mother. — 
No  one  has  demonstrated  a  direct  nervous  connection  between  mother  and 
foetus,  yet  no  one  will  deny  the  remarkable  sympathy  between  the  two. 
Mental  peculiarities,  acquired  perhaps  only  during  pregnancy,  are  not 
rarely  stamped  indelibly  upon  the  foetus.  The  mother  of  Jesse  Pomeroy, 
the  well-known  moral  monstrosity  of  New  England,  took  delight,  while 
carrying  this  child  in  utero,  in  watching  her  husband,  a  butcher,  ply  his 
trade.  The  boy's  irresistible  inclination  to  torture  and  slay  may  well  have 
had  its  origin  in  his  mother's  perverted  taste  during  pregnancy.  But  more 
wonderful  still  is  the  occurrence  of  physical  defects  or  jieculiarities  in  the 
foetus,  photographic  reproductions  of  objects  that  have  produced  a  strong 

217 


218  DISEASES    OF    THE    FCETUS. 

impression  upon  the  mother  during  pregnancy.  I  had  occasion  once  to 
administer  many  hypodermic  injections  to  a  woman  in  the  early  months  of 
gestation,  producing  in  several  instances  small  abscesses  which  left  conspicu- 
ous scars.  The  child  was  born  with  spots  upon  it  identical  in  appearance 
and  situation  with  those  upon  its  mother's  arm.  Still  more  extraordinary 
examples  of  maternal  impressions  have  been  seen  by  others.^  The  fatal 
effect  in  some  instances  upon  the  foetus  of  strong  emotions  in  the  mother 
has  seemed  to  me  explicable  in  the  light  of  recent  discoveries  as  to  the 
formation  of  leukomaines  and  ptomaines :  perhaps  the  powerful  nervous 
disturbance  acts  upon  the  blood  like  an  electric  current  upon  a  chemical 
solution,  altering  its  composition.  It  would  be  difficult  to  explain  by  this 
theory,  however,  cases  of  congenital  idiocy  which  may  be  traced  to  emotions 
of  fear,  anger,  or  disgust  during  pregnancy.  I  have  been  recently  told  of 
a  remarkable  case  of  this  kind.  A  lady  was  obliged  to  pass  the  bridal 
night  with  an  intoxicated  bridegroom ;  conception  occurred,  and  the  child 
became  an  idiot;  three  subsequent  children  were  also  mentally  defective, 
although  there  was  no  taint  of  insanitv  on  either  side  of  the  house.  The 
impression  of  deep  disgust  experienced  at  the  first  conception  exerted  an 
influence  on  the  development  of  the  subsequent  children.  A  great  fright 
during  pregnancy,  if  it  does  not  kill  the  child  outright,  may  much  diminish 
its  mental  capacity.  Down  ^  says  that  he  can  refer  to  a  number  of  cases  of 
feeble-mindedness  which  were  the  outcome  of  the  siege  of  Lucknow,  and 
the  same  author  refers  to  an  incident  of  the  siege  of  Landau  (1793) :  "In 
addition  to  a  violent  cannonading,  the  arsenal  blew  up  with  a  terrific  ex- 
plosion which  few  could  hear  with  unshaken  nerves ;"  of  ninety-two 
children  born  in  that  district  within  a  few  months  afterwards,  eight  became 
idiots.  We  must  frankly  admit  that  an  explanation  of  the  susceptibility 
displayed  by  the  foetus  to  violent  impressions  upon  the  maternal  nervous 
system  is  beyond  our  power ;  we  are  obliged,  notwithstanding,  to  allow  that 
the  fact  is  as  well  established  as  any  in  medicine. 

Tlie  Influence  of  Elevated  Temperature  upon  the  Foetus. — It  used  to  be 
thought  that  fever  of  itself  in  a  pregnant  woman  was  highly  dangerous  to 
the  foetus.  This  idea  was  generally  adopted  after  the  well-known  experi- 
ments of  Runge,^  who  found  that  if  the  body-temperature  of  a  pregnant 
rabbit  was  raised  to  105.8°  F.,  the  young  within  it  died.  Doleris'  in  1883 
pointed  out  a  fault  in  these  experiments ;  the  temperature  was  too  rapidly 
raised :  with  a  gradual  elevation  of  body-heat  to  105°-106°  F.  the  young 
of  pregnant  animals  were  not  at  all  injuriously  affected.     Indeed,,  a  foetus 


1  For  the  best  modern  paper  on  this  subject,  see  Fordyce  Barker,  Trans.  Amer.  Gyn. 
Soc,  vol.  xi.,  1886. 

2  Mental  Affections  of  Childhood  and  Youth,  London,  1887. 

3  Arch.  f.  Gynak.,  1877,  Bd.  xii.  u.  xiii.  Ss.  16,  123. 

*  Comptes-rend.  hebd.  des  Seances  de  la  Societe  de  Biologie,  Nov.  28,  29.  Doleris' 
results  have  been  confirmed  by  Dore,  by  Negri,  and  by  Kunge  himself  in  a  second  set  of 
experiments. 


DISEASES    OF    THE    FCETUS.  219 

has  beeu  known  to  endure  extraordinaiy  heat  without  destruction.  Preyer  ^ 
once  found  a  temperature  of  111.2°  F.  in  the  anus  of  a  young  guinea-pig 
in  utero.  I  have  been  told  by  a  chicken-breeder  that  on  one  occasion  the 
temperature  of  his  incubator  was  found  to  be  115°  F.,  and  yet  only  half  his 
chicks  died  in  consequence.  Usually,  however,  as  Runge  found  in  his  second 
series  of  experiments,  a  maternal  temperature  of  109.5°  F.  must  be  fatal 
to  the  foetus,  even  though  this  heat  be  gradually  produced.  The  practical 
deductions  to  be  drawn  from  these  experiments — and  they  are  in  accord- 
ance with  clinical  experience — are  that  a  sudden  rise  of  temperature  to  106° 
F.  will  probably  kill  the  foetus ;  that  a  gradual  elevation  to  this  point,  on 
the  contrary,  need  not  be  feared ;  and  that  a  temperature  as  high  as  109° 
F.  will,  even  though  gradually  produced,  destroy  foetal  life. 

Defective  Nutrition. — Defective  nutrition  in  the  mother,  with  its  conse- 
quent aneemia,  either  is  fatal  to  the  foetus  in  utero  or  else  is  accountable  for 
the  birth  of  pimy,  wretched  children,  who  die  early  or  drag  through  a  sickly 
childhood.  The  causes  of  the  maternal  malnutrition  are  many  :  among  the 
more  serious  are  chronic  diseases,  as  cancer,  phthisis,  malaria,  nephritis;^ 
chronic  poisoning,  as  by  lead  or  perhaps  tobacco ;  inability  to  retain  food, 
as  in  the  vomiting  of  pregnancy ;  inability  to  obtain  food,  as  during  siege 
and  famine  :  the  "  enfants  du  siege"  of  Paris  were  for  some  time  distin- 
guishable from  the  children  born  before  and  after  them.  The  treatment  of 
foetal  ill  health  from  maternal  ausemia  is  of  course  to  improve  the  mother's 
impoverished  blood :  remove  the  cause  of  the  trouble,  if  possible,  admin- 
ister iron,  and  prescribe  moderate  exercise  in  the  open  air,  with  perhaps 
change  of  climate,  and  the  birth  of  a  vigorous  infant  can  sometimes  be 
secured  which  will  perhaps  contrast  strongly  with  its  predecessors  which 
were  not  treated  in  utero. 

Diseases  of  the  Endometrium,  the  Womb  and  its  Adnexa. — These  need 
only  be  mentioned  here,  for  their  most  frequent  effect  is  the  premature  expul- 
sion of  the  ovum.  I  have  known,  however,  a  great  inflammatoiy  thicken- 
ing of  the  endometrium  to  exist  throughout  pregnancy,  Avith  the  result 
apparently  of  diverting  nutriment  to  itself  which  should  have  gone  to  the 
child,  which  was  born  a  feeble  creature  and  lived  only  a  short  time. 

Alteration  in  the  Maternal  Blood-Pressure. — Runge ^  found  that  sudden 
alterations  of  the  blood-pressure  in  pregnant  animals  were  fatal  to  their 
young.  What  practical  bearing  this  discover}^  may  have  upon  disease  and 
death  of  the  human  foetus  has  not  been  determined. 

Poisons  in  the  Maternal  Blood. — Any  soluble  substance  absorbed  into 
the  maternal  circulation  may  pass  fi'om  mother  to  foetus.*     To  the  presence 

^  Physiologie  des  Embiyo,  Leipsic,  1884. 

"^  E.  Cohn  stated  at  a  meetin'r  of  the  Berlin  Ohstctrical  Society  that  eighty-six  percent, 
of  the  children  from  mothers  with  nephritis  would  be  born  still  or  too  feeble  to  survive  long. 

3  Arch.  f.  Gyniik.,  Bd.  xiii.  S.  488. 

*  Chloroform,  ether,  salicylate  of  sodium,  ben^oate  of  sodium,  atropine,  strychnine,  mor- 
phine, quinine,  corrosive  sublimate,  iodide  of  potassium,  urea,  the  bile  salts,  soluble  salts  of 


220  DISEASES  OF  THE  FOETUS. 

within  the  mother's  blood  of  poisonous  material  may  be  attributed  certain 
cases  of  feebleness  and  ill-development  at  birth.  Paul  ^  observed  one  hun- 
dred and  twenty-three  cases  of  saturnism  in  pregnancy  :  sixty-four  of  these 
ended  in  abortion,  four  in  premature  labor ;  five  children  were  still-born, 
and  of  the  whole  number  only  ten  survived  the  age  of  three  years.  In 
Europe  it  is  claimed  that  tobacco-workers  give  birth  to  feeble  children  ;  here 
this  is  denied.^  For  some  poisons  a  foetus  acquires  remarkable  tolerance. 
Recently  I  administered  large  doses  of  morpliiue  for  a  long  period  to  a  preg- 
nant woman  without  apparently  affecting  the  foetus.  To  the  influences  of 
some  other  substances  the  foetus  in  utero  is  very  sensitive.  For  instance,  the 
bile  salts  seem  to  have  a  most  pernicious  action  upon  foetal  health  and  life.^ 

Heredity. — The  foetus  in  utero  may  acquire  from  its  mother  certain 
tendencies  to  disease  which  may  be  manifested  only  in  after-life:  the  most 
remarkable  example  of  this  is  found  in  the  transmission  of  haemophilia 
through  a  female  to  her  male  offspring.  Another  extraordinary  instance 
of  a  tendency  to  disease  acquired  in  utero,  but  manifested  only  in  adult  life, 
has  recently  been  reported.  A  young  woman  with  a  violent  attack  of  chorea 
in  pregnancy  told  her  physician  that  her  mother  had  been  affected  with  the 
same  disease  while  pregnant  with  herself.  Nothing  is  more  familiar  in 
nature  than  the  transmission  of  mental,  physical,  and  moral  peculiarities 
from  parent  to  child ;  and  this  fact  must  be  taken  into  account  by  all  clini- 
cians. The  question  as  a  whole,  however,  is  too  large  for  consideration 
here,  and  it  must  be  passed  by  with  the  brief  mention  it  has  received. 

Diseases  of  the  Foetus  referable  to  Abnormal  Conditions  of  the 
Father. — It  sometimes  happens  that  the  spermatic  particle,  while  capable 
of  fertilizing  the  ovum,  is  unfit  to  perform  its  sh^re  in  the  work  of  buildiug 
up  a  healthy,  well-developed  foetus.  If  the  father  is  too  young  or  too  old, 
the  subject  of  some  debilitating  disease,  a  victim  of  chronic  poisoning,  or 
a  drunkard,  his  fertilizing  element  may  produce  an  embr}^o  that  will  die 
before  maturity  or  else  be  born  at  term  a  defective,  unsound  infant.  As 
saturnism  in  the  mother  is  disastrous  to  the  foetus,  so  also  a  man  saturated 
with  lead  seems  almost  incapable  of  procreating  healthy  children.  Of 
thirty-nine  pregnancies  in  women  whose  husbands  were  sufferers  from 
chronic  lead-poisoning,  eleven  ended  in  abortion,  there  was  one  still-birth, 
and  only  nine  of  the  children  survived  early  infancy.*  Men  afflicted  witli 
nephritis,^  diabetes,^  phthisis,^  or  cancer''  have  been  found,  in  some  instances, 
unable  to  produce  a  foetus  capable  of  normal  groA^lh,  Avhile  their  widows, 

lead,  and  tobacco  are  some  of  the  substances  that  have  been  known  to  pass  from  the  mater- 
nal into  the  fcetal  blood. 

1  These  de  Paris,  1861. 

"^  Hirst,  Amer.  Syst.  of  Obstetrics. 

3  See  Yalenta,  Oesterreiehische  Jahrb.,  1869,  Bd.  xviii.  S.  163. 

*  Paul,  loc.  cit. 

*  Priestley,  Luraleian  Lectures  on  Intra-uterine  Death,  London,  1887. 
6  D'Outrepont,  Neue  Zeitschr.  f.  Geburts.,  1838,  Bd.  vi.  S.  34. 

^  Jacquemier,  Diet,  encycl.  des  Sci.  iled.,  art.  "  Avortement." 


DISEASES   OF   THE    FCETUS.  221 

subsequently  married,  have  borne  healthy  children.  Drunkenness  in  the 
father  is  not  infrequently  a  cause  of  ill-development  in  the  foetus.  Down  ^ 
has  observed  twelve  cases  of  sporadic  cretinism  in  England,  the  majority 
of  which  could  be  traced  to  drunkenness  in  the  father  at  the  time  of  pro- 
creation. Matthews  Duncan  ^  has  also  called  attention  recently  to  the  evil 
influence  upon  the  foetus  of  intoxication  in  the  parents. 

Syphilis, — This  disease  of  foetal  life  is  put  in  a  separate  section  chiefly 
on  account  of  its  great  importance  and  relative  frequency.^  It  is  separated 
from  the  other  infectious  diseases  because  its  manner  of  invading  the  embryo 
and  foetus  is  peculiar.  If  a  woman  is  syphilitic,  every  ovum  within  the 
ovary  is  diseased,  and  if  fertilized  will  contaminate  the  resulting  embryo. 
On  the  other  hand,  each  fertilizing  element  from  a  man  with  this  disease 
carries  in  itself  the  seed  of  the  disorder  to  infect  the  ovum  which  receives 
it,  although  the  maternal  organism,  as  a  whole,  may  remain  unaffected. 
Again,  if  the  syphilitic  poison  is  introduced  into  the  body  of  a  pregnant 
woman  previously  healthy,  the  disease  may  be  transmitted  to  the  foetus  in 
utero.  This  doctrine  of  the  modes  in  which  an  embryo  may  become  tainted 
with  syphilis  has  not  yet  met  with  general  acceptance,  although  it  can  be 
supported  by  strongest  proofs.  No  one,  of  course,  now  denies  the  fact  that 
a  woman  infected  before  or  at  the  time  of  insemination  will  probably  pro- 
duce syphilitic  offspring.  That  the  disease  can  be  transmitted  to  the  foetus 
in  utero,  or  that  the  ovum  alone  can  be  infected  while  the  mother  remains, 
for  a  time  at  least,  free  from  the  disease,  are  statements  not  so  universally 
admitted.  A  prominent  authority  in  this  country  says,  in  a  recent  edition 
of  his  work  on  obstetrics,  "  The  syphilitic  poison  will  not  traverse  the  septa 
intervening  between  the  foetal  and  the  maternal  vascular  systems."  Neu- 
mann,^ however,  has  seen  this  very  thing  occur  in  five  out  of  twenty  women 
who  were  infected  with  syphilis  during  pregnancy.  In  the  Maternite  at 
Bordeaux,^  of  twelve  women  infected  with  syphilis  in  the  first  four  months 
of  pregnancy,  all  gave  birth  to  dead  children ;  in  those  cases  in  which  in- 
fection occurred  from  the  fourth  to  the  sixth  month  about  half  the  children 
were  still-born,  and  in  seven. cases  of  infection  during  the  last  three  months 
there  were  four  still-births.  I  have  attended,  in  the  Philadelphia  Hospital, 
a  woman  who  acquired  a  chancre  in  the  third  mouth  of  pregnancy :  her 
child,  still-born,  had  on  it  unmistakable  evidences  of  syphilis.  This  cannot 
excite  much  surprise ;  for  it  becomes  every  day  more  clear  that  the  syphi- 
litic poison  is  "  a  particulate  and  living  virus,"  ^  and  we  shall  presently  offer 
ample  evidence  to  prove  that  disease-breeding  germs  can  pass  from  mother 
to  foetus.     Collerier,  Notta,  Follin,  Charnier,  Mireur,  Langlebert,  Corry, 

1  Op.  cit.  2  Edin.  3recl.  Jour.,  April,  1888. 

^  Kuge  estimates  that  eio;hty-three  per  cent,  of  premature  1)irths  and  still-births  may  be 
traced  to  syphilis  in  one  or  both  of  the  parents.     (Zeitschr.  f.  Geburtsh.,  Bd.  i.) 
*  Wien.  Med.  Presse,  xxix.,  xxx.,  1885. 

5  Hirigoyen,  abstract  in  New  York  Med.  Kecord,  April  12,  1887. 

6  J.  Hutchinson,  Brit.  3Iod.  Jour.,  188G,  i.  279. 


222  DISEASES  OF  THE  FCETUS. 

Wolf/  aud  quite  recently  Schadeck/  have  said  that  they  do  not  believe  the 
infection  of  the  foetus  to  be  possible  unless  the  mother  is  syphilitic  ;  but  of 
modern  authorities  Tarnier,  Schroeder,  Charpentier,  Priestley,  and  many 
others  assert  their  positive  belief  in  the  transmission  of  syphilis  to  the  ovum 
directly  from  a  diseased  man,  ^vithout  the  previous  infection  of  the  woman. 
As  the  fcetus  grows,  however,  and  the  syphilitic  poison  develops  with  its 
growth,  the  mother  sometimes  becomes  infected  in  her  turn  directly  from 
the  foetus,  through  the  utero-placental  septum.^ 

Diagnosis  of  Fcetal  Syphilis. — The  infection  of  the  foetus  may  be  in- 
ferred with  reasonable  certainty  if  either  parent  had  acquired  syphilis  at  a 
date  not  too  remote  from  the  procreation.  There  is  no  doubt  that  the  like- 
lihood of  syphilitic  persons  bearing  diseased  children  somewhat  diminishes 
as  time  wears  on ;  but  the  limit  of  safety  has  not  been  discovered.  Lomer* 
tells  of  the  production  of  a  syphilitic  infant  ten  j^ears  after  the  infection  of 
the  father,  and  Kassowitz^  records  a  latent  syphilis  of  twelve  years'  dura- 
tion. If  active  treatment  has  been  pursued,  however,  four  years  should 
serve  to  eliminate  the  poison.^  If  a  woman  should  accjuire  a  chancre  during 
pregnancy,  the  possibility  of  the  disease  attacking  the  fcetus  must  not  be 
overlooked.  A  trustworthy  sign  of  s}^)hilis  in  the  foetus  is  occasionally 
found  in  those  cases  in  which  the  ovum  is  infected  by  the  spermatic  par- 
ticle. The  woman  may  remain  perfectly  healthy  till  the  middle  of  preg- 
nancy, when  signs  of  secondary  syphilis  may  appear,  without  the  slightest 
trace  anywhere  of  a  primary  sore.  In  such  cases  the  poison  of  the  disease 
has  been  transmitted  from  foetus  to  mother. 

Verv  often  the  signs  of  foetal  syphilis  can  be  looked  for  only  in  the 
foetus  itself  after  its  expulsion  from  the  uterus,  and  much  may  depend  upon 
a  correct  diagnosis.  This  is,  however,  not  always  easy  to  reach.  The 
parents'  history,  from  ignorance  or  design,  may  be  entirely  negative ;  the 
child  may  be  born  with  no  distinctive  sign  upon  its  body ;  if  it  is  living, 
however,  the  coryza  and  characteristic  eruptions  during  the  first  few  weeks 
usually  point  clearly  enough  to  the  hereditary  taint ;  if  the  child  is  dead, 
the  diagnosis  can  be  more  easily  made,  unless  maceration  has  proceeded 
very  far ;  even  then,  however,  there  is  one  sign  that  may  be  regarded  as 
quite  distinctive. 

In  these  cases  of  foetal  death  it  is  important  to  ascertain  the  cause  of 
the  misfortune,  in  order  to  prevent  its  recurrence  in  subsequent  pregnancies. 
If  the  practitioner  is  a  trained  pathologist,  the  detection  of  s}^hilis  should 
give  little  trouble.  The  bullous  eruptions  on  the  skin,  the  condylomata 
and  inflammations  of  the  mucous  membranes,  the   inflammations  of  the 

1  Tarnier  et  Budin,  Traite  prat,  des  Aecouchem.,  t.  ii.  p.  36. 

2  St.  Petersburg.  Med.  "SVochenschr. ,  xvi.,  xvii.,  1886. 

3  See  Tarnier  et  Budin,  op.  cit.  ;  Priestley,  loc.  cit.  ;  J.  Hutchinson,  Brit.  3Ied.  Jour., 
1866.  i.  239 ;  Harvey,  Foetus  in  Utero,  1886 ;  G.  S.  West,  Amer.  Jour.  Obstet.,  1885,  p.  182. 

*  Zeitschr.  f.  Geburtsh.,  Bd.  x.  S.  94. 

5  Strieker's  Jahrb..  1875,  S.  476.  ^  Fournier.  Syphilis  et  Manage. 


DISEASES   OF   THE    FCETUS. 


223 


serous  membranes,  the  gummatous  and  miliary  deposits,  and  the  morbid 
growth  of  connective  tissue  in  the  brain,  hings,  pancreas,  kidneys,  liver, 
and  spleen,  and  in  the  coats  of  the  intestines  and  walls  of  the  blood-vessels, 
along  with  a  characteristic  osteochondritis,  should  demonstrate  the  character 
of  the  disease.  It  often  falls  to  the  lot  of  the  general  practitioner,  how- 
ever, to  observe  cases  of  repeated  foetal  death  the  cause  of  which  is  obscure, 
although  suspicion  naturally  rests  upon  syphilis.  Thanks  to  the  investiga- 
tions of  Wegner,^  Ruge,^  Lomer,^  and  others,  it  is  now  well  established  that 
syphilis  can  be  recognized  in  the  foetus  by  a  few  signs  easily  found,  quite 
characteristic,  and  requiring  for  their  detection  no  special  training  in  the 


Fig.  1. 


Fig.  2. 


/-" 


^ 


ve 


f 


Tibia  showing  syphilitic  osteochondritis. 
(Wegner.) 


xi 

Microscopic  appearance  of  syphilitic  osteo- 
chondritis.   (Wegner.) 

methods  of  pathological  research.  Wegner  was  the  first  to  call  attention  to 
a  curious  condition  of  the  dividing-line  between  diaphysis  and  epiphysis  of 
the  long  bones  of  a  syphilitic  infant.  Instead  of  a  sharp,  regular,  delicate 
line  formed  by  the  immediate  apposition  of  cartilaginous  to  bony  tissue,  as 
in  a  healthy  foetus,  there  may  be  seen  in  syphilitic  cases  a  jagged,  rather 
broad  line  of  a  yellow  color  separating  bone  from  cartilage.  A  microscopic 
study  of  this  portion  of  the  bone  shows  that  there  has  been  a  premature 
attempt  at  ossification  which  has  ended  in  fatty  degeneration.  For  more 
than  a  year  I  carefully  looked  for  this  sign  in  every  case  of  unmistakable 
foetal  syphilis  that  occurred  in  the  Philadelphia  and  Maternity  Hos]:>itals, 


1  Virohow's  Archiv,  Bd.  1.  S.  305. 

2  Zeitschr.  f.  Goburtsh.,  Bd.  i. 


8  Ibid.,  Bd.  X. 


224 


DISEASES   OF   THE   FCETUS. 


and  never  failed  to  find  it,  while  in  doubtful  cases  it  proved  a  valuable  aid 
to  a  correct  diao-nosis.  In  the  Frauenklinik  at  Berlin^  this  sign  was  also 
carefully  investigated,  with  a  result  wholly  favorable  to  its  distinctive  char- 
acter.^ 

Tig.  3. 


Head  of  femur  showing  syphilitic  osteochondritis.    (Case  in  Philadelphia  Hospital.) 

According  to  Ruge/  the  liver  of  a  healthy  infant  should  constitute 
about  one-thirtieth  part  of  the  body-weight.  In  syphilitic  infants,  how- 
ever, this  proportion  is  much  exceeded,  the  liver  forming  in  extreme  cases 
one-eighth  of  the  total  body-weight.  The  spleen,  too,  is  much  enlarged  in 
syphilis  :  this  organ,  which  in  a  normal  foetus  at  term  should  be  in  weight 
one-three-hundredth  part  of  the  whole  body,  often  much  exceeds  its  due 
proportion.  Upon  these  three  signs,  the  yellow  line  between  epiphysis  and 
diaphysis,  the  increased  weight  of  liver,  and  the  increased  weight  of  S2)leen, 
all  easily  discovered,  the  diagnosis  of  syphilis  may  rest  with  reasonable  cer- 
tainty. If  one  would  push  the  investigation  further,  perhaps  the  next 
surest  indication  of  syphilis  might  be  found  in  the  lungs.*  These  organs 
will  manifest  a  syphilitic  infection  in  three  ways  :  by  an  interstitial  over- 
growth ;  by  the  presence  of  gummata ;  by  a  peculiar  catarrhal  inflamma- 
tion, resulting  in  what  is  called  white  pneumonia.  The  first  of  these  is  the 
most  common :  the  connective-tissue  overgrowth  about  the  blood-vessels 
and  the  alveoli  gives  the  lungs  greater  weight  and  more  solidity  than  they 
should  possess  ;  their  color  is  often  dark  red  ;  if  the  infant  has  breathed,  as 
it  commonly  does,  although  imperfectly,  for  a  short  time  after  birth,  the 
lungs  will  not  float  buoyantly,  although  they  do  not  usually  sink  outright. 


1  Lomer,  loc.  cit. 

2  Zweifel  thus  describes  the  progress  of  the  disease :  "  There  is  formed,  in  a  certain  region 
of  the  cartilage,  granulation-tissue,  insufficiently  supplied  with  blood-vessels  and  ill  nour- 
ished. There  results  necrosis  of  this  tissue,  with  an  attempt  at  exfoliation  and  an  accom- 
panying suppuration." 

^  Loc.  cit. 

*  For  an  exceedingly  interesting  paper  on  this  subject,  see  Heller,  Die  Lungener- 
krankungen  bei  angeborener  Syphilis,  Deutsch.  Arch.  f.  Klin.  Med.,  Bd.  xlii.  S.  ir)9. 


DISEASES    OF   THE    FCETUS.  225 

Microscopically  it  may  be  seen  that  the  alveoli  are  much  encroached  upon 
by  the  interstitial  thickening,  and  that  lung-expansion  and  adequate  respi- 
ration are  impossible.  The  catarrhal  pneumonia  in  utero  due  to  syphilis  is 
rare.  The  lungs  in  this  form  of  disease  are  large  and  heavy ;  they  quite 
fill  out  the  thoracic  cavity  and  bear  upon  their  external  surface  the  imprint 
of  the  ribs ;  in  color  they  are  white,  the  whole  organ  having  undergone  a 
more  or  less  complete  fatty  degeneration.  This  condition  is  quite  incom- 
patible with  extra-uterine  life  :  the  infant  never  breathes. 

Prognosis. — The  chances,  for  a  syphilitic  embryo  reaching  a  healthy  ma- 
turity are  very  slim.  Charpentier  found  in  an  analysis  of  six  hundred  and 
fifty-seven  cases  that  more  than  a  third  of  the  pregnancies  in  syphilitic 
women  ended  in  abortion,  while  a  large  proportion  of  the  children  born  at 
term  were  dead.  Add  to  this  the  low  vitality  of  syphilitic  infants  and  the 
high  mortality  among  them,  and  it  will  be  found  that,  fortunately  for  the 
race,  hereditary  syphilis  is  not  so  common  as  one  might  expect,  if  it  is 
looked  for  in  children  of  more  than  a  year's  growth. 

Treatment — The  treatment  of  foetal  syphilis  is  best  begun  before  the 
embryo  is  called  into  existence,  by  eradicating  the  disease  from  the  parents. 
If  only  one  is  aifected,  the  treatment  of  the  other  is  of  course  superfluous. 
In  case  of  doubt,  however,  both  man  and  woman  should  be  put  on  a  long 
course  of  antisyphilitic  remedies.  The  direct  treatment  of  the  embryo  or 
foetus  after  conception,  while  not  so  satisfactory,  should  not  be  neglected,  if 
there  is  good  reason  to  believe  it  syphilitic. 

Both  mercury,  in  its  soluble  salts,  and  iodide  of  potassium  will  pass 
into  the  foetal  circulation  and  may  modify  or  entirely  prevent  the  morbid 
processes  characteristic  of  the  disease.  Along  with  these  remedies  it  might 
not  be  amiss  to  give  chlorate  of  potassium.  In  most  cases  the  placenta 
will  be  diseased  and  the  effective  area  for  oxygenating  the  foetal  blood  much 
diminished  ;  and  it  is  in  such  cases  that  this  drug  does  good,  and  has  been 
recommended  by  Simpson,  Barker,  Penrose,  and  others,  although  it  may  be 
doubted  if  the  explanation  formerly  offered  would  account  for  its  favorable 
action, — that  it  increased  the  oxygenating  power  of  the  maternal  blood. 

Infectious  Diseases. — These  affections  are  produced  by  the  entrance 
into  the  body  and  the  development  there  of  some  low  form  of  life :  this 
has  been  conclusively  proved  of  many  infectious  diseases;  of  the  rest  it 
may  be  surely  inferred,  although  the  exact  nature  of  the  materies  morbi  has 
in  some  instances  not  yet  been  demonstrated.  The  only  medium  of  com- 
munication with  the  outer  world  possible  to  the  foetus  is  the  maternal  blood. 
If,  therefore,  the  foetus  is  attacked  by  an  infectious  disease,  the  micro-organ- 
ism that  produces  it  must  have  passed  from  the  maternal  into  the  foetal 
portion  of  the  placenta,  and  so  have  traversed  the  septa  intervening  be- 
tween the  foetal  and  the  maternal  blood.  Many  observers,  however,  deny 
the  possibility  of  this  transmigration.     BrauelP  and  Davaine^  experiment- 

'  Virch.  Archiv,  1838,  p.  459.  ^  Bulletin  dc  TAcademic  de  Medccine,  18G7. 

Vol.  I. — 15 


226  DISEASES    OF    THE    FCETUS. 

ing  with  the  bacilli  of  anthrax  saw  large  colonies  of  them  heaped  up  on 
the  maternal  side  of  the  placenta,  while  the  foetal  structures  were  entirely 
free  from  disease.  Straus  and  Chamberland^  failed  to  infect  animals  by 
injecting  the  blood  of  a  foetus  taken  from  an  animal  that  had  died  of 
anthrax.  Eunge  of  Dorpat  inoculated  a  number  of  pregnant  rabbits  with 
tuberculosis,  but  failed  absolutely  to  detect  the  characteristic  bacillus  in 
a  single  foetus.  Chambreleut^  quotes  Budin,  Tarnier,  Charpentier,  Hoff- 
mann, Jossinsky,  and  Fehling  as  denying  the  possibility  of  the  passage  of 
microbes  from  mother  to  foetus.  V.  Ott,^  in  a  recent  article,  after  giving  a 
rfeume  of  the  literature  on  the  subject,  expresses  his  disbelief  in  the  pas- 
sage of  solid  particles  into  the  placenta,  and  supports  his  statement  by 
describing  exj)eriments  of  his  own  which  altered  the  constitution  of  the 
mother's  blood  without  in  any  way  affecting  that  of  the  foetus.  Wolff* 
infected  a  number  of  rabbits  and  guinea-pigs  with  anthrax,  but  failed  to 
find  a  trace  of  the  disease  in  their  young.  Curt  Jani,'  an  assistant  of  Prof. 
Weigert,  having  an  opportunity  to  examine  the  body  of  a  woman  who 
had  died  in  the  fifth  month  of  pregnancy  from  general  miliary  tuberculosis, 
found  not  a  trace  of  the  bacilli  in  placenta  or  foetus,  although  every 
maternal  organ  swarmed  with  them.  Urvitch^  inoculated  seven  pregnant 
mice  with  the  microbes  of  mouse-septicsemia  :  the  experiment  was  negative 
as  regards  the  young.  Bompiani^  and  Morisani*  have  observed  pregnant 
women  with  anthrax  while  their  infants  remained  unaffected.  Krukenberg^ 
experimented  with  the  bacillus  prodigiosus :  he  could  not  in  a  single 
instance  discover  that  it  passed  into  the  foetal  portion  of  the  placenta.  On 
the  other  hand,  careful  experiments  and  clinical  observations  bear  witness 
to  the  fact  that  microbes  can  pass  from  mother  to  foetus.  In  1882  Arloing, 
Cornevin,  and  Thomas^"  showed  that  the  anthrax-bacilli  could  pass  from 
mother  to  foetus  ;  in  the  same  year  Straus  and  Chamberland  recalled  their 
first-expressed  opinion  and  announced  their  belief  in  the  transmission  of 
■disease-serms  to  the  foetus  in  utero."  Chambrelent^^  was  able  to  cultivate 
the  microbes  of  chicken-cholera  from  the  foetal  blood  and  to  inoculate  other 
animals  with  the  cultures.  Mars^^  of  Cracow  after  injecting  putrid  solutions 
into  the  mother  animal  found  large  numbers  of  micro-organisms  in  the  foetus  ; 
and  Dr.  Pyle,^^  working  in  the  Pathological  Laboratory  of  the  University 
of  Pennsylvania,  obtained  the  same  results ;  he  also  claimed  to  have  found 

1  Comptes-rend.  de  la  Societe  de  Biologie,  1882,  p.  689. 

2  Eecherches  sur  le  Passage  des  Elements  figures  a  travers  le  Placenta,  Paris,  1883. 
^  Arch.  f.  Gynak.,  Bd.  xxvii. 

*  Yirch.  Arch.,  Bd.  cv.  S.  192.  ^  i^id.,  Bd.  ciii.  S.  522. 

6  Inaug.  Dissert.,  St.  Petersburg,  1885,  p.  77. 
»  Annal.  di  Ostet.,  May-June,  1887. 

8  Abstr.  in  Centralbl.  f.  Chirurg.,  vii.,  1887. 

9  Arch.  f.  Gjmak.,  Bd.  xxxi.  H.  iii.  S.  313. 

10  Compt.-rend.  des  Seances  de  I'Acad.  des  Sciences,  1882,  t.  xcii.  p.  739. 

"  See  Koubassofi",  ibid.,  t.  c.  p.  373.  ^-  Op.  cit. 

13  Arch,  de  Tocol.,  1883,  p.  381.  "  Med.  News,  Aug.  30,  1884. 


DISEASES   OF   THE   FCETUS.  227 

micro-organisms  in  a  fetus  that  had  been  removed  by  Caesarean  section  from 
a  woman  dying  of  septicasmia.  Koubassoff,  working  under  the  supervision 
of  Pasteur  in  his  laboratory  in  Paris,  asserted  that  he  never  failed  to  find 
the  anthrax-bacillus  in  the  foetus  when  the  mother  had  been  thoroughly 
infected  with  the  disease,  except  in  one  instance,  where  of  two  foetuses  one 
was  partially  macerated  and  its  placenta  the  seat  of  hemorrhagic  extrava- 
sations, while  the  other  was  well  developed.  In  the  former  of  these  two 
no  bacilli  were  found,  but  in  the  latter  they  were  present  in  large  numbers. 
Upon  this  experience  Koubassoif  bases  the  conclusion  that  the  placenta 
can  offer  effective  resistance  to  the  passage  of  microbes  only  when  its  con- 
dition is  pathological.  Sangalli^  and  Ahlfeld'  have  each  observed  a  case 
of  anthrax  in  pregnancy  in  which  the  foetus  acquired  the  disease.  In 
Ahlfeld's  case,  however,  the  infection  probably  occurred  during  labor.  A 
case  is  recently  reported  in  which  the  foetus  was  infected  by  the  diplococcus 
pneumoniae  (Frankel)  during  an  attack  of  pleuro-pneumonia  in  the  mother ;  ^ 
in  connection  with  this  report  is  detailed  an  experiment  in  which  the  young 
of  a  pregnant  rabbit  Avere  infected  with  the  meningococcus  taken  from  a  case 
of  cerebro-spinal  meningitis  and  injected  into  the  mother  animal.  Jaquet's* 
experiments  showed  that  the  micrococcus  tetragonus  could  pass  from  mother 
to  foetus.  Rosenbach  ^  has  reported  a  case  of  congenital  osteomyelitis,  cysti- 
cerci  have  been  found  in  the  new-born  of  pigs,  and  filarise  have  been  dis- 
covered in  foetal  puppies.**  Collections  of  pus  have  also  been  found  in  the 
new-born  infant.^  Malvoz^  infected  with  anthrax  four  pregnant  rabbits, 
containing  thirty-two  foetuses :  tAvo  of  the  latter  were  infected  in  utero. 
Experiments  with  the  bacillus  prodigiosus  and  micrococcus  tetragonus  were 
negative.  Malvoz  believes  that  only  those  microbes  which  produce  some 
lesion  in  the  placenta  can  pass  into  the  foetal  circulation.®  In  Birch-Hirsch- 
feld's  ^^  experiments  on  pregnant  animals  M^th  anthrax-bacillus  the  results 
were  in  the  majority  of  cases  favorable  to  the  view  that  micro-organisms 
can  pass  from  maternal  into  foetal  blood.^^     An  interesting  study  has  lately 


■  1  Gaz.  Med.  Ital.-Lombard.,  1883,  Nos.  4,  5. 

2  Bericht.  u.  Arbeit,  aus  d.  Geburts.-Gyniik.  Klinik  zu  Marburg,  1885-86. 

3  Foa  and  Bordoni-TJffreduzzi,  La  Kiforma  Med.,  1887,  No.  39. 
*  At  a  meeting  of  the  Berlin  Obstetrical  Society,  Feb.  10,  1888. 

5  Quoted  by  Watson  Cheyne,  Brit.  Med.  Jour.,  1888,  vol.  i.  p.  452. 

^  Bouchut,  Pathologie  generale. 

^  In  the  Lancet,  1887,  vol.  ii.  p.  859,  is  an  account  of  an  abscess  of  the  vestibule  opened 
fourteen  hours  after  birth.  My  friend  Dr.  De  Schweinitz  tells  me  that  in  superintending  a 
post-mortem  examination  of  an  infiint  delivered  in  my  service  in  the  Philadelphia  Hospital, 
he  saw  in  the  anterior  mediastinum  a  fluid  closely  resembling  pus.  The  mother  was  in 
a  dying  condition  from  septicaemia  when  the  child  was  born. 

8  "  Sur  le  Mecanisme  du  Passage  des  Bacteries  de  la  Mere  au  Fetus."  Successful  thesis, 
Brussels,  1887. 

9  Ann.  de  I'lnstitut  Pasteur,  1888,  No.  3. 

'0  Miinchen.  Med.  Wochenschr.,  No.  42,  1888. 

"  See  also  Wolff,  "  Ueber  Vererbung  von  Infectionskrankheiten,"  Virch.  Arch.,  Bd. 
cxii.  S.  136. 


228  DISEASES  or  the  fcetus. 

been  made  of  the  passage  to  and  from  the  blood  in  the  kidneys  of  micro- 
organisms, which  has  a  direct  bearing  upon  the  passage  of  microbes  from 
mother  to  foetus.^  It  was  found  that  bacilli  did  pass  not  only  from  the 
blood  into  the  uriniferous  canals,  but  also  back  again  from  urine  to  blood. 
It  seems  that  we  must  concede  to  these  minute  creatures  the  ability  to  pene- 
trate the  placenta.  Indeed,  in  no  other  way  could  we  explain  the  occur- 
rence of  infectious  diseases  in  the  foetus,  and  the  list  of  these  is  already  a 
long  one.  Perhaps  the  microbes  are  carried  over  to  the  foetus  from  the 
maternal  circulation  enclosed  in  wandering  white  blood-corpuscles. 

Variola.- — The  occurrence  of  variola  in  utero  has  long  been  a  fact  beyond 
dispute.  The  foetus,  however,  is  not  always  affected,  even  though  the 
mother  has  the  disease  badly ;  on  the  other  hand,  the  mother  may  transmit 
the  disease  to  the  child  in  her  womb  although  she  remains  healthy ;  or  a 
light  attack  of  varioloid  in  the  mother  may  be  associated  with  virulent 
small-pox  in  the  foetus.  Again,  it  has  been  noted  that,  of  twins,  one  or 
both  may  be  affected.  Many  observers  have  tried  the  effect  of  vaccinating 
a  pregnant  woman :  in  the  majority  of  cases  a  subsequent  vaccination  of 
the  child  "  took  ;"  occasionally,  however,  it  was  a  failure,  apparently  because 
the  virus  had  affected  both  mother  and  foetus.^ 

Rubeola. — The  transmission  of  measles  from  mother  to  foetus  is  a  rare 
occurrence,  but  is  not  unknown.  Thomas '  was  able  to  collect  six  cases 
from  medical  literature.  There  are  also  cases  recorded  of  measles  appearing 
in  the  first  few  days  after  birth,  making  it  probable,  from  the  short  period 
of  incubation,  that  infection  had  occurred  in  utero. 

Scarlatina. — There  are  a  few  well-authenticated  cases  of  children  born 
with  an  unmistakable  scarlatinous  rash  upon  them,  accompanied  by  fever 
and  followed  by  desquamation  and  albuminuria.  Those  reported  by  Leale  * 
and  Saffin  ^  are  quite  typical. 

Erysipelas. — Kaltenbach,^  Runge,^  and  Stratz  ^  have  reported  cases  that 
were  in  all  probability  erysipelas  in  utero.  Lebedeff,^  however,  has  pre- 
sented convincing  evidence  of  the  possibility  of  intra-uterine  erysipelas.  In 
the  subcutaneous  tissues  of  a  child  born  of  a  mother  in  the  midst  of  an 
attack  of  the  disease  were  found  Fehleisen's  micrococci.  The  child  had 
lived  only  ten  minutes. 

Malaria. — Many  practitioners  have  reported  cases  of  periodic  exacerba- 
tions of  temperature  in  the  new-born  apparently  due  to  malaria  acquired 
during  intra-uterine  life.     I  had  such  a  case  myself  recently,  in  which  the 

1  Schweizer,  "  Ueber  das  Durchgehen  von  Bacillen  durch  die  Nieren,"  Virch.  Arch., 
Bd.  ex.  S.  255. 

^  For  an  extensive  'bibliography  of  intra-uterine  variola  and  vaccination,  see  Tarnier  et 
Budin,  op.  cit. ;  Wolf,  Virch.  Arch.,  Bd.  cv. ;  Chambrelent,  loc.  cit. 

3  Ziemssen's  Haudbuch,  vol.  ii.  p.  50.  , 

*  Med.  News,  1884,  p.  636  (good  bibliography). 

5  New  York  Med.  Kecord,  April  24,  1886. 

6  Centralbl.  f.  Gynak.,  Nr.  44,  1884.  '  Ibid.,  Nr.  48,  1884. 

8  Ibid.,  ix.  213.  °  Zeitschr.  f.  Geburtsh.,  xii,  321, 


DISEASES   OF   THE   FCETUS.  229 

temperature  of  a  new-born  infant  rose  on  two  successive  afternoons  to  103° 
F.,  the  fever  being  preceded  by  great  uneasiness ;  quinine  to  the  mother  in 
large  doses  promptly  cured  the  child.  Unfortunately,  the  germs  of  Labaran 
were  not  looked  for.  Quite  recently  I  have  had  under  my  care  in  the  Ma- 
ternity Pavilion  of  the  Philadelphia  Hospital  a  woman  and  her  new-born 
infant  in  both  of  whom  the  resident  physician,  Dr.  Preston,  discovered  the 
characteristic  bodies  in  the  blood-corpuscles. 

Tabercidosis. — Curiously  enough,  the  transmission  of  tuberculosis  to  the 
foetus  in  utero  is  an  exceedingly  rare  occurrence.  Demme  once  found  the 
tubercle-bacillus  in  the  macerated  foetus  of  a  tuberculous  woman  :  this  is  the 
only  instance  of  foetal  tuberculosis  that  I  know  of,  in  human  pathology  at 
least.  There  is  a  similar  case  in  veterinary  medicine  :  Johne  on  one  occasion 
found  tubercles  in  a  still-born  calf,  in  which  were  discovered  the  bacilli  of 
tuberculosis.  While,  therefore,  the  passage  of  tubercle-bacilli  from  mother 
to  foetus  is  a  possible  occurrence,  it  must  be  regarded  as  very  exceptional. 

Septicaemia. — The  possibility  of  the  transmission  of  septic  micro-organ- 
isms from  mother  to  foetus  has  been  denied  by  many,  but  the  occurrence  of 
septic  infection  in  utero  has  been  strongly  affirmed  by  KoubasspiF,  Chambre- 
lent,  Pyle,  Mars,  Von  Hoist,  and  others.  Von  Holst,^  after  an  extensive 
search  through  medical  literature,  asserts  positively  that  although  septicaemia 
in  utero  is  rare,  it  has  undoubtedly  occurred. 

Cholera. — Tarnier  ^  says  there  is  nothing  to  justify  a  belief  in  the  occur- 
rence of  intra-uterine  cholera,  and  Queirel  ^  asserts  that  it  is  doubtful  whether 
cholera  directly  affects  the  foetus  in  utero ;  but  nevertheless  early  abortion 
is  the  rule,  or  if  the  child  is  born  alive  it  survives  only  a  few  days. 

Typhoid  Fever. — The  most  serious  effect  upon  the  foetus  of  typhoid  fever 
in  pregnancy  is  usually  a  premature  expulsion  of  the  ovum :  this  occurs  in 
sixty-five  per  cent,  of  the  cases.*  It  would  seem,  however,  that  the  disease 
can  directly  attack  the  foetus ;  for  Neuhaus  ^  on  one  occasion  found  what 
are  supposed  to  be  the  specific  micro-organisms  of  this  disease  in  the  lungs, 
spleen,  and  kidneys  of  a  four-months'  foetus  from  a  woman  who  was  conva- 
lescing after  a  prolonged  attack  of  typhoid  fever. 

Articular  Rheumatism. — There  are  two  instances  on  record  of  the  trans- 
mission of  this  disease  from  mother  to  foetus, — one  described  by  Pocock,^ 
the  other  by  Schaeffer.'^  -In  botli  instances  a  woman  affected  with  articular 
rheumatism  gave  birth  to  a  child  presenting  in  one  case  at  once,  in  the  other 
at  the  end  of  three  days,  unmistakable  signs  of  the  same  disease. 

Recurrent  Fever. — Albrecht^  has  described  three  cases  of  congenital  re- 
current fever,  and  in  one  foetus  he  found  the  spirilla. 

I 

1  Dissert.  Inaug.,  Dorpat,  1884.  ^  Qp.  cit. 

^  ISTouvelles  Archives  d'Obstet.  et  de  Gynec,  1887,  p.  157. 

*Duguyot,  These  de  Paris,  1879.  *  Berlin.  Klin.  Wochenschr.,  1886,  S.  389. 

^  London  Lancet,  1882,  vol.  ii.  p.  804. 

7  Berlin.  Klin.  Wochenschr.,  1886,  S.  79. 

8  St.  Petersburg.  Med.  Wochenschr.,  1880,  Nr.  18  u.  1884,  S.  129. 


230 


DISEASES    OF    THE    FCETUS. 


Yellow  Fever. — Dr.  Bemiss,^  of  Xe^y  Orleans,  says,  "The  pregnant 
woman  being  attacked  by  yellow  fever  and  recovering  without  miscarriage, 
immunity  from  future  attacks  is  conferred  upon  the  offspring  contained  in 
the  womb  during  the  attack."  If  this  is  true,  it  certainly  seems  that  the 
foetus  too  must  have  been  infected  by  the  disease. 

Pneumonia. — Cases  of  foetal  pneumonia  are  reported  not  infrequently ; 
in  the  great  majority  of  cases  they  are  no  doubt  the  interstitial  pneumonitis 
of  S}q3hilis.  Geyl  has  shown,  however,  that  if  a  foetus  be  deprived  of  the 
necessary  amount  of  oxygen  for  its  blood,  it  will  make  inspiratory  efforts  in 
utero,  drawing  into  its  lungs  liquor  amnii  with  whatever  that  fluid  may 
contain,  a  sufficient  irritant  in  some  cases  to  arouse  a  catarrhal  inflamma- 
tion. I  have  placed  foetal  pneumonia  in  the  list  of  infectious  diseases  on 
account  of  that  observation  already  referred  to  in  which  the  diplococcus 
pneumonige  (Frankel)  was  found  transmitted  from  mother  to  foetus  during 
an  attack  of  pleuro-pneumonia  in  the  former. 

Non-Infectious  Diseases. — Under  this  heading  are  grouped  rather 
loosely  a  number  of  heterogeneous  affections.  Inflammations  of  the  serous 
inembranes  not  dependent  upon  syphilis,  with  its  accompanying  exudations ; 
some  congenital  skin-affections,  as  ichthyosis,  hypertrichosis,  albinism,  pur- 
pura hsemorrhagica,  and  elephantiasis ;  intra-uterine  diseases  of  the  brain, 
which  may  consist  in  sclerosis,  atrophy,  lack  of  development,  tumors,  cysts, 
or  inflammation  of  the  membranes ;  diseases  of  the  liver,  whether  multi- 
cystic  or  sclerotic ;  cystic  disease,  cirrhosis,  or  hypertrophy  of  the  kidneys, 
and  the  congenital  tumors,  whether  solid  or  cystic,  malignant  or  benign, 
need  simply  be  mentioned  as  in  this  class.  There  are  other  diseases,  how- 
ever, deserving  a  more  extended  notice. 

Rachitis. — Intra-uterine  rachitis  is  not  common,  but  there  is  abundant 
evidence  to  prove  that  the  disease  may  occur  in  utero.  Indeed,  it  appears 
that  in  Europe  at  least  congenital  rachitis,  in  its  minor  grades,  is  by  no 
means  rare.^  As  the  etiology  of  infantile  rachitis  is  not  at  all  clear,  so  the 
causes  of  the  disease  in  the  foetus  are  all  the  more  obscure.  Most  likely 
the  nutrition  of  the  mother  is  at  fault ;  and  not  only  improper  or  insufficient 
food,  but  also  other  unfavorable  conditions  of  life,  as  cold,  dampness,  lack 
of  light  and  ventilation,  may  play  a  part  in  the  production  of  foetal  rachitis. 
In  the  more  advanced  degrees  of  the  affection,  an  inspection  of  the  product 
of  conception  after  its  expulsion  from  the  womb  can  leave  no  doubt  as  to 
the  true  condition.  A  stunted  gro^^i;h,  heavy  joints,  limbs  bent  in  curves  or 
angles  and  abnormally  short,  a  distended  belly  with  a  "  pigeon-breast,"  the 
large  square  head  with  gaping  sutures  and  fontanels,  and  the  bowed  spine, 
all  point  unmistakably  to  this  curious  disease  of  the  bones.     A  closer  inspec- 


^  Parvin's  Obstetrics,  p.  222. 

2  "  Die  Kachitis,  eine  congenitale  Krankheit,"  Felix  Schwarz,  abstr.  in  Allgemein. 
Wien.  Med.  Zeitun.:?,  .Tanner,  1888,  S.  6.  This  author  claims  to  have  found  signs  of  rachitis 
in  four  hundred  and  three  out  of  five  hundred  new-born  infants  examined. 


DISEASES   OF   THE   FCETUS.  231 

tion  ^vill  show  that  the  long  bones  are  either  abnormally  hard  and  tough, 
or  that,  while  unusuallj  thick,  they  are  very  fragile  and  may  be  snapped 
across  by  the  slightest  exercise  of  force  ;  in  this  latter  condition  the  medullary 
spaces  have  much  encroached  upon  the  external  layer  of  hard  bone,  which, 
may  be  reduced  to  the  merest  shell.  This  indicates  a  more  active  stage  of 
the  disease ;  but  if,  on  the  other  hand,  the  long  bones  are  firm,  tenacious, 
and  unbending,  set,  perhaps,  in  the  unnatural  shapes  they  have  acquired 
in  utero  while  in  a  more  pliable  condition,  it  is  evident  that  the  intra-uterine 
disease  has  ruu  a  longer  course  and  has  passed  from  an  active  process  of 
destruction  to  one  of  attempted  repair  (and  cure).  The  diagnosis  of  the 
disease  in  the  foetus  during  pregnancy  is,  of  course,  impossible ;  therefore 
no  treatment  will  be  attempted.^ 

Anasarca. — One  rarely  sees  marked  anasarca  of  the  foetus,  occurring 
perhaps  in  connection  with  general  dropsy  of  the  mother,  or  as  an  entirely 
independent  condition  untraceable  to  any  maternal  affection.  This  disease 
of  the  foetus  usually  determines  its  premature  expulsion,  most  often  between 
the  fourth  and  eighth  months,  and  the  infant,  even  though  it  reach  a  viable 
period,  is  commonly  born  dead.  Foetal  anasarca  has  been  attributed  to 
dropsy  in  the  mother,  to  syphilis,  in  two  instances  to  foetal  leukaemia,^  in 
another  to  obstruction  of  the  umbilical  vein,^  and  Steinwirke*  describes  a 
case  under  the  name  of  elephantiasis  congenita  cystica.  The  serous  infil- 
tration of  the  skin  is  often  accompanied  by  collections  of  fluid  in  the 
abdominal  and  pleural  cavities,  and  the  placenta  is  often  oedematous. 

Spontaneous  Fractures  in  Utero. — A  syphilitic  osteochondritis  results 
not  uncommonly  in  a  separation  of  epiphysis  and  diaphysis  in  the  long 
bones,  simulating  fracture.  Advanced  rachitis  in  the  foetus  is  undoubtedly 
the  commonest  cause  of  intra-uterine  fractures  occurring  independently  of 
violence  during  pregnancy  and  labor.^  Link,^  however,  describes  a  peculiar 
"  uncomprehended  intra-uterine  foetal  bone-disease"  associated  with  extreme 
brittleness  of  the  long  bones :  in  a  case  reported  by  this  observer,  ribs, 
clavicles,  and  the  long  bones  of  the  extremities  were  broken. 

iMxations  and  Ankyloses. — These  affections  of  the  joints  in  foetal  life 
are  not  common.  Dislocations  have  been  found  more  frequently  in  females 
than  in  males,  and  are  more  commonly  seen  in  the  lower  than  in  the  upper 
extremities.'     If  in  a  breech  presentation  the  presenting  part  is  detained 

1  See  Tarnier  et  Budin,  op.  cit.,  p.  255;  Schorlaw,  Monatschr.  f.  Geburtsh.,  Bd.  xxx. 
S.  401 ;  Grdfe,  Arch.  f.  Gynak.,  Bd.  viii.  S.  500;  Fehling,  Arch.  f.  Gynak.,  Bd.  x. ;  Trans, 
of  the  Meeting  of  German  Naturalists  and  Phj'sicians,  1886;  Virch.  Arch.,  Bd.  c.  S.  256. 
Dr.  Hamill  recentlj'  presented  a  very  typical  case  of  foetal  rachitis  to  the  Philadelphia  Ob- 
stetrical Society. 

2  Klebs,  Prag.  Med.  Wochenschr.,  1878,  Nr.  49;  Sanger,  Arch.  f.  Gyn-ik.,  Bd.  xxxiii. 
H.  2,  p.  101. 

3  Breslau.  Klinik,  Bd.  i.  S.  260.  *  Di.ssert.  Inaug.,  Halle,  1872. 
*  See  Heinrich  Braun,  Arch.  f.  Klin.  Chirurg.,  Bd.  xxxiv.  S.  668. 

6  Arch.  f.  Gynak.,  Bd.  xxx.  S.  204. 
^  Tarnier  et  Budin,  op.  cit. 


232  DISEASES    OF    THE    FCETUS. 

for  a  long  time  in  the  pelvic  canal,  there  may  be  an  apjDarent  ankylosis  of 
the  hip-  and  knee-joints  for  some  time  after  birth, — ^the  limbs  rigidly  re- 
taining the  position  they  occupied  during  labor.  True  ankylosis  is  chiefly 
of  interest  in  connection  with  the  study  of  dystocia. 

Intra-uterine  Amputations. — Complete  severance  of  some  portion  of  the 
body  from  the  trunk  can  almost  always  be  traced  to  a  disease  of  the  amnion 
with  the  formation  of  constricting  amniotic  bands.  The  theory  that  a  part 
encircled  by  the  umbilical  cord  will  be  cut  through  is  not  tenable.  Carl 
Braun  points  out  that  although  the  soft  tissues  may  be  constricted  to  the 
bone  by  a  loop  of  the  cord,  yet  the  cord  itself  must  yield  before  the  osseous 
tissue  is  cut  through.  Ectromelic  monsters  have  been  erroneously  described 
as  the  victims  of  intra-uterine  amputations ;  and  the  writer  once  heard  a 
pathologist  hazard  the  opinion  that  an  acardiac  monster  might  be  the  result 
of  the  intra-uterine  amputation  of  the  head  ! 

Perforation  of  the  Intestine. — Paltauf^  has  recently  reported  five  cases  of 
death  in  the  first  few  hours  after  birth  due  to  perforation  of  the  large  in- 
testines and  escape  of  meconium  into  the  peritoneal  cavity.  In  three  cases 
the  rupture  of  the  bowel  was  found  at  the  sigmoid  flexure ;  in  another,  at 
the  splenic  flexure ;  and  in  the  fifth  the  point  of  perforation  was  in  the 
transverse  colon.  In  two  of  the  cases  there  was  a  good  opportunity  to  study 
the  morbid  process  that  resulted  in  this  lesion,  for  several  spots  were  found 
in  the  large  bowel  exhibiting  the  different  stages  of  the  diseased  condition 
until  complete  perforation.  The  muscularis  first  gives  way,  next  the  serosa, 
and  last  of  all  the  mucosa.  A  microscopic  examination  of  the  spots  from 
a  beginning  in  an  extravasation  of  blood  and  rupture  of  the  muscular  coat 
until  complete  perforation  showed  a  process  of  tissue-necrosis. 

It  will  be  noticed  that  rupture  occurred  four  times  out  of  five  at  the 
flexures  of  the  colon,  where  an  accumulation  of  meconium  might  exert  the 
most  pressure,  and  this  seems  the  most  probable  explanation  :  just  as  a  large 
collection  of  fseces  in  the  lower  bowel  can  end  in  fistula,  so  it  would  seem 
an  unusually  large  collection  of  meconium  in  the  colon  might  result  in  per^ 
foration.  Although  the  accident  occurred  in  Paltauf's  cases  after  birth,  the 
diseased  condition  of  the  bowel  must  have  had  its  origin  in  utero;  in  fact, 
there  are  two  records  of  intra-uterine  rupture  of  the  colon.  In  one  a  child 
was  extracted  after  craniotomy ;  its  abdominal  cavity  was  filled  with  meco- 
nium which  had  escaped  from  a  small  perforation  found  at  the  junction  of 
the  ascending  and  the  transverse  colon  :  there  were  evidences  of  peritonitis 
with  exudation.^  In  the  second  case  there  was  discovered  in  a  foetus  a  pecu- 
liar abdominal  tumor,  which  turned  out  to  be  a  collection  of  meconium, 
encapsulated;  hence  the  rupture  of  the  intestine  must  have  occurred  in 
utero  at  a  period  quite  remote  from  birth. 

Foetal  Traumatism. — In  spite  of  a  position  which  secures  it  the  great- 


1  Virch.  Arch.,  Bd.  cxi.  S.  461. 

2  Breslau,  Monatschr.  f.  Geburtsh.,  1863,  Bd.  xxi.,  supplem.  hf.  (quoted  by  Paltauf). 


DISEASES    OF    THE    FCETUS. 


233 


est  possible  immunity  from  external  violence,  the  foetus  has  been  seriously 
and  fatally  injured.  In  cases  of  gunshot,  stab,  or  other  perforating  wounds 
of  the  abdomen  in  pregnant  women,  the  fcetus  has  been  also  wounded.^ 
The  trocar,  plunged  into  what  was  thought  to  be  an  ovarian  cyst,  has  pene- 
trated the  child  in  utero,  and  wounds  have  been  inflicted  with  sharp  and 
dull  instruments  ignorantly  used  to  bring  on  an  abortion,  or  in  the  hands 
of  physicians  who  overlooked  the  condition  of  pregnancy  ;  even  the  ex- 
amining finger  has  injured  the  child's  head.^  Falls  from  a  height,  blows 
and  kicks,  or  a  crushing  force  upon  the  mother's  abdomen,  have  killed  the 
child  within  her  womb.  The  damage  done  the  foetus  by  this  indirect  vio- 
lence is  manifold  :  the  abdominal  viscera  may  be  almost  disintegrated,*  the 
skull  may  be  fractured,^  there  may  be  intracranial  hemorrhage,  leading,  per- 
haps, as  in  one  case,  to  intra-uterine  hemiplegia.^  A  fatal  injury  to  a  foetus 
from  violence  done  the  mother  by  another  person  might  raise  an  important 
medico-legal  question :  the  offence,  if  it  could  be  proved,  should  be  consid- 
ered a  grave  one.^ 

Diseases  of  the  Foetal  Appendages  which  react  injuriously  or 
fatally  upon  the  Fcetus  itself. — The  foetus  is  essentially  a  parasite,  de- 
pending for  its  well-being  upon  the  health  of  its  host  and  the  normal  con- 
dition of  the  tissues  that  put  it  into  communication  with  its  source  of  oxygen 
and  nourishment, — the  maternal  blood.  Diseases,  therefore,  of  the  placenta, 
cord,  and  membranes  must  exert  a  malign  influence  upon  the  health  and 
growth  or  even  the  life  of  the  product  of  conception.  Degenerations  of 
the  placental  villi,  apoplexies  of  the  maternal  capillary  loops  that  surround 
the  villi  in  early  intra-uterine  life,  thrombosis  of  the  blood  which  moves 
in  a  sluggish  current  through  the  maternal  lacunae,  retro-placental  effusions 
which  separate  a  certain  portion  of  the  placenta  from  the  uterine  wall, 
syphilitic  overgrowth  of  the  placental  decidua  which  crowds  in  upon  the 
inter-villous  blood-spac.es,  must  all  abrogate  the  vital  functions  of  the  pla- 
centa to  a  greater  or  less  degree,  with  the  result  either  of  destroying  the 
foetus  outright,  or  else,  half  starving  and  strangling  it,  of  producing  at  term 
a  puny,  wretchedly-developed  infant.  Even  should  the  placenta  be  in  per- 
fect condition  to  perform  its  part  in  the  physiology  of  the  foetus,  the  um- 
bilical cord  may  fail  to  convey  the  blood  to  and  from  the  foetal  body  in  a 
natural  manner ;  the  circulation  in  it  may  be  obstructed  by  knots,  although 
these  by  no  means  invariably  cut  off  the  blood-current ;  the  cord  may  be 
compressed  in  other  ways,  wound  tightly  about  some  portion  of  the  body,  or 


1  Hays,  Ann.  de  Gyn.,  1880,  t.  xiil.  p.  153 ;  Fennell,  Trans.  New  York  Path.  Soc,  vol. 
iii.  p.  249;  Tarnier  et  Budin,  op.  cit.,  p.  345;  Guelliot,  Gazette  des  Hopitaux,  1886,  p.  405. 

2  Dohn,  Zeitschr.  f.  Geburtsh.,  Bd.  xiv.  S.  366. 

'  Von  Hoffmann,  Wien.  Med.  Presse,  xxvi.,  1885,  Nrs.  18,  20,  etscq. 
*  Hirst,  Amer.  System  of  Obstetrics,  New  York  Med.  Jour.,  1888. 

5  Gibbs,  Lancet,  1858,  vol.  ii.  p.  497. 

6  For  an  illustration,  see  the  case  reported  by  Gorham,  Wien.  Med.  Presse,  Bd.  xxvi 
S.  370. 


234  DISEASES    OF   THE    FCETUS. 

caught  between  the  child's  limbs.  The  calibre  of  the  vessels  may  be  dimin- 
ished also  by  disease  of  their  walls,  by  the  great  growth  of  connective  tissue 
encircling  both  arteries  and  vein  that  is  commonly  seen  in  syphilis,  or  the  ves- 
sels may  be  almost  occluded  by  a  cellular  infiltration  of  the  cord-substance, 
which  is  also  to  my  mind  a  valuable  sign  of  syphilis.  The  umbilical  Vein 
shows  constantly  in  one  portion  of  its  course,  near  the  umbilicus,  a  physio- 
logical constriction :  according  to  Leopold,  foetal  death  can  in  rare  instances 
be  traced  to  an  exaggeration  of  this  narrowing  until  almost  complete  atresia 
is  produced,  and  this,  too,  in  cases  not  syphilitic.  The  foetal  circulation  may 
be  disturbed,  if  not  entirely  suspended,  by  hemorrhage  from  the  vessels  in 
the  cord ;  the  escape  of  blood,  however,  into  the  cord-substance  is  neces- 
sarily limited  by  the  narrow  area  in  which  it  is  confined ;  but  in  contrast  to 
this  is  the  bleeding  that  may  follow  rupture  of  the  large  branches  of  the 
umbilical  vein  spread  out  under  the  amnion  on  the  foetal  surface  of  the  pla- 
centa. I  recently  had  the  privilege  of  examining  a  very  interesting  speci- 
men of  this  sort  presented  to  the  Philadelphia  Obstetrical  Society  by  my 
friend  Dr.  Hamill :  pretty  much  all  the  blood  of  the  foetal  body  was  col- 
lected in  an  enormous  clot  under  the  amniotic  covering  of  the  placenta,  and 
the  foetus  had  evidently  bled  to  death  at  some  time  prior  to  its  expulsion, 
from  a  ruptured  branch  of  the  umbilical  vein.  This  specimen,  to  the  best 
of  my  knowledge,  is  unique.  Diseases  of  the  deciduse  need  hardly  be  con- 
sidered here,  for  their  influence  is  usually  felt  early  in  pregnancy  and  is 
manifested  by  the  premature  expulsion  of  the  ovum.  Cystic  degeneration 
of  the  chorion,  too,  almost  invariably  involves  the  destruction  of  the  em- 
bryo or  foetus ;  yet  cases  have  been  reported  of  healthy,  well-developed 
infants  born  at  term  with  rather  extensive  cystic  disease  of  the  chorion  villi. 
Abnormalities  of  the  amniotic  secretion  have  a  very  decided  influence  upon 
the  growth  and  well-being  of  the  foetus. 

Hydramnion  is  so  often  associated  with  and  dependent  upon  some  defect 
or  disease  in  the  foetus  or  mother  that  it  would  give  an  incorrect  idea  of  the  , 
influence  exerted  simply  by  the  increased  quantity  of  liquor  amnii  to  present 
the  statistics  of  foetal  disease  and  death  associated  with  this  affection.  And 
yet  it  is  impossible  to  ignore  the  fact  that  a  large  quantity  of  fluid  distending 
the  uterine  cavity  must  of  itself  become  a  mechanical  hinderance  to  the  free 
access  of  maternal  blood  to  the  placenta,  while  the  increased  intra-uterine 
pressure  must  exert  an  unfavorable  influence  upon  the  foetus.  There  are  a 
few  who,  believing  the  foetus  derives  nourishment  from  drinking  the  liquor 
amnii,  would  look  to  the  composition  of  that  fluid  for  an  explanation  in 
some  cases  of  foetal  malnutrition ;  but  I  am  not  of  that  number.  The 
foetus,  it  is  true,  swallows  liquor  amnii,  perhaps  in  considerable  quantities ; 
but  from  time  to  time  there  are  born  children  with  a  lack  of  continuity  in 
the  upper  part  of  the  alimentary  tract,  and  yet  they  are  well  nourished  and 
full-grown.  The  quantity  of  albumen,  too,  in  the  liquor  amnii  is  against 
the  theory  that  the  fluid  can  support  life. 

The  amniotic  fluid  plays  an  important  part  in  the  growth  of  the  foetus 


DISEASES    OF    THE    FCETUS.  235 

by  distending  the  uterine  cavity,  allowing  room  for  the  free  play  of  foetal 
movements,  and  preventing  injurious  pressure  by  the  uterine  walls.  There- 
fore an  insufficient  quantity  of  fluid  will  prove  a  disadvantage  to  the  foetus. 
Schatz^  has  reported  a  good  illustrative- case, — an  infant  born  with  ulcers 
on  the  internal  malleoli  and  inner  surface  of  the  knees,  due  to  an  extraor- 
dinarily small  quantity  of  liquor  amnii.  Some  curious  deformities  in  the 
foetus  may  be  traced  to  the  same  cause.^ 

The  study  of  foetal  disease  is  a  large  and  interesting  one,  of  no  little 
practical  importance.  To  obtain  a  thorough  grasp  of  the  subject  it  would 
be  well  to  consider  carefully  normal  growth,  development,  and  existence 
in  utero,  in  order  intelligently  to  contrast  pathological  with  physiological 
processes.  It  would  be  an  advantage  to  begin  the  observation  of  the  foetus 
as  well  as  its  treatment  a  hundred  years  before  its  procreation,  in  a  study  of 
antecedent  generations ;  but  all  this  is  beyond  the  limitation  imposed  upon 
me  by  the  title  of  my  chapter.  Even  a  superficial  examination,  however,  of 
simply  the  diseases  that  affect  intra-uterine  life  cannot  fail,  I  think,  to  clear 
up  much  that  would  otherwise  be  obscure,  perhaps  inexplicable,  in  the  life- 
history  of  the  young  infant,  the  child,  and  the  adult. 

1  Arch.  f.  Gjaiak.,  Bd.  xix.  S.  329.  ^  Tarnier  et  Budin,  op.  cit.,  p.  294. 


THE  CARE  OF  THE  CHILD  AT  AND  IMMEDIATELY 
AFTER  BIRTH  IN  HEALTH  AND  DISEASE. 

By   E.  a.  F.  PENEOSE,  M.D.,  LL.D. 


THE   CHILD   IN   HEALTH. 

As  soon  as  born,  the  child  should  be  placed  on  its  right  side,  since  this 
position,  for  evident  reasons,  favors  the  prompt  closure  of  the  foramen  ovale. 
Its  face  should  be  turned  from  the  maternal  organs,  thus  avoiding  the  pos- 
sibility of  any  sudden  discharges  from  these  organs,  as  blood,  coagula,  or 
placenta,  entering  or  obstructing  the  respiratory  orifices.  Finally,  the  child 
must  be  placed  sufficiently  near  the  mother's  body  not  to  put  the  umbilical 
cord  on  a  stretch  and  thus,  prematurely,  drag  on  the  placenta. 

When  respiration  is  thoroughly  established — a  circumstance  that,  under 
ordinary  conditions,  happens  immediately  after  delivery — the  cord  must  be 
ligated  and  the  child  separated  from  its  maternal  connection.  Should  the 
business  be  left  to  Nature,  something  of  this  sort  would  happen.  In  the 
course  of  a  variable  period  (from  a  few  minutes  to  several  hours,  or  even 
days)  the  placenta  would  be  expelled  from  the  vagina,  and  the  pulsations  in 
the  cord  woidd  gradually  cease,  since  the  functions  of  the  placenta  are  now 
no  longer  performed,  and  the  act  of  respiration  has  caused  the  blood  of  the 
child  to  circulate  in  new  channels  and  organs.  This  is  what  takes  place 
after  delivery  in  animals.  The  young  animal  is  born  with  its  placenta 
attached ;  the  mother  separates"  it  by  biting  the  cord,  and,  in  some  cases, 
devouring  the  placenta,  leaving  only  a  part  of  the  cord  adhering  to  the 
umbilicus  of  its  offspring.  In  other  words,  the  mother  divides  the  cord  by  a 
sort  of  natural  ^craseur,  and  thus  prevents  hemorrhage  from  the  vessels  of 
the  stump.  This  stump  speedily  dries  and  sloughs,  since  both  placenta  and 
cord  derive  their  organic  supplies  from  the  maternal  vascular  system,  and, 
necessarily,  die  when  the  placenta  becomes  separated  from  its  uterine  connec- 
tion. However,  the  human  female,  unlike  the  cow,  does  not  look  upon  the 
placenta  of  her  offspring  as  a  bonne  bouche,  and  we  therefore  separate  it  by 
other  means  than  by  making  a  meal  of  it. 

We  begin  by  applying  a  ligature  to  the  cord.  Before  doing  so,  the 
child  should  be  brought  fairly  in  view,  and  the  medical  attendant  should 
have  the  assistance  of  some  other  person.  It  has  been  suggested  that  these 
236 


THE    CARE   OF   THE    CHILD    AT    BIRTH.  237 

manipulations  should  be  performed  under  the  covering  protecting  the 
mother,  so  as  to  avoid  unseemly  exposure  of  the  woman's  person.  All 
such  advice  is  based  on  a  sentimental  mock  modesty,  more  nearly  related 
to  immodesty  than  to  real  purity. 

The  child  should  then  be  brought  fairly  in  view,  and,  as  respiration  is 
completely  established,  it  may  lie  on  its  back,  as  a  more  convenient  position. 
Before  applying  a  ligature,  we  examine  the  root  of  the  cord,  to  ascertain 
if  it  is  in  a  normal  condition ;  since,  should  umbilical  hernia  exist,  it  will 
be  necessary  to  reduce  the  protruding  abdominal  structures  before  ligation. 
Again,  should  the  cord  be  a  thick  one,  a  "  fat  cord,"  it  is  desirable  to  press 
away  with  the  fingers  the  gelatinous  matter  surrounding  the  blood-vessels, 
at  the  point  we  propose  to  tie,  before  applying  the  ligature,  since,  should 
this  precaution  be  neglected,  it  may  happen  that  the  gelatinous  matter  will 
ooze  from  the  cut  extremity  of  the  cord,*  reducing  the  bulk  of  the  terminal 
part  of  the  stump,  and  the  consequence  may  be  slipping  off  of  the  ligature, 
and  subsequent  hemorrhage  from  the  vessels  of  the  stump. 

We  apply  this  ligature,  as  I  have  just  remarked,  as  soon  as  the  function 
of  respiration  becomes  fully  established, — that  is,  when  the  child  breathes 
well,  and,  in  most  instances,  has  cried  lustily.  This  assures  us  that  the 
placental  functions  are  no  longer  necessary,  and  we  separate  the  child  from 
its  placenta,  even  though  the  blood-vessels  of  the  cord  still  pulsate  strongly. 
Should  we  wait,  as  has  been  suggested  and  urged,  this  would  happen. 
The  pulsations  would  gradually  become  more  and  more  feeble,  and  finally 
would  cease  altogether,  failing  to  be  felt  first  at  the  placenta.  No  good, 
however,  would  attend  or  follow  this  over-sensitive  conservatism.  Much 
time  would  be  lost,  thus  delaying  the  attentions  necessary  for  the  comfort 
and  welfare  of  the  mother ;  while  the  child  w^ould  be  exposed  to  the  risk 
of  "  taking  cold,"  etc. 

The  ligature  may  be  any  strong  string  not  too  thick.  Nothing  answers 
as  well  as  a  skein  of  common  thread,  which  should  always  be  prepared 
beforehand.  This  skein  should  be  cut,  the  ends  tied,  and  a  ligature  secured 
of  the  proper  thickness,  and  so  strong  that  it  cannot  break.  I  never  use 
any  other  material.  The  string  usually  furnished  for  this  purpose  in  the 
"  baby-basket"  is  so  rotten  and  weak  that  it  generally  breaks  at  the  time 
of  tying,  not  only  causing  annoying  delay,  but  also  taxing  severely  the 
patience  of  the  often  wearied  medical  attendant. 

It  has  been  suggested  not  to  tie  the  cord  at  all ;  and  many  evils  have 
been  assumed  as  consequences  of  ligation.  Diseases  of  the  blood-vessels 
of  the  stump  of  the  tied  cord,  diseases  of  the  liver,  and  the  jaundice  inci- 
dent to  such  affections,  are  by  some  attributed  solely  to  ligation.  As  every 
medical  practitioner  of  judgment  and  experience  well  knows,  these  evil 
results  of  ligation  arc  absolutely  imaginary ;  while  dangerous  or  even  fatal 
hemorrhage  from  the  unclosed  blood-vessels  of  the  cut  cord  is  too  real  a 
trouble  to  be  forgotten  or  io-nored. 

Undoubtedly,  if  the  cord  were  divided  by  an  t^craseur,  or  by  biting, 


238  THE    CAEE    OP    THE    CHILD    AT    BIRTH. 

instead  of  by  a  sharp  instrument,  the  danger  of  hemorrhage  would  be 
greatly  lessened,  but  it  would  never  be  so  completely  obviated  as  by  the 
application  of  a  ligature, — an  expedient  as  safe  as  it  is  sure. 

The  ligature  should  be  applied  about  the  breadth  of  three  fingers  from 
the  child's  body ;  that  is,  far  enough  to  allow  for  re-tying  should  any  acci- 
dent render  this  necessary,  and  not  so  near  as  to  cause  the  true  skin  of  the 
child  to  be  caught  in  the  tie. 

It  has  been  advised  to  apply  a  second  ligature  about  two  inches  nearer 
the  placenta  than  the  first,  or  child's  ligature,  and  to  divide  the  cord  between 
the  two.  This  practice  should  be  limited  to  cases  of  plural  births ;  and 
the  reason  for  its  employment  in  these  is,  that,  where  there  are  two  or  more 
foetuses  in  the  cavity  of  the  uterus,  the  placental  circulations  of  the  children 
sometimes,  though  rarely,  communicate,  and,  as  a  result  of  this  communi- 
cation, after  the  birth  of  the  first  child,  should  the  second  ligature  be 
omitted,  hemorrhage  may  take  place  froni  the  placenta  of  the  child  or 
children  still  in  the  cavity  of  the  uterus.  When,  however,  we  realize  that 
we  have  to  do  with  a  single  child  only,  we  should  not  apply  the  second 
ligature.  It  must  be  borne  in  mind  that  the  blood  which  escapes,  for  a  few 
minutes,  freely  from  the  placental  extremity  of  the  cut  cord  is  useless  blood, 
— is  foetal  blood,  not  maternal.  It  is  blood  that  has  done  its  work,  and, 
like  the  placenta,  of  whose  mass  it  forms  a  large  part,  its  life  and  usefulness 
are  ended.  This  placental  blood  is  not  needed  by  the  child,  whose  vascular 
system  has  retained  all  that  is  necessary  for  the  welfare  of  the  individual, 
and  any  attempt  to  secure  for  the  child  a  portion  of  this  blood  will  be  use- 
less, or  worse  than  useless,  since,  if  successful,  the  delicate  blood-vessels  of 
the  child  would  become  too  full,  and  a  plethora  would  be  produced  that 
might  have  the  most  disastrous  consequences, — a  plethora  which,  even  under 
the  most  favorable  circumstances,  would  be  very  much  more  undesirable  than 
its  opposite  condition  of  ansemia.  When  the  placental  extremity  of  the  cut 
cord  is  not  ligated,  blood  flows  freely  from  it  for  a  few  moments  after  the 
vessels  are  divided.  This  escape  of  now  useless  placental  blood  is  important 
in  the  physiology  of  the  third  stage  of  labor.  In  consequence  of  its  escape, 
the  mass  of  the  placenta  is  greatly  reduced  in  volume,  perhaps  to  a  size  of 
less  than  one-half  of  what  it  would  have  been  had  a  second  ligature  been 
applied  and  the  blood  retained.  This  great  shrinking  of  the  after-birth, 
prior  to  its  expulsion,  undoubtedly  helps  greatly  the  speed  and  ease  of  its 
delivery. 

The  next  thing,  after  ligation,  is  to  cut  the  cord.  The  best  instrument 
for  this  purpose  is  a  pair  of  strong,  sharp,  blunt-pointed  scissors. 

Here  again  we  are  advised,  in  the  same  vein  of  ma^vkish  prudery  that 
I  have  already  referred  to,  to  seize  the  cord  in  a  particular  manner,  i.e., 
between  certain  fingers  and  the  thumb,  and  to  cut  it,  thus  guarded  between 
them,  under  the  clothes,  so  as  to  avoid  exposure.  The  great  objection  to 
this  highly  moral  and  modest  method  is  that  at  times  the  embarrassed 
attendant  has  cut  off  the  fingers  or  toes,  or,  still  more  unfortunately,  the 


THE    CARE    OF    THE    CHILD    AT    BIRTH.  239 

penis,  of  the  unlucky  infant,  instead  of  amputating  its  umbilical  cord. 
The  best  method  is  to  direct  the  nurse,  or  some  intelligent  assistant  (the 
child  lying  on  its  back),  to  hold  the  cord,  thus  guarding  the  child  from  any 
sudden  movement  of  its  limbs ;  and  then  the  scissors  can  be  employed  to 
sever  the  cord  with  absolute  safety. 

In  cutting  the  cord,  we  do  so  about  a  half-inch  from  the  ligature,  thus 
furnishing  a  little  nubbin  or  button  beyond  the  ligature  which  serves  as  a 
guard  to  keep  it  from  slipping. 

Having  cut  the  cord,  we  wipe  the  cut  surface  of  the  stump  with  a  towel 
to  assure  ourselves  that  the  occlusion  of  the  blood-vessels  is  complete,  and 
then  the  child  is  ready  to  be  handed  to  its  temporary  nurse. 

Some  caution  is  desirable  in  handling  a  new-born  infant :  the  surface  of 
the  child  is  very  slippery,  and,  should  this  be  forgotten,  the  infant  might 
easily  escape  from  the  grip  of  the  careless  attendant.  The  child  may  be 
seized  and  handed  to  its  nurse,  securely  and  safely,  by  the  following  methods. 
Place  one  hand  under  the  anterior  part  of  the  thorax,  so  that  in  lifting  the 
child  its  head  and  limbs  will  hang  flexed ;  or,  supporting  the  back  of  the 
head  and  neck  with  one  hand,  grasp  the  inferior  extremities  with  the  other. 
The  nurse,  or  some  one  especially  detailed  for  the  service,  should  receive  the 
child  in  a  piece  of  well-warmed  flannel  or  other  suitable  material,  and, 
wrapping  it  well  up,  should  hold  it  in  her  lap  or  arms,  preferably  on  the 
right  side,  until  the  time  for  its  toilet.  I  say  she  should  hold  it  in  her  lap, 
since  I  have  known,  especially  in  instances  where  the  people  were  poor,  and 
the  apartment  small, — I  have  known  a  child  to  be  wrapped  up  in  a  piece 
of  old  blanket,  or  some  old  garment,  then  to  be  placed  hurriedly  and 
thoughtlessly  on  the  mother's  bed,  or  on  a  sofa,  or  a  dressing-table,  or  a 
wash-stand,  or  a  rocking-chair,  or  even  on  the  floor.  If  it  should  happen 
to  be  a  quiet  child,  and  not  cry,  and  should  any  circumstance  direct  especial 
attention  to  the  mother,  as  hemorrhage,  presently  it  will  be  forgotten. 
Small,  and  wrapped  in  its  old  covering,  it  looks,  lying  on  the  sofa  or  the 
floor,  as  if  it  were  merely  one  of  the  many  old  towels  or  other  old  things 
used  during  the  labor,  and  not  the  precious  baby, — the  cause  of  the  whole 
business.  I  have  known,  under  such  circumstances,  the  new-born  infant 
to  be  sat  upon ;  to  be  rolled  off  the  bed ;  to  be  trodden  upon.  Hence  tlie 
great  importance  of  the  direction  I  have  given, — that  the  new-born  child  is 
to  be  held  by  some  responsible  person,  on  its  right  side,  from  the  time  it  is 
separated  from  its  maternal  connections  until  it  receives  its  first  toilet. 

We  find  the  surface  of  the  child,  at  birth,  covered,  more  or  less  thickly, 
with  a  sebaceous  coating,  the  product  of  the  glands  of  the  skin,  looking  as 
if  it  had  been  plastered  with  a  mixture  of  lard  and  tallow.  This  covering, 
whatever  may  have  been  its  other  uses,  has  served  admirably  to  protect  the 
delicate  surface  of  the  foetus  from  the  macerating  influence  of  the  liquor 
amnii,  in  whicli  it  has  been  soaking  during  gestation.  Some  children  are 
much  more  thickly  covered  or  plastered  over  witli  this  substance  than 
others;  and  in  all  children  it  is  found  in  greater  quantity  in  certain  locali- 


240  THE  CARE  OF  THE  CHILD  AT  BIRTH. 

ties,  as  the  head,  about  the  genitals,  etc.  The  soap  and  water  employed  to 
cleanse  the  infant  from  the  accidental  foulings  incident  to  delivery,  as  blood, 
fseces,  etc.,  will  not  remove  it.  It  should  not  be  suffered,  however,  to  remain. 
If  left  on  the  skin,  presently  it  dries,  cracks,  and  finally  causes  more  or  less 
irritation  of  the  surface.  We  remove  this  sebaceous  matter  by  anointing  the 
infant,  before  washing,  with  some  substance  in  which  it  is  soluble.  It  is 
readily  dissolved  by  animal  oils  and  fats,  by  albumen,  by  alcohol.  The 
substance  usually  employed  to  dissolve  it  is  hog's  lard. 

We  can  now  intelligently  consider  the  toilet  of  the  new-born  child,  and, 
as  this  toilet  relates  to  both  its  health  and  its  comfort,  I  will  describe  it  spe- 
cifically and  minutely.  If  the  weather  be  cold,  this  toilet  must  be  made  in 
a  very  warm  room, — preferably  in  front  of  an  open  fire  or  grate.  It  must 
never  be  forgotten  that  the  child,  until  the  moment  of  its  birth,  has  always 
been  in  a  temperature  of  98°  to  100°  Fahrenheit,  and  that  any  prolonged 
exposure  to  cold  after  birth  may  be  followed  by  disease  and  even  death. 

The  nurse  should  prepare  beforehand  and  have  within  easy  reach  the 
following  :  a  cup  or  tumbler  of  clean  cold  water ;  a  large  basin  or  a  tub  of 
hot  water  of  not  less  than  100°  Fahrenheit,  while  it  will  often  be  better  to 
have  the  water  of  the  temperature  of  105°  or  even  110°  ;  some  hland  soap, 
as  old  white  Castile  or  pure  palm ;  a  teacupful  of  fresh  hog's  lard ;  soft 
wash-rags  or  sponges ;  some  soft  warm  towels ;  some  soft  old  rag :  muslin 
is  as  good  as  linen  for  the  purposes  needed,  or  even  better. 

Sitting  in  front  of  the  fire, — should  there  be  one, — the  baby  on  its  back, 
and  an  assistant  at  hand  to  lend  her  aid  if  necessary, — the  toilet  is  begun 
and  conducted  as  follows. 

The  nurse  should  begin  at  the  mouth,  and  with  a  clean  rag  over  her 
finger  wash  out  the  buccal  cavity ;  having  removed  the  epithelial  and 
mucous  accumulations  of  gestation,  the  infant  may  be  given  a  few  drops 
of  water  to  swallow,  or  a  little  sweetened  water,  taking  it  by  sucking  from 
a  piece  of  clean  rag,  or  from  the  finger  of  the  nurse,  or  from  a  teaspoon. 

The  next  step  is  to  remove  the  sebaceous  matter  from  the  child's  skin. 
For  this  purpose  the  nurse  takes  a  piece  of  old  rag, — nothing  better  than  a 
piece  of  soft  old  flannel, — and,  keeping  the  child  well  wrapped  in  its  cover- 
ing, begins  at  the  head,  rubbing  the  surface  briskly  with  the  lard  by  means  of 
the  rag ;  instantly  the  cerumiuous  coating  disappears,  dissolved  by  the  lard  ; 
the  capillary  circulation,  stimulated  by  the  brisk  friction,  becomes  active, 
and  the  surface  in  consequence  a  bright  red  color.  Similar  applications  of 
lard  to  the  other  parts  of  the  surface  secure  similar  results ;  and  presently 
the  infant  is  ready  to  receive  the  detergent  benefits  of  soap  and  hot  water. 

It  is  well  to  follow  a  systematic  method  in  giving  this  bath.  The  nurse 
should  begin  with  the  head,  keeping  the  body  well  covered.  The  hot  water 
and  bland  soap  quickly  remove  the  lard  and  the  sebaceous  matter  it  has  dis- 
solved, together  with  the  soiling  incident  to  labor.  The  nurse  should  be 
cautioned  to  apply  the  soap  prudently  about  the  eyes.  Conjunctivitis  in  the 
new-born  child  may  be  due  to  other  causes  than  the  acrid  secretions  of  the 


THE    CARE    OF    THE    CHILD    AT    BIRTH.  241 

maternal  parturient  surfaces.  Among  these  causes  are  exposure  to  cold,  to 
too  bright  light,  and  last,  but  by  no  means  least,  the  careless  application  of 
soap  to  the  eyes  during  the  first  bath. 

After  the  head  is  washed  and  carefully  dried,  the  same  detergent  appli- 
cation of  soap  and  hot  water  is  made  successively  to  the  other  parts  of  the 
body,  the  child  still  lying  on  its  nurse's  lap,  and  still  covered,  save  the  part 
undergoing  the  cleansing  process.  Speedily  the  parturient  soilings  are  all 
removed,  and  the  infant  is  then  ready  for  its  grand  and  final  hot  bath.  For 
this  purpose  it  is  best  to  have  a  large  wash-basin  or  a  bath-tub  containing 
hot  water  that  has  not  been  contaminated  by  the  cleansing  wash  just  de- 
scribed. The  temperature  of  this  water  should  be  the  same  as  I  have  sug- 
gested as  desirable  for  that  used  in  the  detergent  wash, — that  is,  from  100° 
to  110°  Fahrenheit. 

Into  this  hot  bath  the  whole  body  of  the  infant,  save  its  head,  is  now  to . 
be  plunged ;  and  this  immersion  may  be  prolonged  from  half  a  minute  U\ 
one  or  two  or  more  minutes, — in  other  words,  until  the  child  is  well  rinsed, 
and,  if  need  be,  well  stimulated  by  this  bath  of  clean,  hot  water. 

Usually,  during  the  various  manipulations  I  have  described,  but  almost 
certainly  during  the  final  plunge,  the  child  cries  vigorously.  This  appar- 
ently mere  automatic  action  is  highly  beneficial  in  completely  establishing 
the  respiratory  function,  stimulating,  at  the  same  time,  in  a  most  salutary 
manner  the  general  as  well  as  the  capillary  circulation. 

The  infant,  on  removal  from  its  bath,  should  be  enveloped  in  hot,  soft, 
absorbing  towels,  and  gently  and  thoroughly  dried.  The  nurse  should  now 
change  the  apron  she  has  worn  during  the  bath  for  a  fresh  dry  one,  before 
proceeding  with  the  dressing  of  the  infant.  Before  applying  the  cloths,  the 
stump  of  the  umbilical  cord  must  be  "dressed."  "Dressing  the  cord"  means 
enveloping  the  stump  of  the  cord  in  some  soft  absorbing  material  which  will 
soak  up  the  putrid  fluids  incident  to  the  process  of  sloughing.  Usually 
some  old  linen  rag  is  furnished  for  this  purpose.  This  linen  rag  is  in  no 
respect  to  be  preferred  to  old  muslin  rag,  and  often  is  not  so  soft  or  absorb- 
ing as  the  old  muslin,  and  therefore  not  so  suitable  for  the  object  in  view. 
The  medical  attendant  should  "dress  the  cord"  himself,  after  which  the 
nurse  may  put  on  the  child's  garments.  There  are  several  styles  of  dressing 
the  cord.  The  usual  one  is  to  take  a  square  of  old  rag  (three  or  four  inches 
square),  composed  of  two  or  more  layers ;  a  hole  is  cut  in  the  centre  of  this 
square,  through  which  the  stump  of  cord  is  passed,  and  is  placed  on  the  sur- 
face of  the  abdomen  :  or  the  cord  may  be  dressed  with  borated  or  sublimated 
absorbent  cotton.  The  cut  surface  of  the  cord  is  directed  to  the  chin  of  the 
child  ;  the  square  is  folded  over  the  stump,  and  then  folded  laterally,  and  thus 
the  cord  is  enveloped  in  several  layers  of  absorbing  rag,  which  keep  it  well 
protected  until  the  sloughing  is  accomplished.  This  covering  may  be  kept 
more  securely  by  tying  it  to  the  cord  with  a  soft  string.  Another  method 
of  dressing  the  cord  is  to  prei)are  a  small  roller,  say  a  foot  long  and  an  inch 
wide,  and  apply  this  to  the  stump  until  it  is  protected  by  several  layers  of  the 
Vol.  I.— 16 


242  THE    CAEE    OF   THE    CHILD    AT   BIRTH. 

material.  The  cord,  being  by  one  of  these  methods  properly  enveloped,  is  then 
to  be  secured  to  the  surface  of  the  abdomen,  both  for  the  child's  comfort  and 
to  prevent  injury  to  the  blood-vessels  of  the  umbilicus.  This  may  be  done 
simply  by  turning  the  end  of  the  stumj)  towards  the  child's  chin,  and 
securing  it  by  means  of  a  couple  of  strips  of  adhesive  plaster, — a  most 
excellent  method.  The  usual  mode,  however,  is  to  apply  the  "binder." 
This  binder  should  be  made  of  flannel,  wide  enough  to  reach  from  the  hips 
to  the  axilhe,  and  long  enough  to  go  twice  around  the  child's  body ;  it  should 
not  be  hemmed,  as  it  usually  is  prepared,  since  the  hem  makes  a  cord,  and 
when  applied  presses  uncomfortably  on  the  skin.  In  applying  the  binder 
the  stump  is  turned  towards  the  chin,  and  is  secured  by  rolling  the  binder 
twice  round  the  child's  body  and  fastening  with  safety-pins.  Nurses  often 
apply  this  binder  too  tight,  intending  by  so  doing  to  prevent  umbilical  and 
other  forms  of  hernia  :  really,  however,  the  practice  favors  the  development 
of  hernia,  or  aggravates  it  if  already  existing.  The  binder  should  be  applied 
as  loosely  as  is  consistent  with  the  purpose  for  v/hich  it  is  used.  It  might 
be  remarked  here  that  a  healthy  infant,  properly  dressed,  should  be  entirely 
comfortable,  a  good  deal  fatigued,  and  very  ready  for  a  good,  quiet  sleep, 
immediately  after  its  first  toilet.  Hence,  when  an  apparently  healthy  child, 
afcer  being  dressed,  is  restless  and  uneasy  and  disposed  to  cry,  the  difficulty, 
usually,  is  not  "  colic,"  which  is  almost  always  given  as  the  cause  of  these 
symptoms,  but  some  error  in  the  dressing  ;  and  the  physician  should  examine 
the  child  carefully  to  ascertain  what  it  is.  The  best  way  to  do  this  is  to 
place  the  infant  in  the  middle  of  a  bed,  then  to  have  it  undressed,  scruti- 
nizing closely  each  garment  and  the  way  it  has  been  applied  and  secured ; 
and  it  will  often  be  found  that  the  cause  of  the  "  colic"  is  some  pricking 
pin,  or  too  tightly  applied  binder,  etc.,  the  removal  of  which  will  be  speedily 
followed  by  the  disappearance  of  all  the  unpleasant  symptoms. 

The  stump  of  the  cord  will  slough  oif  in  from  four  to  seven  days, 
leaving,  in  a  healthy  child,  a  superficial  and  healthy  ulcer  which  quickly 
heals.  Should  the  raw  surface  be  disposed  to  become  sluggish,  some  mild 
astringent  may  be  applied,  as  the  oxide  of  zinc,  or  iodoform,  or  a  mixture 
of  both  of  these.  During  the  process  of  sloughing  the  stump  becomes  more 
or  less  oifensive,  sometimes  quite  disagreeably  so.  An  excellent  corrective 
application  is,  daily,  after  the  child's  bath,  indeed,  in  some  instances,  oftener 
than  once  daily,  to  envelop  the  stinking  stump  and  its  original  covering 
(which  should  not  be  interfered  with)  with  several  layers  of  well  burnt  and 
charred  old  rag ;  in  other  words,  to  apply  several  coatings  of  freshly-pre- 
pared charcoal.  This  acts  most  happily  as  an  absorber  of  offensive  gases, 
as  an  antiseptic,  and,  what  is  of  equal  or  even  greater  importance,  as  a 
dryer;  rapid  desiccation  of  the  stump  being  important  not  only  to  the 
speedy,  but  the  safe,  separation  of  the  decomposing  structure. 

Before  putting  on  the  garments  the  child  should  be  examined  carefully 
all  over,  to  ascertain  the  presence  or  absence  of  any  vice  of  conformation. 

The  medical  attendant  is  not  usually  consulted  regarding  the  clothes  the 


THE    CAEE    OF    THE    CHILD    AT    BIETH.  243 

infant  is  to  be  dressed  in.  All  that  he  is  called  upon  to  look  after  is  that, 
in  cold  weather,  the  child  is  clad  sufficiently  warmly.  This  can  roughly  be 
determined  by  feeling  its  hands  and  feet :  if  these  are  warm,  its  clothing  is 
usually  sufficient ;  if  cold  and  clammy,  the  child  needs  more  covering.  It 
must  always  be  borne  in  mind  that  heat  means  life  to  the  new-born.  It  is 
best  to  err  by  having  too  much  rather  than  too  little  of  it. 

In  view  of  the  active  circulation  in,  and  the  rapid  development  of,  the 
child's  brain  after  birth,  no  covering  is  applied  to  the  head.  Formerly  this 
was  not  the  practice,  and  all  children  had  the  head  covered  with  caps  from 
birth.  The  present  practice  of  omitting  the  cap,  for  the  reasons  I  have 
given,  seems  to  be  attended  by  such  good  results  that  it  is  to  be  commended. 

The  child's  toilet  is  now  completed.  If  the  mother  have  recovered 
sufficiently  from  the  fatigues  of  labor,  it  should  now  be  put  to  the  breast ; 
indeed,  this  early  application  to  the  breast  is  so  very  desirable,  for  both 
mother  and  child,  that  no  ordinary  circumstance  should  be  permitted  to  post- 
pone it.  For  the  mother  it  is  valuable  in  securing  jDfompt  and  continued  con- 
traction of  the  uterus,  thereby  preventing  post-partum  hemorrhage,  excessive 
bloody  lochial  discharge,  and  after-pains.  For  the  child  it  is  important 
in  furnishing  some  nourishment,  and  in  affording  an  opportunity  for  early 
exercise  of  its  automatic  faculty  of  sucking,  a  matter  of  no  little  moment, 
since  it  sometimes  happens,  when  the  application  of  the  infant  to  the  breast 
is  postponed  for  several  days,  that  the  faculty  seems  to  be  lost,  and  the  child, 
ever  after,  refuses  to  take  the  breast.  Should  the  child  for  any  reason  not 
be  put  to  the  breast,  it  may  be  given  a  few  teaspoonfuls  of  warm,  sweetened 
water,  and  then  may  be  placed  in  its  cradle  or  crib,  on  its  right  side,  well 
covered,  and  out  of  all  draughts.  Its  eyes  should  be  protected  from  ex- 
posure to  all  bright  lights,  natural  and  artificial,  and  its  surrounding  atmos- 
phere should  be  as  pure  as  the  possibilities  of  the  situation  admit  of. 

I  have  said  that  the  child  should  be  placed  in  its  crib  or  cradle  :  I  advise 
a  cradle.  It  is  the  fashion  of  our  generation,  it  was  not  of  our  fathers  and 
grandfathers,  to  proscribe  cradles.  It  is  held  that  the  rocking  movement 
of  the  cradle  is  injurious  to  the  child ; — how  injurious  does  not  seem  to  be 
definitely  determined. 

This  theory  I  am  convinced,  through  long  observation  and  large  experi- 
ence, is  absolutely  Avithout  foundation.  Nay,  more,  I  hold  that  the  results 
of  the  soothing  rocking  movements  of  the  cradle  are  positively  beneficial. 
I  consider  a  nursery  lacking  a  cradle  as  destitute  of  an  article  not  only 
of  great  present  comfort  to  the  child,  and  very  great  relief  to  its  care-takers, 
but  also  of  no  little  importance  to  the  future  welfare  of  the  infiint.  The 
dreadful  increase  in  affections  of  the  nervous  system  which  the  present 
generation  experiences  is  undoubtedly  due  to  many  and  complex  causes ; 
and  I  here  throw  out  the  suggestion,  would  not  the  sootliing  influences  of  a 
cradle  on  the  nervous  system  of  infancy  have  rendered  that  system  less 
irritable,  and,  consequently,  less  disposed  to  be  injuriously  affected  by  the 
innumerable  causes  of  nervous  disease  incident  to  the  whirl  of  modern  life? 


244  THE    CARE    OF    THE    CHILD    AT    BIETH. 


THE   CAKE   OF   THE   CHILD   AT   BIKTH   IjST  ABNOKMAL   CONDITIONS. 

We  must  not  expect  to  find  the  child  at  birth  always  in  health,  and  pre- 
senting the  appearances  I  have  just  described  as  characterizing  that  con- 
dition :  it  is  not  always  plump  and  red,  with  a  cry  whose  pitch  and  volmne 
at  once  suggest  the  lungs  of  a  youthful  Stentor. 

Sometimes  the  child  is  in  a  condition  of  debility,  sometimes  not  only 
weak,  but  the  victim  of  disease,  sometimes  apparently  dead,  sometimes 
really  dead, — still-born. 

The  causes  of  these  abnormal  conditions  are  many  and  varied.  They 
are  the  results  of  diseases  of  the  foetus  during  gestation,  or  the  results  of 
the  accidents  of  gestation  and  parturition. 

The  product  of  conception  evolves,  during  gestation,  from  a  cell  to  a 
matured  foetus,  and,  in  this  evolution,  passes  through  changes  and  meta- 
morphoses of  the  most  extraordinary  nature ;  and  yet,  in  healthy  gestation, 
it  accomplishes  these  changes  and  metamorphoses  with  a  precision  and  ex- 
actness as  mathematically  accurate  as  the  crystallization  into  definite  and 
well-known  forms  of  a  saline  solution.  Hence,  it  is  evident  that  if  the 
building-material,  out  of  which  the  future  man  is  to  be  erected,  be  good, 
from  it  will  evolve  a  structure  that  will  be  correspondingly  good.  The 
evolution  of  a  healthy,  well-developed  infant  is,  then,  not  a  matter  of  chance 
or  accident ;  but  it  takes  place  as  the  result  of  laws  as  unerring  and  precise 
as  the  laws  of  crystallization. 

Healthy  men  and  healthy  women,  inheriting  themselves  good  constitu- 
tions, and  living  healthy  moral  and  healthy  physical  lives,  cannot  have  any 
but  healthy  children.  But,  unfortunately,  all  men  and  all  women  are  not 
healthy ;  unfortunately,  they  have  either  inherited  or  acquired  bad  constitu- 
tions. Still  worse,  few  men  and  few  women  lead  typically  healthy  moral 
and  typically  healthy  physical  lives ;  and  the  inevitable  consequence  of  it  all 
is  that,  when  these  imperfect  men  and  imperfect  women  marry,  if  they  have 
children,  they  must  necessarily  be  more  or  less  imperfect  children. 

The  study  of  prenatal  diseases  shows  that  these  conditions,  to  which  I 
am  now  referring,  cause  all  sorts  of  abnormal  evolutions  in  the  embryo  and 
foetus,  and  lead  to  a  great  variety  of  diseases,  deformities,  and  monstrosi- 
ties ;  they  constantly  cause  the  death  of  the  product  of  conception  during 
gestation,  and,  hence.  Abortion,  the  great  accident  of  gestation,  is  frequently 
due  to  them. 

Over  the  threshold  of  life  is  written  the  declaration  of  Xature's  right- 
eous and  inexorable  law,  "  The  fittest  shall  survive ;"  and  this  law,  so  just, 
so  stern,  so  merciless  in  its  unpitying  exactions,  is  the  law  which  governs, 
not  only  life's  beginning,  but  life's  progress  and  life's  end. 

Man's  intellect  may  enable  him  to  elude  the  workings  of  this  law  for  a 
time,  but  ultimately  its  majestic  omnipotence  triumplis  ;  ultimately  the  fittest 
alone  survive. 

Innumerable  children  die  before  birth,  or  at  birth,  or  shortly  after  birth, 


THE    CARE    OF    THE    CHILD    AT    BIRTH.  245 

or  even  years  after  birth,  not  because  our  science  or  skill  is  valueless,  but 
because  Nature's  doom  was  pronounced  at  the  moment  of  conception ;  and 
that  wise  and  holy  fiat,  by  which  alone  a  perfect  race  of  men  can  be  possible, 
"  The  fittest  shall  survive," — that  fiat  proves  their  destruction. 

It  is  evident,  therefore,  that  we  are  not  to  mourn,  nor  even  to  regret, 
every  child  that  is  born  dying  or  dead ;  indeed,  often  this,  apparently  sad, 
termination  of  gestation  is  a  matter  for  congratulation  rather  than  grief; 
and  though  we  are  professionally  bound  to  do  all  we  can  for  our  suffer- 
ing charges,  w^e  may  comfort  ourselves,  when  the  results  are  unfavorable, 
with  the  reflection  that  man  cannot  contend  successfully  against  the  laws  of 
Nature. 

Sometimes,  then,  children  are  born  dead,  sometimes  apparently  dead, 
sometimes  in  a  condition  of  asthenia  or  debility.  Let  us  consider  first  the 
condition  of  Asthenia  or  Debility. 

DEBILITY   IN   THE   NEW-BOKN   CHILD. 

There  is  no  difficulty  in  recognizing  asthenia  in  the  child.  The  infant 
is  pale,  at  times  blue ;  its  features  shrivelled  ;  if  the  victim  of  prenatal  dis- 
ease, often  more  or  less  emaciated ;  though  just  born,  often  presenting  the 
appearance  of  age  and  decrepitude. 

In  these  cases,  we  listen  in  vain  for  the  welcome  music  of  the  child's 
first  cry ;  instead,  we  notice  the  convulsive  gasp,  or  hear  low  moans,  and 
perhaps  the  gurglings  of  air,  as  it  is  painfully  and  laboriously  drawn 
through  the  mucous  accumulations  in  the  larynx  and  trachea.  The  child 
breathes  imperfectly,  either  because  it  is  too  feeble  to  expand  its  lungs,  or 
because,  being  a  premature  child,  these  organs  are  not  sufficiently  developed. 
Hence  its  blood  is  not  aerated ;  hence  it  is  blue  ;  hence  it  is  cold  ;  hence  it 
cannot  cry. 

In  the  treatment  of  the  new-born  child,  in  such  conditions,  we  must 
carefully  bear  in  mind  the  possible  causes  of  the  asthenia. 

Perhaps  we  are  most  frequently  called  to  treat  the  debility  in  premature 
children ;  children  born,  more  or  less,  before  full  term.  We  must  be  careful 
not  to  exhaust  the  feeble  or  fainting  child  by  our  washing,  etc.  A  weak 
child  might  die  if  subjected  to  manipulations  most  desirable  for  a  strong 
and  healthy  one.  The  child  may  be  too  weak  to  rub  ^^'ith  lard  and  wash. 
If  possible,  however,  it  is  best  to  grease  and  wash  it.  Under  such  circum- 
stances, the  water  should  be  as  hot  as  can  be  used,  from  110°  to  120°  Fah- 
renheit ;  and  sometimes  it  is  best  to  use  whiskey,  or  w^hiskey  and  ANater,  at 
the  same  temperature.  At  times  the  child  is  so  weak  that  it  is  not  prudent 
to  dress  it ;  and  all  that  can  be  done  is  to  envelop  it  in  hot  flannel,  or,  better 
still,  in  hot  carded  cotton  or  wool. 

There  are  three  elements,  each  of  which  is  essential  to  the  proper  man- 
agement of  these  feeble  children.  These  essentials  are,  the  removal  of  all 
obstructions  to  res]iiration,  a  very  high  external  temperature,  and  the  use 
of  nourishment  and  internal-  stimuli. 


246  THE   CAEE   OF   THE   CHILD   AT   BIETH. 

Obstructions  to  respiration  in  the  mouth  should  be  removed  by  wiping 
out  the  buccal  cavity :  those  in  the  larynx  and  trachea  are  not  so  easily 
got  rid  of.  An  expedient,  at  times,  of  value  is  to  hold  the  child  by  the 
lower  extremities,  with  its  head  down,  and  then  to  shake  it  briskly,  or  spank 
it  sharply  on  the  nates :  a  sudden  inspiration,  followed  by  a  cough,  may 
remove  the  whole  trouble. 

Should  such  efforts  fail,  nothing  is  left  but  to  wait,  in  the  hope,  too  often 
vain,  that  the  child  will  ultimately  acquire  strength  sufficient  to  take  a  full 
inspiration,  and  thus  get  rid  of  the  obstruction. 

The  second  essential  is  a  very  high  external  temperature.  We  must 
recollect  that  these  feeble  children  breathe  more  or  less  imperfectly ;  hence 
they  do  not  inhale  nearly  enough  oxygen  to  aerate  their  blood ;  hence  they 
must  be  cold ;  hence  they  must  be  weak. 

As  such  children  cannot  make  heat  for  themselves,  we  must  supply  it 
from  without.  Should  we  permit  the  child's  temperature  to  fall  much 
below  normal,  it  will  certainly  die  :  many  feeble  children  die  from  this 
cause  alone,  who,  treated  in  the  way  I  am  about  to  describe,  would  as 
certainly  have  survived. 

It  is  difficult  to  define  with  precision  the  exact  amount  of  heat  demanded 
or  borne  under  such  circumstances.  Each  case  requires  such  careful  and 
constant  attention  and  watching,  that  the  temperature  may  be  increased  or 
diminished  as  may  seem  to  be  necessary. 

In  many  cases  the  temperature  should  be  paradoxically  high.  The  body 
of  the  child  should  be  kept  at  a  temperature  of  not  less  than  98°  to  100° 
Fahrenheit,  and,  to  secure  this,  may  demand  almost  literal  "roasting." 
Hot  bottles  and  bags,  etc.,  are  to  be  used ;  so  also  is  radiated  heat  from  an 
open  fire.  The  surrounding  atmosphere  should  be  very  hot ;  in  this  way  the 
blood  is  warmed  through  the  lungs,  as  well  as  external  temperature  main- 
tained. Cases  are  reported  where  feeble  new-born  children  have  been  given 
up  as  dead,  have  been  left  hopelessly  in  front  of  a  very  hot  fire,  and,  after 
a  prolonged  "  toasting,''  have  been  discovered  to  be  alive,  and  have  subse- 
quently done  well. 

The  third  essential,  in  these  cases,  is  the  use  of  nourishment  and  internal 
stimuli.  The  child  is  too  feeble  to  take  nourishment  by  sucking,  and  it 
should  be  administered  by  a  mop  or  a  teaspoon.  It  should  be  given  in  small 
quantities,  a  few  teaspoonfuls  at  a  time,  very  hot,  and  should  be  frequently 
repeated.  Hot  milk  mixtures  and  hot  dilute  spirit  are  best.  A  good  formula 
for  the  dilute  spirit  is,  a  teaspoonful  of  spirit  (brandy  or  whiskey)  added  to 
five  teaspoonfuls  of  hot  water  slightly  sweetened.  Of  this  mixture,  the 
child  may  be  given  one  or  more  teaspoonfuls  from  every  few  minutes  to 
every  hour  or  more,  as  may  be  necessary.  I  think  I  have  saved  the  lives 
of  some  feeble  children  by  intoxicating  them  with  hot  spirit-and-water,  and 
keeping  them  mildly  drunk  for  some  time  after. 

By  treating  feeble  children  in  this  Avay  we  often  have  the  great  satisfac- 
tion of  saving  lives  otherwise  doomed.     But  often  they  die,  in  spite  of  all 


THE    CARE    OF    THE    CHILD    AT    BIRTH.  247 

our  efforts.  They  gradually  become  colder  and  colder;  their  faces  and 
hands  bluer  aud  bluer ;  their  respiration  more  and  more  gasping  and  feeble, 
until  it  finally  ceases.  Such  cases  die,  not  because  the  treatment  has  not 
been  the  best  and  most  efficient,  but  because  all  treatment  would  have  been 
useless. 

THE   NEW-BORN   CHILD  APPARENTLY   DEAD. 

Children  are  sometimes  born  not  merely  in  a  condition  of  asthenia,  but 
in  a  state  of  apparent  death ;  which  apparent  death  speedily  becomes  real 
death,  unless  proper  means  are  used  to  prevent  it,  and  often  in  spite  of  all 
remedies.  We  find  children  born  in  this  condition  of  apparent  death  pre- 
senting very  different  appearances.  Sometimes  the  face  and  upper  part  of 
the  body  are  red ;  sometimes  marked  with  bluish  spots,  and  swollen ;  the 
eyes  are  prominent  and  injected.  Again,  the  child  may  be  pale,  and  may 
exhibit  marked  evidences  of  profound  prostration. 

These  varied  appearances  are  produced  by  very  different  lesions,  and 
are  designated  by  a  variety  of  names  by  different  authors.  Some  speak  of 
ihem  as  the  "  apoplexy  and  syncope"  of  the  new-born ;  others,  as  the  "  con- 
gestive and  simple  asphyxia"  of  the  child.  Others  reject  these  terms  as 
very  imperfectly  designating  the  pathological  conditions  they  are  meant  to 
describe.  If  we  understand  the  causes  that  may  produce  these  conditions, 
and  the  treatment  necessary  under  the  circumstances,  it  matters  little  by 
what  name  we  call  them. 

OF    THE    APOPLECTIC    CONDITION,    OR    THE    CONDITION    OF    CON- 
GESTIVE  ASPHYXIA. 

In  this  condition  we  find  the  surface  swollen,  the  face  red,  or  bluish,  or 
spotted.  The  child  lies  apparently  dead ;  makes  no  effort  at  inspiration, 
makes  no  movement.  The  heart  may,  or  may  not,  pulsate.  Should  the 
child  die,  and  a  post-mortem  examination  be  made,  the  vessels  of  the  brain 
will  be  found  gorged  with  blood,  with,  at  times,  effiisions  of  blood  into  its 
substance,  or  on  its  surface.  The  thoracic  and  abdominal  organs  will  also 
be  found  congested ;  and  it  is  said  that,  at  times,  effusions  of  blood  into  the 
peritoneal  cavity  have  been  noticed. 

The  causes  which  may  occasion  these  phenomena  are  either  asphyxia,  or 
direct  compression  of  the  cervical  vessels  of  the  child.  Asphyxia  produces 
them  in  the  new-born  child,  just  as  asphyxia  produces  similar  conditions  in 
the  breathing  child,  or  in  the  adult.  The  blood  is  not  aerated,  congestion 
of  the  brain  and  hmgs  follows,  and  paralysis  of  the  cerebral  centres  results. 
Anything  occasioning  asphyxia,  either  during  labor  or  after  deliveiy,  may 
be  considered  as  a  cause  of  the  apoplectic  state  of  the  child. 

Hence,  compression  of  the  cord  during  labor,  twisting  of  the  cord,  pre- 
mature separation  of  the  placenta,  etc., — in  other  words,  anytliing  suspend- 
ing the  foeto-placental  circulation,  before  delivery, — will  produce  aspliyxia, 
as  surely  as  plugging  up  the  larynx  of  the  breathing  animal  will  produce 


248  THE    CAEE    OF    THE   CHILD    AT   BIETH. 

it.  So,  too,  after  birth,  any  cause  suspending  respiration,  as  mucus,  oi* 
any  other  material,  in  the  larynx  or  trachea,  may  occasion  it. 

The  apoplectic  condition  may  also  be  produced  by  any  cause  giving  rise 
to  direct  compression  of  the  cervical  vessels.  Hence  we  meet  with  it  in 
face-presentation,  and  in  cases  where  the  cord  has  been  wrapped  several 
times  round  the  neck  during  labor,  etc. 

It  is  not  difficult  to  comprehend  the  pathology  of  these  cases ;  indeed,  a 
clear  knowledge  of  this  suggests,  immediately,  the  appropriate  treatment. 

Tlie  child's  brain  is  engorged  with  blood  ;  this  engorgement  has  produced 
pressure  on  the  cerebral  centres,  which  pressure  has  paralyzed  their  action. 
Hence,  when  the  child  is  born,  its  brain  fails  to  respond  to  those  stimuli 
which  Nature  has  provided  to  rouse  it  to  the  performance  of  the  great  func- 
tion of  respiration.  The  cold  air,  striking  on  the  warm  and  wet  surface  of 
the  child,  ordinarily  a  most  powerful  stimulus  to  respiratory  action,  now  is 
incapable  of  waking  up  the  oppressed  and  congested  and  paralyzed  medulla 
oblongata.  But  if  we  cannot  awaken  the  medulla,  the  custodian  of  life's 
essential  functions,  the  child  must  inevitably  perish. 

Bearing  all  this  in  mind,  the  treatment  is  evident.  If  the  cerebral 
paralysis  be  the  result  of  mere  congestion,  in  most  instances  the  child, 
iproperly  treated,  will  recover.  If  the  paralysis  be  due  to  effusion  of  blood 
into  the  substance  or  on  the  surface  of  the  brain,  it  will  die. 

There  are,  however,  no  symptoms  that  enable  us  to  determine  whether 
the  cerebral  paralysis  is  the  result  of  mere  cerebral  engorgement,  and,  there- 
fore, curable,  or  the  result  of  cerebral  effusion,  and,  therefore,  almost  neces- 
sarily fatal.  Hence  we  treat  all  these  cases  alike.  Remembering  that  con- 
gestion of  the  brain  is  the  curable  cause  of  the  paralysis,  we  must  endeavor 
to  remove  it.  We  bleed  the  child  ;  that  is,  we  suffer  to  escape,  from  the  cut 
cord,  one,  two,  or  even  three  tablespoonfuls  of  blood ;  should  blood  not  flow 
from  the  cut  cord,  we  may  press  and  squeeze  it  from  its  insertion  to  the  cut 
extremity.  Failing  in  obtaining  blood  from  the  cord,  an  attempt  might  be 
made  to  obtain  it  by  opening  a  vein ;  though  I  fear  all  such  forlorn  efforts 
would  not  succeed. 

While  the  blood  is  flowing  from  the  cord,  sometimes,  the  blue  color  dis- 
appears ;  a  rosy  tint  shows  itself,  first  in  the  lips,  then  over  the  face,  and, 
finally,  over  the  body.  The  medulla  acts,  respiration  is  established,  the 
child  is  saved. 

The  next  remedy  is  the  very  hot  bath, — a  bath  of  a  temperature  from 
105°  to  120°  Fahrenheit.  This  very  hot  bath  acts  as  a  powerful  revul- 
sive, tending  to  relieve  the  overloaded  brain  and  to  equalize  the  circulation, 
while  at  the  same  time  it  is  a  powerful  stimulus  to  the  respiratory  cerebral 
centre.  After  depletion,  or  without  it,  a  basin  or  bucket  of  hot  water  may 
be  brought  to  the  bed,  should  the  child  not  yet  be  separated  from  the  pla- 
centa, because  depletion  from  the  cut  cord  has  not  been  practised,  and  the 
body  of  the  infant  may  be  plunged  in  the  hot  bath ;  after  immersion  for 
from  a  few  seconds  to  half  a  minute,  the  body  may  be  brought  to  the  surface, 


THE    CARE    OF    THE    CHILD    AT    BIRTH.  249 

and  water,  as  cold  as  can  be  obtained,  may  be  dashed  suddenly  on  the  face 
and  anterior  surface  of  the  thorax.  This  expedient  is  a  most  powerful 
stimulus  to  respiratory  action ;  the  first  contact  of  the  cold  water  with  the 
previously  very  hot  skin  of  the  infant  is  frequently  followed  instantly  by 
a  sudden  and  full  inspiration,  and  the  treatment  continued  soon  secures 
a  satisfactory  establishment  of  the  respiratory  process. 

Should  bleeding  and  flie  hot  bath  fail,  there  may  be  tried,  as  a  forlorn 
nope,  artificial  respiration ;  though  artificial  respiration  is  indicated  rather 
for  the  next  condition  I  am  about  to  describe,  than  for  the  present  one  of 
apoplexy  or  congestive  asphyxia. 

There  are  several  methods  followed  in  artificial  respiration  practised 
on  adults,  but  for  the  apparently  dead  new-born  child  I  am  confident  that 
there  is  but  one  way,  and  that  way  is  to  blow  directly  into  the  lungs  of  the 
child.  To  do  this  efficiently,  the  nostrils  must  be  pressed  upon,  to  jjrevent 
the  escape  of  air  from  the  nose ;  the  larynx  must  be  pressed  back  against 
the  anterior  surface  of  the  cervical  vertebrae,  to  o-uard  ao;ainst  the  air  enter- 
ing  the  stomach.  The  practitioner,  applying  his  mouth  to  the  mouth  of  the 
child,  blows  directly  into  it ;  if  preferred,  some  tube  may  be  used,  but  the 
mouth  is  the  better  expedient.  As  soon  as  the  lungs  are  sufficiently  inflated 
to  depress  the  diaphragm  and  raise  the  walls  of  the  thorax,  the  blowing  is 
to  be  discontinued,  and  the  thorax  and  abdomen  are  to  be  gently  pressed, 
imitating  expiration.  The  blowing  is  then  to  be  resumed,  and  the  mechan- 
ical expiration  to  be  repeated,  as  long  as  it  is  thought  desirable. 

How  long  is  it  desirable  to  practise  artificial  respiration  in  this  way  on  an 
asphyxiated  child  ?  This  question  is  not  easily  answered,  and  I  shall  reply 
to  it  by  giving  the  history  of  a  case,  all  the  parties  in  which  subsequently 
were  my  patients  for  many  years,  and  those  now  living  are  still  under  my 
professional  care.  Thirty-five  years  ago,  the  wife  of  a  young  physician 
was  confined  with  her  first  child,  under  the  care  of  a  celebrated  professor 
of  obstetrics.  The  labor  was  complicated  and  tedious  ;  the  patient,  during 
labor,  and  after  delivery,  was  in  great  peril,  demanding  the  entire  attention 
of  her  medical  attendant.  The  child,  when  born,  was  apparently  dead.  The 
old  professor  said  to  the  young  doctor  father  (the  mother  was  unconscious, 
and  therefore  did  not  hear),  "  Doctor,  cut  the  cord,  and  take  the  child  a^^-ay  : 
it  is  dead,  and  your  wife's  condition  claims  my  whole  care."  The  father 
separated  the  child,  carried  it  into  the  next  room,  and  placed  it  upon  a  bed. 

He  then  went  back,  and  again  asked  the  professor  if  he  were  sure  the 
child  was  dead,  receiving  again  a  positive  opinion  that  the  child  was  dead, 
and  that  all  attempts  to  revive  it  would  be  useless. 

The  father  returned  to  his  dead  baby,  and,  having  notliing  to  do,  in  a 
wild,  hysterical,  utterly  hopeless  sort  of  way,  began  artificial  res})! ration, 
after  the  manner  I  have  just  described.  Half  an  hour  passed,  with  no 
results  ;  the  agonized  father  continued  his  efforts ;  an  hour  passed,  but 
the  infant  seemed  as  hopelessly  dead  as  it  was  before  artificial  respiration 
was  attempted.     The  man's  emotional  paroxysm  began  to  subside,  and  he 


250  THE   CARE   OF   THE   CHILD   AT   BIETH. 

began  to  realize  that  he  was  literally  wasting  his  breath :  still  he  did  not 
desist.  Suddenly  he  was  startled  by  a  slight,  apparently  spontaneous  move- 
ment on  the  part  of  the  child ;  with  renewed  energy  he  continued  his  labors, 
and  in  a  short  time  normal  respiration  took  place,  and,  to  his  supreme 
felicity,  and  the  astonishment  of  the  medical  attendant,  the  child  was  saved. 
This  happened  thirty-five  years  ago.  The  great  professor  is  dead ;  the 
doctor  father  (my  friend  and  patient)  is  also  dead  ;  but  the  child,  called 
back  to  life  by  the  hysterical  blowings  of  an  agonized  father,  hopelessly 
practised  for  the  very  long  period  of  perhaps  an  hour  and  a  half, — ^the 
child,  now  a  grave,  mature  man,  still  lives,  the  comfort  and  solace  of  the 
mother  who  that  day  so  nearly  died  in  giving  him  birth. 

Let  this  most  interesting  case  be  my  answer  to  the  question,  "  How  long 
shall  artificial  respiration  be  kept  up  in  similar  exigencies  ?" 

Electricity  and  galvanism  have  been  suggested  as  agents  valuable  for 
arousing  these  torpid  nerve-centres,  and  may,  I  have  no  doubt,  in  some 
cases  prove  efficient.  They  should  be  employed  after  the  other  remedies  I 
have  suggested  have  failed. 

SYNCOPE  OF  THE   NEW-BOKN  CHILD,  OR  THE   CONDITION  OF  SIMPLE 

ASPHYXIA. 

Another  condition  of  apparent  death  in  the  new-born  child  is  syncope, 
or  simple  asphyxia. 

In  simple  asphyxia,  or  syncope,  we  do  not  notice  the  swollen  and  turgid 
face,  etc.,  that  characterize  the  apoplectic  condition  that  we  have  just  studied. 
The  child  exhibits  a  mortal  pallor,  with  all  the  evidences  of  profound 
debility.  This  syncope  may  be  the  result  of  two  essentially  different 
causes :  it  may  be  due  "to  excessive  debility  of  the  child,  or  to  some  lesion 
of  its  cerebral  centres.  Hence  we  meet  with  it  when  the  infant  is  diseased, 
or  premature,  or  has  lost  blood  during  labor.  Again,  it  may  be  the  result 
of  a  prolonged  labor,  especially  when  the  head  has  been  subjected  to  great 
and  long  pressure.  In  such  cases  the  brain  is  compressed,  and  the  cerebral 
respiratory  centres,  in  consequence,  are  paralyzed,  and  fail  to  act  when  the 
child  is  born. 

Here  we  have  the  brain-centres  paralyzed,  but  not  from  cerebral  conges- 
tion or  apoplectic  effusions,  as  in  the  paralysis  of  the  apoplexy  of  the  new- 
born ;  the  paralyzing  pressure  is  from  the  outside,  and  not  from  the  inside,  of 
the  head  ; — there  is  too  little,  not  too  much,  blood  in  the  child's  brain.  The 
indications  for  treatment  in  such  cases  are,  in  the  first  place,  to  preserve  the 
connection  between  the  child  and  the  placenta  as  long  as  the  latter  performs 
its  respiratory  functions ;  in  the  next  place,  to  endeavor  to  arouse  the  para- 
lyzed cerebral  centres  to  work ;  in  the  third  place,  to  stimulate  the  feeble 
and  fainting  child  generally  and  locally.  Evidently  these  syncoptic  children 
do  not  require  bleeding :  they  have  too  little,  not  too  much,  blood.  We 
direct,  therefore,  a  large  basin  of  very  hot  water  to  be  brought  to  the  bed, 
and  the  child,  still  attached  to  the  placenta,  is  plunged  into  the  water ;  the 


THE   CARE   OF   THE   CHILD   AT    BIETH.  251 

heat  acts  generally  and  locally  as  a  powerful  stimulant.  Presently,  as  in 
the  administration  of  the  hot  bath  already  described,  the  body  is  to  be 
brought  to  the  surface,  and  cold  or  iced  water  is  to  be  dashed  suddenly  and 
forcibly  on  the  face  and  anterior  surface  of  the  thorax.  This  acts  as  the 
most  powerful  stimulus  we  have,  to  arouse  the  benumbed  cerebral  respira- 
tory centres  to  work,  and  this  we  keep  up,  immersing  the  body  in  the  hot 
water,  and  alternating  these  immersions  with  the  dashing  of  cold  water  over 
the  face  and  anterior  surface  of  the  thorax,  as  I  have  already  directed,  for 
some  minutes.  Often,  the  first  dash  of  the  cold  water  will  cause  an  instant 
response  ■.  the  child  will  give  a  spasmodic  gasp,  the  lungs  instantly  fill,  and 
the  infant's  life  is  saved.  If  the  child  can  swallow,  it  will  be  desirable,  as 
soon  as  possible,  to  administer  hot  spirit-and-water  freely. 

When  all  pulsation  has  ceased  in  the  cord,  and  we  realize  that  the 
placenta  is  of  no  further  use,  we  may  separate  the  child.  The  subsequent 
treatment  must  be  something  like  that  which  I  have  suggested  as  proper  for 
the  asthenic  infant ;  that  is,  the  removal  of  all  obstructions  to  respiration,  and 
active  external  and  internal  stimulation.  These  are  the  very  cases  for  arti- 
ficial respiration,  practised  as  I  have  already  described ;  for  high  external 
and  internal  temperature ;  for  the  use  of  the  galvanic  battery. 

THE   HEAD   AS   MODIFIED   IN   SHAPE    AND    DIMENSIONS    BY   PKO- 

LONGED   LABOE. 

Children  after  tedious  labors  are  sometimes  born  with  their  heads  greatly 
compressed,  and  frequently  much  out  of  shape.  It  is  not  well  to  interfere 
in  these  cases  :  the  proper  treatment  is  to  trust  to  Nature,  and  not  attempt 
to  force  or  squeeze  the  head  into  a  good  shape  and  appearance.  In  a  few 
days  the  natural  elasticity  of  the  structures  will  bring  all  the  parts  into 
harmonious  relationship. 

The  swelling  of  the  scalp  occurring  as  a  sequence  of  tedious  labor 
(caput  succedaneum)  is  also  not  to  be  actively  treated.  The  effused  blood 
in  a  few  days  will  be  absorbed,  and  the  child  will  experience  no  subsequent 
inconvenience. 


THE    CLOSURE 

OF   THE 


DUCTUS  ARTERIOSUS  AND  OF  THE  UMBILICAL 
AND  HYPOGASTRIC  ARTERIES. 


By  J.  COLLINS  WAEREN,  M.D. 


At  the  period  of  birth,  and  before  any  structural  change  has  taken 
place  in  its  walls,  the  ductus  arteriosus  forms  a  more  or  less  tortuous  canal 
running  obliquely  downward  from  the  pulmonary  artery  to  the  aorta,  into 
which  it  opens  just  below  the  somewhat  sharp  curve  of  the  lower  border  of 
the  arch  at  the  beginning  of  the  descending  aorta.  The  ends  of  the  duct 
are  still  open,  but  in  the  central  portions  the  walls  are  approximated, 
partly  from  the  twisting  of  the  vessel,  which  now  is  empty,  and  partly  from 
a  circular  and  longitudinal  contraction-  of  the  walls.  Water  will,  however, 
readily  trickle  through  the  canal. 

The  anatomical  structure  differs  materially  from  that  seen  in  any  other 
portion  of  the  arterial  system. 

The  inner  coat  forms  one  of  the  most  marked  peculiarities  of  the  canal. 
The  enormous  thickness  of  the  intima  is  readily  apparent,  and  it  also 
appears  to  vary  considerably  in  width  at  diiferent  points  when  seen  in  longi- 
tudinal sections.  The  inner  surface  consequently  presents  many  irregulari- 
ties, and  frequently  sharp  projections.  This  condition  is  probably  more 
apparent  than  real,  the  inequalities  being  largely  caused  by  the  twists  and 
curves  of  the  canal,  which  render  it  impossible  to  cut  sections  of  the  wall 
which  are  in  all  parts  parallel  to  the  axis  of  the  duct.  The  intima  rapidly 
diminishes  in  thickness  as  it  approaches  the  ojjening  into  the  great  vessels. 

The  cells  of  which  the  intima  is  composed  lie  in  a  transparent  inter- 
cellular substance,  and  are  fusiform.  They  are  arranged  for  the  most  part 
longitudinally.  By  some  authors  they  are  supposed  to  be  connective-tissue 
cells,  by  others,  muscular.  The  more  superficial  cells  do  not,  as  a  rule, 
present  the  type  of  the  muscular  cell ;  but  very  perfect  examples  of  the 
muscular  cells  are  seen  in  the  deeper  portions  of  this  layer. 

Tlie  boundary-lines  of  the  different  coats  are  exceedingly  indistinct. 
The  lamina  elastica  appears  to  be  wanting  at  many  points ;  it  is  more 
252 


THE    CLOSURE    OF    THE    DUCTUS    ARTERIOSUS.  253 

readily  made  out  in  cross  than  in  longitudinal  sections.  The  media  con- 
sists chiefly  of  bands  of  longitudinally-arranged  muscular  cells  :  these  are 
occasionally  separated  from  one  another  by  circular  bands  of  muscular 
cells,  chiefly  at  the  outer  border  of  the  vessel.  This  coat  is  almost  entirely 
a  cellular  one.  The  few  elastic  fibres  which  it  contains  can  be  traced  into 
the  aorta  and  the  pulmonary  artery ;  they  are  most  abundant  in  the  outer 
layers  of  this  coat,  and  occasionally  extend  throughout  its  whole  length. 

As  the  ductus  enters  the  aorta  very  obliquely,  the  angle  made  by  the 
upper  edge  of  the  ductus  with  the  aorta  is  an  acute  one,  and  the  wall  is 
here  thin  in  comparison  with  the  lower  margin  of  the  opening,  where  the 
wall  of  the  aorta  forms  a  nearly  continuous  straight  line  with  that  of  the 
ductus.  The  tissues  of  the  coats  of  the  aorta  and  ductus  are  interwoven  at 
this  point,  and  those  of  the  ductus  are  spread  out  in  a  fan-like  shape  and 
are  lost  in  the  different  layers  of  the  wall  of  the  aorta.  The  elastic  lamina 
of  the  aorta  does  not  form  here  a  continuous  layer,  but  is  broken  into 
several  more  or  less  parallel  layers.  According  to  Thoma,^  that  portion  of 
the  wall  has  a  muscular  reinforcement,  which  he  places  in  the  intima.  This 
confusion  of  the  layers  is  in  reality  due  to  the  tendency  of  the  elastic  tissue 
to  form  a  less  perfect  limiting  membrane  near  the  ductus,  where  all  layers 
are  ill  defined. 

The  arrangement  of  the  walls  of  the  pulmonary  artery  resembles  that 
seen  at  the  aortic  opening,  but  in  a  reverse  order.  There  the  upper  wall  is 
the  thicker,  and  it  receives  the  tissues  of  the  upper  wall  of  the  ductus, 
which  are  freely  interlaced  with  it.  The  difference  between  the  two  margins 
of  the  pulmonary  opening  is  not  so  marked  as  at  the  aortic  end. 

A  few  weeks  after  birth  a  very  marked  change  has  taken  place  in  all  the 
tissues  of  the  ductus,  which  appear  to  be  undergoing  hyaline  degeneration 
preparatory  to  absorption.  The  outer  walls  alone  remain,  and  later  appear 
to  become  greatly  strengthened  and  form  a  layer  of  circular  muscular  fibres 
which  encloses  the  tissues  of  the  ligament  and  is  continuous  with  the  mediae 
of  the  two  great  vessels. 

A  longitudinal  section  of  the  ligamentum  arteriosum  at  this  period  shows 
well  the  relation  of  the  degenerating  tissue  to  that  which  remains. 

The  central  portion  of  the  ligament  is  composed  of  a  mass  of  degener- 
ated hyaline  tissue,  a  cleft  in  which  indicates  the  site  of  the  former  duct. 

Surrounding  this  is  the  wall  of  muscular  tissue,  which  can  be  traced 
into  the  outer  layers  of  the  adjacent  mediae  of  the  great  vessels. 

At  the  site  of  the  aortic  orifice  we  find  the  inner  layers  of  the  media 
aortse  greatly  approximated,  but  still  not  in  contact.  The  intervening  space 
is  occupied  by  a  transparent  tissue  in  which  large  numbers  of  spindle-shaped 
cells  are  embedded.  This  new  growth  springs  partly  from  the  intima  and 
partly  from  the  media  aortse.  Its  centre  is  pierced  by  a  small  vessel,  which 
soon  breaks  up  into  capillary  branches. 

1  Thoma,  Arch.  f.  Path.  Anat.,  1884. 


254  THE    CLOSURE    OF    THE    DUCTUS    ARTERIOSUS. 

At  eighteen  months  the  ligament  is  fully  formed,  and  undergoes  no 
essential  change  in  later  life.  It  now  consists  of  a  dense  bundle  of  longi- 
tudinal fibres  composed  of  fibrous  and  elastic  tissue  interspersed  with  fusi- 
form cells  :  here  and  there  traces  of  the  hyaline  degenerated  tissue  are 
found.  Surrounding  this  bundle  of  fibres  is  a  layer  of  circular  muscular 
fibres  of  varying  thickness,  and  enclosing  all  is  the  adventitia  reflected  from 
the  adjacent  vessels.  In  the  central  axis  of  the  ligament  a  small  vessel  is 
usually  found  which  can  be  traced  either  directly  or  through  a  few  capil- 
laries to  the  aorta  or  pulmonary  artery ;  occasionally  a  cleft  or  blood-space, 
lined  with  endothelium,  is  seen  connecting  at  either  end  with  a  small  vessel. 
Less  frequently  the  bundle  of  fibres  of  which  the  ligament  is  composed  is 
divided,  a  mass  of  loose  areolar  tissue  occupying  the  space  between  them : 
this  tissue  usually  contains  a  rich  capillary  net-work. 

At  the  aortic  end  of  the  ligament  there  is  still  a  slight  opening  in  the 
media  aortse.  This  coat  is  slightly  everted  at  this  point,  and  forms  a  de- 
pression in  the  aorta,  quite  visible  to  the  naked  eye,  situated  just  beneath  an 
overhanging  ridge  formed  by  the  inferior  wall  of  the  aortic  arch. 

The  free  edges  of  the  media  aortse  at  this  point  are  somewhat  expanded, 
and  interlace  with  the  tissues  of  the  ligament,  which  are  here  much  richer 
in  cells.  Bands  of  muscular  fibres  can  be  seen  running  ft-om  the  ligament 
into  the  media  and  deeper  layers  of  the  intima  aortse.  In  the  centre  of  the 
depression  is  an  arteriole  surrounded  by  a  growth  from  the  superficial  layers 
of  the  intima  aortse.  Occasionally  no  depression  is  found,  and  the  central 
arteriole  is  then  wanting,  the  edges  of  the  media  aortse  being  directly  united 
by  a  musculo-elastic  growth  from  that  layer. 

The  same  conditions  are  observed  at  the  pulmonary  extremity  of  the 
ligament,  but  in  a  less  marked  degree. 

In  later  life  patches  of  calcification  are  seen  here  and  there  in  the  liga- 
ment, which  are  probably  caused  by  further  degenerative  change  in  islets  of 
unabsorbed  foetal  tissues. 

In  brief,  the  foetal  tissues  at  the  period  of  birth  undergo  a  hyaline  de- 
generation and  are  absorbed.  They  are  replaced  by  a  ligamentous  tissue 
which  assumes  a  more  muscular  character  at  either  end,  where  it  is  attached 
to  the  medlse  of  the  two  great  vessels  and  is  surrounded  by  a  musculo-elastic 
layer  throughout  its  whole  length. 

Occasionally  at  the  period  of  birth  the  ductus  is  occluded  by  a  thrombus  ; 
but  this  is  exceptional.  The  presence  of  a  thrombus  in  such  a  position  is  in- 
teresting in  the  light  of  recent  discussions  as  to  its  traumatic  or  septic  origin. 

The  muscular  and  elastic  nature  of  the  tissue  which  seals  the  aortic  open- 
ing, the  overhanging  ridge  above  the  depression,  and  the  obliquity  with 
which  the  ligament  is  inserted  into  the  aorta,  all  combine  to  give  great 
strength  to  this  spot  in  the  aortic  wall.^ 


'  The  Healing  of  Arteries  after  Ligature  in  Man  and  Animals,  William  Wood  &  Co., 
1886. 


THE    CLOSURE    OF    THE    DUCTUS    ARTERIOSUS. 


255 


According  to  Thoma/  a  thickening  of  the  intima  aortae  is  seen,  after 
closure  of  the  foetal  vessels,  extending  from  the  ductus  arteriosus  through 
the  entire  length  of  the  descending  aorta  to  the  origin  of  the  hypogastric 
artery,  lining  nearly  the  whole  tract  concerned  during  foetal  life  in  the 
umbilical  circulation  [Nabelblutbahn),  It  is  described  by  Thoma  as  a  hya- 
line connective  tissue  containing  at  some  points  large  spindle-shaped  cells 
and  branching  anastomosing  cells.  This  he  interprets  as  a  compensatory 
thickening  of  the  wall  adapting  the  lumen  to  the  new.  conditions  of  the 
circulation. 

Thoma  regards  these  cells  as  connective-tissue  cells  ;  but  it  is  not  improb- 
able that  many  of  them  are  muscular  in  origin. 

The  foetal  cord  encloses  three  blood-vessels, — the  umbilical  vein,  and 
the  two  umbilical  arteries,  which  are  continuations  of  the  two  hypogastric 
arteries. 

The  hypogastric  arteries  take  their  origin  nominally  from  the  internal 
iliacs,  but  in  reality  form  with  the  upper  portion  of  those  vessels  the  trunks 
from  which  the  future  internal  iliacs  are  given  off  as  branches  a  short  dis- 
tance below  the  point  of  bifurcation  with  the  external  iliac  artery.  They 
ascend  from  the  pelvis  in  front  of  the  bladder,  occupying  the  positions  of 
the  future  superior  vesical  arteries,  to  the  anterior  abdominal  wall,  and 
pass  through  the  umbilical  ring  to  become  continuous  with  the  umbilical 
artery. 

The  umbilical  vein  originates  in  the  placenta,  runs  with  the  cord  in 
spiral  convolutions  and  enters  the  abdomen  at  the  umbilicus,  attaches  itself 
to  the  loose  connective  tissue  of  the  anterior  aspect  of  the  suspensory  liga- 
ment, and  thus  reaches  the  liver.  After  giving  off  a  few  branches  to  the 
left  lobe,  it  di\^des  into  two  main  branches,  one  of  which  enters  the  portal 
vein  and  the  other  the  vena  cava. 

The  hypogastric  artery  presents  certain  peculiarities  which  distinguish 
it  from  other  arteries :  its  walls  are  thick  and  strong  and  contain  a  large 
amount  of  longitudinal  muscular  fibre.  In  this  respect  it  bears  a  resem- 
blance to  the  structure  of  the  ductus.  It  has  another  peculiarity  also  in 
common  with  that  vessel,  consisting  in  the  absence  of  a  well-defined  outline 
to  the  inner  wall  of  the  media  which  a  well-formed  lamina  elastica  gives. 
Elastic  tissue  is  found  separating  the  two  coats,  but  the  membranes  are  thin, 
not  always  continuous,  and  sometimes  hard  to  find.  Near  the  distal  end  of 
the  vessel  and  in  the  umbilical  arteries  there  is  little  to  be  seen  of  any  such 
structure.  The  tortuous  character  of  the  umbilical  arteries  produces  great 
irresularities  on  the  inner  surface.  The  large  amount  of  muscular  fibre 
favors  rapid  contraction  of  the  vessels  and  cessation  of  tiie  blood-flow 
although  no  ligature  have  been  applied.  This  vigorous  contraction,  accord- 
ing to  Jacobi,^  is  the  result  of  the  rigor  mortis  of  the  muscular  layer  and 


J  Op.  cit. 

»  Brooklyn  Medical  Journal,  March,  1888. 


256  THE    CLOSURE    OF    THE    DUCTUS   ARTERIOSUS. 

the  reflex  action  produced  by  the  influence  of  the  cooler  temperature  sur- 
rounding the  newly-born. 

The  umbilical  vein  differs  but  slightly  from  the  arteries,  the  muscular 
layer  being  well  developed.  There  is  no  true  lamina  elastica,  and,  according 
to  Jacobi,  no  intima.  This  statement  may  hold  good  for  the  umbilical 
arteries,  as  also  the  assertion  that  there  are  no  nerves  nor  vasa  vasorum 
in  their  walls ;  but  the  hypogastric  arteries  in  these  respects  do  not  differ 
essentially  from  other  vessels  of  their  size. 

When  the  placental  circulation  ceases,  a  marked  contraction  takes  place 
throughout  the  greater  part  of  the  vessel,  and  its  most  distal  portion  is  filled 
with  a  thrombus.  While  the  healing  of  the  umbilical  cicatrix  is  taking 
place,  the  distal  end  of  the  artery  undergoes  a  hyaline  degeneration  which 
pervades  its  whole  thickness.  The  extremities  of  the  two  vessels,  in  contact 
just  within  the  umbilicus,  are  soon  reduced  to  a  cord  of  gelatinous  tissue  in 
which  all  traces  of  the  vessel  have  disappeared.  This  change  extends  for  a 
distance  of  two  centimetres,  and  is  subsequently  replaced  by  a  fibrous  cord 
which  attaches  the  superior  vesical  artery  to  the  umbilicus.  In  the  early 
days  of  life  but  little  change  is  seen  in  the  interior  of  the  vessel :  a  slight 
proliferation  of  the  cells  of  the  intima  is  noticed  near  the  apex  of  the 
thrombus,  but  not  elsewhere.  By  the  second  month,  however,  a  distinct 
growth  of  tissue  may  be  observed  throughout  the  entire  length  of  the  inner 
wall.  The  coats  have  contracted,  and  the  inner  surface  is  thrown  into  deep 
folds  which  are  bridged  over  by  a  growth  of  young  cells  lying  embedded  in 
a  hyaline  intercellular  substance.  This  new  tissue  fills  out  the  irregularities, 
and  in  cross-section  the  lumen  may  now  be  seen  to  present  a  smooth  con- 
tour. In  the  region  occupied  by  the  thrombus  the  growth  of  new  tissue  is 
most  active :  granulation-like  masses  intersect  the  clot  and  are  rapidly 
obliterating  the  lumen.  Complete  obliteration  of  the  vessel  does  not  take 
place,  but  in  adult  life  a  considerable  portion  still  remains  as  the  superior 
vesical  artery.  This  vessel  has,  hoAvever,  unusually  thick  walls,  and  the 
lumen  is  greatly  diminished  in  calibre.  A  microscopical  examination  of  its 
walls  shows  that  the  old  hypogastric  wall  has  been  greatly  contracted,  the 
elastic  tissue  being  thrown  into  deep  folds  when  seen  in  cross-section. 
Within  exists  a  tissue  evidently  formed  after  this  contraction.  The  new 
tissue  consists  of  an  endothelium,  a  well-formed  lamina,  and  a  muscular 
layer.  The  adult  artery  has,  therefore,  a  double  set  of  walls,  the  old  walls 
having  apparently  contracted  to  their  utmost  capacity,  and  the  lumen  being 
further  narrowed  by  a  compensatory  growth.  The  newly-formed  wall  is 
distinctly  muscular  in  character,  and  has  evidently  been  developed  from  the 
old  wall  by  a  growth  penetrating  through  the  imperfectly-formed  lamina. 

Tracing  the  vesical  artery  to  its  extremity,  we  find  the  lumen  constantly 
diminishing  in  size,  the  newly-formed  internal  coat  becoming  less  distinct, 
until  the  structures  examined  consist  of  a  cord  of  fibrous  tissue  in  wliich  a 
tortuous  arteriole  finally  breaks  up  into  smaller  vessels  which  are  not  to  be 
distinguished  from  capillaries.     Beyond  this  point  we  see  only  a  fibrous 


THE    CLOSURE    OF    THE    DUCTUS    ARTERIOSUS.  257 

•cord,  in  the  centre  of  which  is  some  denser,  more  opaqne  tissue,  intermingled 
with  traces  of  an  elastic  membrane. 

The  series  of  changes  which  has  taken  place  since  birth  result  in  a  con- 
traction of  the  vessel,  followed  by  a  still  greater  diminution  of  its  calibre 
by  an  obliterating  growth  in  the  interior.  There  is  a  complete  destruction 
of  the  distal  portion  of  the  vessel,  the  result  partly  of  hyaline  degeneration 
and  partly  of  an  obliterating  growth.  About  one-third  of  the  vessel  at  its 
terminal  portion  is  thus  replaced  by  ligamentous  tissue.  According  to  Baum- 
garten,^  this  band  of  fibres  is  a  cicatricial  tissue  which  has  stretched  with 
the  growth  of  the  individual,  the  superior  vesical  artery  being  actually  the 
same  length  that  it  was  at  birth.  But  this  view  is  not  in  accord  with  the 
writer's  observations,  which  show  that  a  considerable  portion  of  the  vessel 
lias  been  destroyed. 

1  Centralbl.  f.  Med.  Wiss.,  No.  41,  1877. 
Vol.  I.— 17 


INJURIES  OF  THE  NEW-BORN. 

By  THEOPHILUS   PAEYIN,  M.D.,  LL.D. 


The  injuries  received  by  the  child  during  or  in  connection  with  labor 
may  be  classified  as  external  and  internal,  the  latter  of  course  being,  as  a 
rule,  the  more  serious. 

But  a  more  convenient  classification  is  given  by  the  part  involved ;  and 
thus  these  injuries  will  here  be  considered  as  of  the  head,  associating  with 
them  those  of  the  neck,  of  the  t7'unk,  and  of  the  members. 

Injuries  of  the  Head  and  Neck. — From  the  fact  that,  in  the  vast 
majority  of  cases,  the  cephalic  pole  of  the  foetal  ovoid  descends  the  birth- 
canal  first,  that  the  propelling  force  of  labor  drives  this  passive  mass  against 
resistances,  overcoming  them,  or,  on  the  other  hand,  moulding  that  mass, 
modifying  its  form,  and  sometimes  even  its  structure,  and  from  the  additional 
fact  that  in  these  cases  of  cephalic  presentation,  whether  cranial  or  facial, 
the  part  is  accessible  to  digital,  manual,  or  instrumental  means  for  facilitating 
delivery,  it  necessarily  follows  that  injuries  of  the  head  during  labor  are 
much  more  frequent  than  those  of  any  other  part  of  the  foetus.  The  great 
majority  are  not  serious ;  they  are  superficial,  and  in  a  few  days  usually  dis- 
appear, either  with  or  without  the  employment  of  very  simple  therapeutic 
means.  Some,  however,  leave  permanent  disability,  or  even  may  be  so 
grave  that  death  results. 

Caput  Succedaneum,  Sero-Sanguineous  Infiltration,  Kephalohse- 
matoma  spurium. — This  is  a  common,  but  not  a  constant,  phenomenon ; 
for,  if  the  labor  be  rapid  and  the  resistance  slight,  the  child  may  be  born 
without  this  swelling.  Nevertheless,  such  cases  are  exceptional,  and  the 
occurrence  of  the  caput  succedaneum  is  so  common  that  it  might  be  regarded 
as  a  physiological  condition. 

This  swelling  may  be  round,  or  oval,  or  in  some  cases  greatly  elongated, 
projecting  almost  like  a  pudding-shaped  mass.  In  some  instances  it  may 
be  less  than  an  inch  in  its  longest  diameter,  supposing  it  to  be  oval,  but  in 
others  two  or  three  inches.  The  skin  which  covers  it  has  changed  in  color,, 
in  consequence  of  the  congestion ;  if  the  labor  has  been  long,  the  surface  of 
the  tumor  may  be  purplish,  or  violet-colored.  So,  too,  in  case  of  protracted 
parturition  the  surface  of  the  tumor  may  present  phlyctenulse  which  whem 
ruptured  leave  the  derm  exposed. 
258 


INJURIES    OF    THE    NEW-BORN. 


259 


Caput  succedaneum,  vertex  presentation,  right  oc- 
cipito-posterior  position.    (From  Depaul.) 


In  some  instances,  instead  of  there  being  simply  an  effusion  of  serum 
or  sero-sanguineous  fluid  in  the  connective  tissue,  rupture  of  blood-vessels 

has  occurred,  permitting   hemor- 
FiG.  1.  rhage,  which,  breaking  this  tissue, 

may   be   so   considerable    that   a 
fluctuating  tumor  results. 

The  generally  received  origin 
of  the  caput  succedaneum  is  that 
at  that  part  of  the  child  there  is 
no  pressure,  while  all  other  parts 
are  uniformly  pressed,  and  hence 
the  former  becomes  swollen.  Mau- 
riceau  explained  the  tumor  as  re- 
sulting from  the  resisting  and  par- 
tially-dilated OS,  acting  as  a  cord 
about  the  part  of  the  head  where 
the  swelling  occurs,  preventing  the 
return  of  fluids  :  this  explanation 
was  accepted  by  Depaul  as  being 
in  some  instances  one  of  the  causes, 
the  chief  cause  being  that  which  has  been  stated. 

The  rule  is  that  the  swelling  does  not  occur  as  long  as  the  membranes 
are  unruptured ;  but,  as  observed  by  Tarnier,  such  rupture  is  not  absolutely 
necessary,  not  only  according  to  the  statement  of  Schroeder,  but  Budin  has 
met  with  the  tumor  in  some 

cases  where  the  coverings  of  '^'     ' 

the  foetus  were  intact  but  ex- 
tensible :  Depaul  also  refers 
to  the  fact  that  this  swelling 
may  be  developed  prior  to 
escape  of  the  amnial  fluid. 
(Figs.  1  and  2.) 

The  caput  succedaneum 
is  usually  formed  during  the 
dilatation  of  the  os  uteri ;  but 
should  tliere  be  delay  subse- 
quently in  any  part  of  the 
birth-canal — such  delay  being 
especially  frequent  at  the  vul- 
var orifice — a  secondary  caput 
is  formed.  If  the  pelvic  inlet 
be  narrowed,  and  the  head  pressed  against  the  resisting  bony  ring  by  active 
uterine  contractions,  sero-sanguineous  effusion  soon  occurs,  and  the  tumor 
often  becomes  so  large  as  to  approach  the  vulvar  opening  while  the  liead 
still  remains  above  the  superior  strait. 


The  same  head  as  represented  in  the  preceding  figure,  but 
some  days  after  birth.    (From  Depaul.) 


260 


INJURIES    OF    THE   NEW-BORX. 


The  seat  of  the  caput  succedaneum  indicates  the  position  which  the  head 
occupied  in  a  cranial  presentation.  Thus,  if  the  tumor  be  upon  the  superior 
and  posterior  angle  of  the  right  parietal  bone,  the  occiput  was  at  the  left 
and  anterior ;  but  if  at  a  corresponding  part  of  the  left  parietal,  then  the 
position  was  right  posterior.  In  occipito-posterior  positions,  the  tumor 
corresponds  to  the  superior  and  anterior  portions  of  that  parietal  which  is 
in  relation  with  the  pubic  arch. 

In  facial  presentation  the  facial  or  fronto-mental  circumference  is  rarely 
parallel  with  the  pelvic  planes,  but  the  cheek  which  is  anterior  is  somewhat 
lower  than  the  posterior  one,  and  the  former  will  be  the  seat  of  the  sero- 
sanguineous  effusion,  which  will  be  in  proportion  to  the  delay  in  anterior 

rotation    of    the    chin ; 
Fig.  3.  after    this    rotation,    if 

delay  occurs,  the  swell- 
ing occupies  the  entire 
facial  oval.  If  extension 
is  rapidly  eifected,  the 
swelling  is  found  upon 
the  cheek,  the  mouth, 
and  the  chin  ;  but  if  the 
process  is  slow,  the  de- 
flection remaining  for 
some  time  incomplete, 
then  the  swelling  will  be 
upon  "that  portion  of 
the  facial  oval  which  oc- 
cupies the  centre  of  the 
basin, — that  is,  the  fron- 
tal and  ocular  region." 
(Fig.  3.) 

A  single  word  may 
be  said  as  to  the  position 
of  the  so-called  caput 
succedaneum  in  presentation  of  the  pelvis,  and  in  that  of  the  shoulder :  the 
inappropriateness  of  the  term  is  obvious,  nevertheless  the  tumor  designated 
by  it  has  precisely  the  same  origin  and  the  same  essential  character  as  in 
presentation  of  the  vertex.  The  swelling  in  presentation  of  the  pelvis  occu- 
pies the  hip  which  is  the  lower,  and  this  is  usually,  though  not  invariably, 
the  anterior.  "  If  in  some  cases  the  swelling  upon  the  pelvic  region  is  uni- 
form, this  is  explained  either  by  the  slight  obliquity  of  the  presenting  part, 
or  its  early  correction,  the  two  hips  descending  equally.  Here,  as  elsewhere, 
the  skin  is  of  a  more  or  less  dark  blue,  and  the  tumor  formed  by  the  sero- 
sanguineous  efPusion  variable  in  prominence  and  extent."  If  the  child  be 
male,  the  scrotum  may  become  doubled  in  size,  and  black  :  indeed,  instances 
in  which  sloughing  occurred  have  been  recorded.     In  presentation  of  the 


Caput  succedaneum  occupying  the  face  and  the  vertex,  a,  b,  c,  d. 
The  head  was  between  flexion  and  extension,  the  occiput  corre- 
sponding with  the  left  extremity  of  the  transverse  diameter  of  the 
pelvis,  and  the  forehead  with  the  right  extremity.  The  pelvis  was 
narrowed,  and  the  labor  was  long.    (From  Depaul.) 


INJURIES    OF   THE    NEW-BORN.  261 

shoulder  the  sero-sangiiineous  tumor  occupies  the  lowest  portion,  but  ex- 
tends thence  anteriorly  or  posteriorly  upon  the  trunk  according  as  the  latter 
may  be  inchned  in  front  or  behind.  In  case  the  elbow  or  hand  descend 
first,  then  these  become  greatly  swelled  and  discolored. 

Diagnosis. — It  is  very  rare  that  a  true  kephalohsematoma  forms  during 
labor,  and  therefore  mistaking  a  caput  succedaneum  for  it  will  be  almost 
impossible ;  the  distinctive  marks  of  the  former  will  be  given  hereafter. 
An  encephalocele  has  more  of  a  cylindrical  form,  the  skin  covering  it  is  not 
discolored,  the  tumor  becomes  larger  when  the  child  cries,  the  opening  in 
the  cranial  vault  through  which  the  hernia  comes  may  be  discovered,  and 
possibly  pressure  upon  the  tumor,  in  an  effort  to  reduce  the  hernia,  produces 
nervous  accidents. 

Treatment. — The  vast  majority  of  cases  of  spurious  kephalohsematoma 
recover  without  any  treatment.  Nevertheless,  if  the  skin  be  broken,  and  if 
the  swelling  be  great,  or  if  the  effusion  be  of  blood  rather  than  of  serum, 
an  erysipelas  may  arise  from  the  former,  or  even  gangrene  ensue,  and  in  the 
other  case  phlegmonous  inflammation  or  suppuration  may  occur.  Following 
a  facial  presentation,  the  great  swelling  of  the  eyelids  and  the  subconjunc- 
tival ecchymoses  predispose  to  conjunctivitis ;  the  lips  and  the  tongue  may 
be  so  swelled  that  the  child  cannot  nurse  for  several  days,  and  it  therefore 
must  be  fed. 

The  broken  surface  resulting  from  ruptured  phlyctenulae,  or  possibly 
from  the  rude  use  of  the  finger-nails,  may  be  dusted  with  iodoform  or  with 
boracic  acid ;  if  the  swelling  is  great,  compresses  dipped  in  a  solution  of 
muriate  of  ammonia  or  in  a  mixture  of  alcohol  and  water  may  be  applied ; 
should  suppuration  be  threatened,  warm  fomentations  and  the  application 
of  a  poultice  are  indicated  ;  while  if  the  distinct  formation  of  pus  be  recog- 
nized, opening  the  abscess  and  washing  out  the  cavity  with  a  warm  anti- 
sej)tic  solution  would  be  proper. 

Kephalohsematoma,  or  Thrombus  Neonatorum. — By  this  is  meant  a 
soft,  fluctuating  tumor  of  the  scalp  caused  by  efflision  of  blood  between  the 
periosteum  and  the  bone.  It  is  usually  situated  upon  one  of  the  parietals, 
upon  the  right  more  frequently  than  upon  the  left,  in  some  cases  upon  both, 
rarely  upon  the  frontal  or  the  occipital,  or  upon  one  of  the  temporals. 
x4.uthors  generally  state  that  the  swelling  never  transgresses  a  suture ; 
Bouchut,  however,  asserts  that,  while  usually  limited  by  a  suture,  it  may 
pass  over  and  involve  the  adjoining  bone ;  he  also  quotes  the  remarkable 
case  of  Ducrest,  in  which  the  primary  thrombus  occupying  one  of  the 
parietals  passed  over  the  intervening  suture  and  under  the  other  parietal. 

This  tumor  does  not  usually  appear  until  from  one  to  three  days  after 
birth, — that  is,  when  the  caput  succedaneum  is  disappearing ;  it  may  be  no 
larger  than  a  pigeon's  egg,  or  may  have  the  size  of  a  small  apple ;  the  skin 
covering  it  is  not  discolored,  and  thus  a  marked  diffbrence  exists  between 
this  tumor  and  that  previously  described ;  it  fluctuates,  is  not  increased  in 
size  when  the  child  is  crying,  and  usually  presents  a  distinct  bony  margin 


262  INJURIES    OF    THE    XEW-BORN. 

around  its  base.  Hemorrhages,  either  beneath  or  above  the  cranial  aponeu- 
rosis, have  been  observed  after  the  application  of  the  forceps,  but  these  are 
diffuse,  have  no  bony  margin  defining  their  extent,  and  generally  are  rapidly 
absorbed. 

Thrombus  neonatorum  occurs,  according  to  Kleinwachter,  once  in  two 
hundred  to  two  hundred  and  fifty  cases.  The  swelling  disappears  in  some 
instances  in  two  weeks,  but  more  frequently  it  remains  for  a  month  or 
more.  Rarely  suppuration  occurs,  and  this  is  liable  to  be  followed  by 
caries  of  the  bone.  If  there  should  be  also  an  internal  as  well  as  an  ex- 
ternal effusion  of  blood,  the  child  perishes  with  convulsions. 

The  cause  of  the  affection  is  by  no  means  clear.  Those  who,  like  Earle, 
Godson,  and  Descroizilles,  accept  the  opinion  that  it  results  from  the  por- 
tion of  the  head  where  it  is  found  being  constricted  by  the  os  uteri,  can 
give  no  explanation  for  its  occurrence,  as  has  been  the  case  in  several  in- 
stances, in  pelvic  presentations.  Mildner  and  Hecker  held  that  it  resulted 
from  the  coats  of  the  blood-vessels  being  thin,  and  consequently  rupturing ; 
while  Langenbeck  and  Ritter  attributed  it  to  defective  development  of  the 
bone. 

Treatment. — Since  absorption  of  the  effused  blood  takes  place  in  the 
great  majority  of  cases  spontaneously,  and  as  the  child  does  not  suffer  in 
any  wise  from  the  tumor,  active  interference  is  not  usually  indicated.  By 
some  the  application  of  a  solution  of  muriate  of  ammonia,  of  tincture  of 
iodine,  or  of  mercurial  ointment,  or  compression  by  means  of  collodion,  or 
of  a  thin  plate  of  metal,  is  advised.  Descroizilles  remarks  that  these  dif- 
ferent applications  appear  to  accelerate  the  disappearance  of  the  tumor,  and 
cannot  cause  any  irritation  or  other  accidents  when  prudently  made.  The 
employment  of  setons  or  of  punctures  is  not  advised ;  nevertheless,  should 
an  abscess  form,  opening  it  is  indicated,  and  it  is  possible,  too,  if  the  col  • 
lection  of  blood  remains  for  some  time  without  change,  that  aspiration, 
all  antiseptic  precautions  being  used,  would  be  beneficial  without  in  any 
respect  being  evil. 

"Wounds  of  the  Scalp  and  of  the  Pace. — Contused  wounds  of  the 
face  or  of  the  scalp  may  be  caused  by  the  forceps,  the  accident  depending 
upon  the  form  of  the  instrument  or  upon  the  mode  in  which  it  is  used :  the 
prophylaxis  belongs  to  obstetrics,  and  therefore  will  not  be  here  considered. 
Generally  such  wounds  are  quite  superficial,  and  disappear  in  a  few  days. 
In  their  treatment  antiseptic  powders,  ointments,  or  fomentations  may  be 
used.  Punctured  or  incised  wounds  of  the  scalp  have  usually  been  caused 
by  the  obstetrician  mistaking  the  caput-  succedaneum  for  the  bag  of  waters  : 
antiseptic  applications  are  indicated.  More  or  less  serious  injury  to  the  eyes 
has  sometimes  been  done  by  the  finger  of  the  accoucheur  in  case  of  presen- 
tation of  the  face.  Such  injury,  as  well  as  that  spontaneously  resulting 
more  especially  to  the  eyelids  in  this  presentation,  do  not  require  special 
directions  as  to  treatment.  In  rare  instances  dangerous,  and  even  fatal, 
consequences  have  followed  sloughing  of  the  scalp :  this  accident  has  been 


INJURIES    OF    THE    XEW-BORX.  263 

observed  after  spontaneous  labor,  and  also  has  followed  delivery  with  the 
forceps,  one  of  the  blades  causing  such  severe  pressure  that  gangrenous 
inflammation  results. 

Facial  Paralysis. — This  accident,  in  most  instances  unilateral,  has  been 
observed  following  spontaneous  delivery,  but  in  the  majority  of  cases  results 
from  the  use  of  the  forceps,  and  is  caused  by  pressure  of  one  of  the  blades 
at  the  stylo-mastoid  foramen,  or  a  little  in  front  of  the  lobe  of  the  ear.  As 
has  been  stated,  in  the  infant  the  complete  absence  of  the  mastoid  apophysis 
and  the  slight  development  of  the  auditory  canal  favor  compression  of  the 
facial  nerve  near  its  point  of  emergence.  In  some  instances  only  branches 
of  the  facial  are  compressed,  and  then  the  paralysis,  instead  of  involving 
the  entire  half  of  the  face,  of  course  affects  only  the  muscles  to  which  those 
branches  are  distributed.  Facial  paralysis  from  intracranial  causes  will  be 
referred  to  hereafter. 

The  paralysis  will  not  be  observed  when  the  infant  is  sleeping,  but  when 
awake  and  crying,  or  when  attempting  to  nurse,  it  is  quite  apparent.  In 
the  majority  of  cases  recovery  occurs  spontaneously  in  from  ten  days  to  two 
weeks,  and  usually  there  is  a  notable  lessening  of  the  affection  within  a 
week.  In  rare  instances  the  paralysis  becomes  permanent,  remaining  after 
years  unchanged ;  and  therefore  the  practitioner  ought  to  beware  of  making 
a  positive  statement  as  to  the  certainty  of  recovery. 

It  is  generally  advised  not  to  employ  any  treatment  until  at  least  a 
month  has  passed  without  any  improvement ;  then  electricity  may  be  used, 
the  induction  current  being  first  employed,  and,  if  the  muscles  fail  to  re- 
spond, the  continuous  current. 

Injuries  to  the  Bones  of  the  Head. — Depressions^  Fractures,  and 
Dislocation.'!. — Depressions  and  indentations  of  the  cranial  bones  are  most 
frequently  seen  when  deliver}^  has  been  effected  by  the  forceps,  but  they 
have  also  been  observed  after  spontaneous  expulsion  of  the  child.  Still 
more  remarkable  was  the  case  reported  by  Matthews  Duncan,  in  which  a 
persistent  impression  was  made  by  the  finger  of  the  accoucheur  upon  the 
right  parietal  bone  in  an  effort  to  produce  anterior  rotation.  The  first  illus- 
tration on  the  following  page  shows  a  ftinnel-shaped  depression  caused  by 
pressure  of  the  sacral  promontoiy  in  a  narrow  pelvis. 

While  it  was  formerly  believed  that  a  fracture  always  occurred  Avitli 
depression,  this  view  is  no  longer  held.  In  one  instance  a  country  practi- 
tioner informed  me  that  he  had  successfully  used  a  cupping-glass  to  relieve 
a  depression  of  the  parietal  in  a  new-born  child ;  but  such  practice  has 
not  been  recommended  by  any  professional  autliority,  though  it  seems 
rational,  and  certainly  might  be  tried,  as  trephining  has  been  proposed  by 
an  eminent  American  surgeon.  Dr.  Nancrede,  in  case  of  such  depression,  if 
paralysis  be  consequent.  In  most  cases,  however,  these  depressions  in  time 
disappear,  or  notably  diminish.  Indentations,  whether  made  by  the  forceps 
or  occurring  in  spontaneous  labor,  are  frequently  permanent,  but  are  not 
usually  the  cause  of  any  disability. 


264 


INJURIES   OF   THE   NEW-BORN. 


Fig.  4. 


Funnel-shaped  depression  of  the  anterior  half  of  the  left  parietal 
bone  from  the  promontory.  (From  AVinckel's;'  Lehrhuch  der  Geburts- 
hulfe.") 


Fractures  of  the  cranial  bones  have  been  observed  following  sponta- 
neous, and  artificial,  whether  manual  or  instrumental,  delivery.  The  pari- 
etal bones  are  those 
most  frequently  frac- 
tured, especially  where 
the  fracture  occurs  in 
unassisted  labor;  but 
the  frontal,  the  occip- 
ital, or  one  of  the 
temporals  may  suffer 
this  injury.  The  acci- 
dent most  frequently 
occurs  in  case  of  nar- 
rowing of  the  pelvic 
inlet,  but  has  also 
been  observed  when 
there  was  no  pelvic 
deformity,  and  the 
child  normal  in  size, 
and  it  has  been  sug- 
gested that  in  such  cases  the  injury  may  have  resulted  from  the  untimely 
administration  of  ergot,  causing  violent  and  rapid  expulsion  of  the  child. 
The  posterior  parietal  bone  is  the  one  usually  fractured,  when  the  head  is 

either  driven  or  dragged  through 
^^*^-  '^-  the  pelvic  inlet  narrowed  in  the 

conjugate  diameter,  the  injury  re- 
sultine;  from  the  resistance  of  the 
sacral  promontory.  -  (Fig.  4.) 

Lomer^  has  recently  reported 
twenty-seven  cases  of  fracture  of 
the  skull  from  the  use  of  the  for- 
ceps. In  ten  the  fracture  involved 
the  frontal  bone,  four  of  these  in- 
juries being  over  the  orbit;  five 
were  of  one  of  the  parietal  bones. 
The  sagittal  suture  was  ruptured 
six  times,  the  lambdoidal  four 
times,  and  the  occipital  bone  de- 
tached in  five  cases.  (Fig.  5.) 
If  the  fracture  have  associated 
with  it  rupture  of  the  longitudinal  sinus,  a  mortal  hemorrhage  ensues. 
Even,  however,  if  there  be  no  injury  to  large  blood-vessels,  that  of  smaller 
ones  may  give  rise  to  bleeding  of  consequence,  or  there  may  be  injury  done 


Fissure  of  the  right  parietal  bone  from  the  parietal 
protuberance  to  the  sagittal  suture,  the  anterior  por- 
tion pressed  under  the  posterixir.    (From  Winckel.) 


Zeitschrift  fiir  Geburtshiilfe  und  Gyniikologie. 


INJURIES    OF    THE    XEW-BORX.  265 

to  the  brain  with  that  of  the  bone,  so  that  these  fractures  should  in  no 
instance  be  regarded  as  triviah  Further,  such  brain-lesion  may  not  always 
give  immediate  proof  of  its  presence,  but  remote,  it  may  be,  in  imperfect 
mental  development. 

Experiment  seems  to  have  pretty  conclusively  proved  that  a  force  ap- 
proaching one  hundred  pounds  applied  in  extraction  of  the  child,  whatever 
the  method,  is  very  liable  to  produce  fracture  of  one  of  the  parietal  bones. 
Fractures  of  the  cranial  bones  are  especially  liable  to  occur  in  irregular 
applications  of  the  forceps, — that  is,  when  the  blades  are  not  applied  to  the 
sides  of  the  child's  head, — because  they  do  not  embrace  uniformly  so  large 
a  surface,  and  more  pressure  is  required  to  prevent  slipping.  A  less  force 
will  cause  fracture  under  these  conditions  than  in  the  ordinary  method  of 
using  the  instrument.  Fractures  of  the  bones  of  the  face  are  almost  ex- 
clusively those  of  the  inferior  maxillary,  and  result  from  traction  made  by 
the  obstetrician's  fingers  in  head-last  labors.  It  seems  probable,  from 
the  investigations  of  Matthews  Duncan,  Champetier,  and  others,  that  the 
inferior  maxilla  may  be  subjected  to  a  force  of  about  fifty  pounds  Mdthout 
sustaining  injury.  In  some  instances  traction  upon  this  bone  causes  separa- 
tion of  the  mental  symphysis. 

It  is  well  known  that  among  the  plastic  phenomena  of  labor  is  lessening 
of  the  occipito-frontal  diameter  by  advance  of  the  squamous  portion  of  the 
occipital  bone  beneath  the  parietals,  the  movement  being  permitted  by  the 
hinge-like  cartilage  and  fibrous  tissue  which  at  this  period  of  development 
is  present,  uniting  the  j)reviously  mentioned  part  with  the  basilar  portion. 
Should  the  forceps  be  applied  to  the  forehead  and  occiput,  this  movement 
may  be  exaggerated,  and  injurious  pressure  upon  the  brain  result.  Xot 
only  this,  but  either  with  or  without  the  forceps  the  two  portions  of  bone 
may  become  separate,  and  the  anterior  inferior  margin  of  the  squamous  part 
be  forced  against  the  medulla. 

Little  is  to  be  said  as  to  the  treatment  of  these  various  injuries :  some 
of  them  are  incompatible  Avith  life,  the  child  perishing  from  convulsions,  it 
may  be.  Yet,  on  the  other  hand,  an  infant  may  survive  some  very  serious 
injuries  of  the  head.  Thus,  Duges  has  mentioned  an  instance  in  which  the 
child  was  born  with  the  left  eye  almost  completely  outside  the  orbit,  so 
greatly  was  the  frontal  bone  depressed ;  yet  the  iufant  did  not  have  convul- 
sions or  other  grave  symptoms. 

By  gentle  and  careful  manipulation  in  suitable  cases,  the  normal  shape 
of  the  head  may  be  restored,  fragments  of  displaced  bones  being  brought  in 
apposition,  and  pressure  upon  the  brain  relieved. 

The  6nly  injury  of  the  neck  which  Avill  be  referred  to  is  that  involving 
the  sterno-cleido-mastoid.  Torticollis  of  obstetric  origin  has  been  attributed 
to  injuiy  of  this  muscle  by  one  of  the  blades  of  the  forcej)s.  This  may 
explain  the  condition  in  some  cases,  but  does  not  do  so  in  all,  for  children 
born  head-last  have  been  affected.  It  seems  more  probable,  however,  that, 
whether  the  forceps  was  used  or  the  delivery  was  by  the  breech,  the  labor 


266  INJURIES    OF    THE    NEW-BORN. 

was  difficult,  great  traction  being  necessary,  this  traction  causing  an  injury 
to  the  muscle,  rupture  of  some  of  its  fibres,  and  a  consequent  hsematoma. 
Others  have  regarded  the  injury  as  resulting  in  inflammation  of  the  muscle. 
But,  whatever  the  explanation,  the  characteristic  condition  present  is  a  tumor 
situated  just  above  the  clavicle  and  in  the  muscle.  As  a  rule,  this  tumor 
disappears  spontaneously,  though  several  weeks  elaj)se  before  the  event,  and 
the  function  of  the  muscle  is  not  permanently  impaired.  Active  treatment 
is  not  indicated,  though  after  the  tumor  has  lost  the  sensitiveness  it  has  at 
first,  gentle  friction  and  the  application  of  a  weak  tincture  of  iodine  may 
assist  its  disappearance. 

Intracranial  Injuries. — These  are  liable  to  occur  in  difficult  deliveries, 
whether  those  deliveries  are  spontaneous,  or  either  manual  or  instrumental. 
Rupture  of  the  longitudinal  sinus  has  been  observed  in  some  cases,  and 
the  hemorrhage  results  in  death,  though  sometimes  this  may  be  delayed  for 
one  or  even  for  two  days  after  birth.  Meningeal  hemorrhage  is  a  common 
cause  of  the  child  perishing  during  labor ;  according  to  Cruveilhier,  it  is 
the  cause  of  death  in  one-third  of  the  cases  of  children  dying  in  this  period. 
Should  the  child  be  born  alive  it  may  die  from  asphyxia  soon  after,  but  if 
respiration  is  fairly  established  the  child  may  become  comatose,  have  con- 
vulsions, usually  unilateral,  and  die  :  if  it  escapes  these  dangers,  it  is  liable 
to  spastic  hemiplegia.  Sinkler  ^  refers  to  the  fact  that  in  the  cases  of  paraly- 
sis following  difficult  labors,  spontaneous  or  artificial,  the  lesion  is  often  an 
extravasation  of  blood  over  the  motor  convolutions,  and  states  that  if  the 
quantity  of  effused  blood  is  not  great,  recovery  occurs.  Osier  ^  found  in 
the  records  of  the  Philadelphia  Infirmary  for  ISTervous  Diseases  nine  cases 
of  palsy  following  delivery  with  the  forceps ;  in  some  of  the  subjects  there 
were  scars  caused  by  the  instrument.  McNutt^  has  reported  ten  cases  of 
intracranial  hemorrhage  occurring  in  difficult  or  instrumental  labors :  it 
is  remarkable  that  paralysis  occurred  in  three  of  these,  the  delivery  being 
pelvic,  while  it  was  absent  in  the  seven  others,  the  presentation  being 
cranial. 

Gowers*  attributes  great  importance  to  difficult  labor  in  causing  cerebral 
palsy  of  the  new-born.  He  states,  "  Of  twenty-six  well-marked  cases  of 
this  affection,  of  which  I  have  notes,  the  child  was  the  first  born  in  no  less 
than  sixteen,  or  at  least  three  times  as  many  as  would  have  been  without 
some  causal  relation  to  the  fact.  Of  the  remaining  ten,  the  head  was  born 
last  in  no  less  than  six.  Thus,  the  labor  was  '  unnatural'  in  no  less  than 
twenty-two  out  of  twenty-six  cases.  Of  the  remaining  four,  in  three  it  was 
known  to  have  presented  special  difficulty :  in  two,  for  instance,  preceding 
children  had  died  during  birth  in  consequence  of  the  difficulty."  ♦Lovett,* 
on  the  other  hand,  concludes  from  his  statistics  that  the  influence  of  dif- 
ficult labor  in  producing  cerebral  paralysis  must  have  been  overestimated, 

1  Medical  and  Surgical  Eeporter,  1887.  ^  Philadelphia  Medical  News,  1888. 

3  American  Journal  of  Obstetrics,  1885.  *  Lancet,  April,  1888. 

5  Boston  Medical  and  Surgical  Journal,  June,  1888. 


INJURIES   OF   THE   NEW-BOEN.  267 

stating  that  probably  accounts  of  the  labors  from  unprejudiced  persons 
would  show  a  much  higher  percentage  of  normal  labors. 

The  essential  characteristics  of  a  cerebral  paralysis  in  the  new-born 
caused  by  labor  are  that  there  is  no  history  of  disease  or  injury  happenino- 
after  birth  which  can  explain  the  condition,  and  that  the  paralysis  gradually 
lessens. 

There  is  little  to  be  said  as  to  the  treatment  of  meningeal  hemor- 
rhage. Aspiration  of  the  effused  blood  has  been  proposed,  but  it  cannot  be 
recommended.  If  convulsions  occur,  the  potassic  bromide  and  chloral  may 
be  given.  But  when  the  acute  stage  has  passed — ^when  effused  blood, 
for  example,  has  been  absorbed  or  repair  of  injured  brain-tissue  accom- 
plished— there  is  little  to  be  hoped  for  from  medicines,  and,  as  remarked  by 
Gowers,  drugs  are  useless  unless  to  combat  some  of  the  effects  of  the  disease. 

If  there  be  associated  with  facial  hemiplegia  paralysis  of  the  internal 
parts  of  the  mouth,  an  internal  injury  of  the  nerve  has  occurred,  and  thera- 
peutic means  are  without  value. 

Drs.  W.  J.  Little,^  Langdon  Down,^  and  Arthur  Mitchell,^  among 
others,  have  apparently  established  a  close  connection  between  difficult  labor 
and  the  idiocy  of  many  of  the  children  thus  born ;  but  the  discussion  of 
this  subject  cannot  be  presented  here. 

Injuries  of  the  Trunk. — There  will  be  omitted  grave  lesions  of  the 
spine,  such  as  fractures  of  vertebrae  and  injuries  of  the  cord,  ruptures  of 
internal  organs,  whether  of  chest  or  of  abdomen,  and  intra-abdominal  as 
well  as  intra-thoracic  hemorrhages :  a  jDaraplegia  in  the  new-born  in  almost 
all  cases  is  the  result  of  such  serious  harm  that  death  soon  comes :  it  can 
neither  be  averted  nor  delaj^ecl. 

Muscles  of  the  trunk  may  suffer  such  injury  that  a  hsematoma,  similar  to 
that  described  as  occurring  in  the  sterno-cleido-mastoid,  may  be  present :  its 
treatment  is  the  same  as  that  given  for  the  affection  previously  mentioned. 

In  seventy-three  cases  of  injury  to  the  foetus  during  delivery,  collected 
by  Huge,  the  child  having  presented  by  the  pelvis  or  podalic  version  having 
been  performed,  there  were  three  instances  of  rupture  of  the  sacro-iliac 
joint.  It  is  possible  that  some  cases  of  ankylosis  of  the  joint  result  from 
such  injur>\  Dr.  W.  H.  Parish  states  that  he  has  seen  a  tear  of  the  peri- 
neum, extending  from  the  vulvar  orifice  to  the  rectum,  in  a  new-born,  caused 
by  the  tip  of  one  of  the  blades  of  the  forceps  which  the  practitioner  had 
attempted  to  a])ply  to  an  unrecognized  breech-presentation. 

Injuries  of  the  Arms. — In  connection  with  lesions  of  the  superior 
members,  those  of  the  clavicle  and  scapula,  which  belong  to  the  arms 
rather  than  to  the  trunk,  will  be  referred  to. 

Fractures  of  the  humerus  are  more  frc(|uent  than  all  other  fractui-es  of 
the  upper  extremity  and  of  the  clavicle  and  scapula.     The  injury  generally 

'  London  Obstetrical  Society's  Transactions,  vol.  xviii.  ^  Ibid.,  vol.  iii. 

3  Medical  Times,  1862-63. 


268  INJURIES    OF    THE    NEW-BORN. 

occurs  in  an  eifort  to  bring  down  an  arm  which  has  ascended  in  a  head-last 
labor ;  the  ascension  is  almost  invariably  the  consequence  of  a  hasty  effort 
to  extract  the  child,  for  if  expulsion  be  left  to  natural  forces  the  arms  will 
remain  folded  upon  the  chest.  Separation  of  the  epiphysis  of  the  head,  of 
the  humerus  from  the  diaphysis  is  an  accident  which  may  be  overlooked, 
or  thought  to  be  a  luxation,  or  a  paralysis,  from  an  injury  to  nerves. 
Kiistner,^  who  has  especially  described  this  injury,  states  that  its  character- 
istic symptom  is  that  when  the  infant  attempts  to  move  the  arm  the 
humerus  rotates  iuAvard.  In  its  treatment  he  advises  that  the  epiphysis, 
now  rotating  outward,  be  brought  in  contact  with  the  diaj)hysis,  and  then 
the  arm  fixed  by  a  bandage  in  a  position  somewhat  outward  and  backward 
to  the  thorax.  ISTancrede  advises  in  the  treatment  of  a  fracture  of  the 
humerus  fixing  the  whole  upper  extremity  with  a  moulded  splint  in  a 
straight  position. 

Paralysis  of  the  arm  has  been  observed  in  connection  with  a  hsematoma 
of  the  sterno-cleido-mastoid,  injury  of  the  deltoid,  compression  of  the 
axillary  nerve,  as  from  the  employment  of  the  finger  or  of  the  blunt-hook 
to  effect  extraction  of  the  body  when  there  is  delay  after  the  delivery  of 
the  head,  and  it  has  followed  a  shoulder-presentation,  the  arm  protruding, 
delivery  being  finally  accomplished  by  podalic  version, — the  want  of  power 
being  independent  of  any  cerebro-spinal  lesion.  Recovery  is  the  rule  in 
these  cases.  Delore  believes  that  paralysis  may  result  from  rupture  of  a 
nerve-trunk  near  the  spinal  cord ;  if  an  upper  member  only  be  affected,  the 
palsy,  though  incurable,  does  not  interfere  with  the  life  of  the  child. 

Gowers,  in  referring  to  paralysis  of  the  arm,  remarks  ^  that  the  nei'ves  of 
the  arms  may  be  damaged  in  several  ways.  "  The  injury  may  be  -associated 
with  fracture  of  the  humerus,  and  is  then  due  either  to  the  displacement  of 
the  broken  ends  of  the  bone,  or  to  the  force  that  caused  the  fracture.  In 
such  cases  the  distribution  of  the  palsy  is  irregular,  and  varies  in  each  in- 
stance. In  other  cases,  however,  the  injury  is  higher  up  to  the  roots  of  the 
nei'ves  as  they  enter  the  brachial  plexus.  This  injury  is  commonly  pro- 
duced by  pressure  at  one  spot,  in  front  of  the  edge  of  the  trapezius.  In  a 
few  instances  the  extremity  of  a  much-curved  blade  of  the  forceps  has 
pressed  deeply  here  and  has  effected  the  injury,  leaving  at  the  same  time  a 
mark  on  the  skin.  In  other  and  more  frequent  cases  the  injury  is  produced 
by  the  point  of  a  traction-hook,  or  the  tip  of  the  bent  finger,  placed  above 
the  shoulder  for  this  purpose." 

Fracture  of  the  clavicle  is  usually  caused  by  direct  pressure  of  one  or 
two  fingers  upon  the  bone  in  the  effort  to  deliver  the  head  after  pelvic 
presentation  or  after  podalic  version.  The  injury  is  treated  by  fixing  the 
arm,  the  forearm  being  flexed,  by  means  of  a  roller  bandage,  to  the  chest,  and 
then  properly  supporting  the  member ;  the  child  should  be  as  far  as  possible 
kept  lying  upon  the  back :  the  fracture  is  consolidated  in  six  or  seven  days. 

1  ITeber  die  Verletzungen  der  Extremitateu  des  Kindes.  ^  Op.  cit. 


INJURIES   OF    THE    XEW-BORN. 


269 


Fig 


Separation  of  the  clavicle  from  the  sternum,  transverse  fracture  of  the 
scapula,  rupture  of  the  epiphysis  of  the  neck  of  the  bone,  and  injury  of 
the  acromion  process  are  among  rare  lesions  that  have  been  observed  in  the 
new-born. 

Injuries  of  the  Lower  Limbs. — A  few  instances  of  fracture  of  the 
femur  occurring  in  spontaneous  labor  have  been  reported ;  but  most  fre- 
quently this  injury  has  followed  an  effort  to  bring  down  the  thigh  in  a  case 
of  pelvic  presentation,  where  the  presenting  part  was  in  the  mother's  pelvis, 
before  pushing  up  that  part  so  that  room  for  the  movement  of  the  thigh 
could  be  given,  or  from  traction  upon  the  thigh  by  means  of  the  fillet  or  of 
the  blunt-hook. 

Dr.  Xancrede  advises  that  sheet  vulcanite  should  be  used  in  the  treat- 
ment of  a  fractured  femur :  the  material  is  softened  in  hot  water  and 
accurately  moulded  to  the  limb.  "An  anterior  splint  should  be  made 
which  will  extend  well  up  over  the  abdomen,  and  a  posterior  splint  which 
will  reach  from  the  buttock  well  below  the  knee,  thus  fulfilling  the  impor- 
tant indication  of  fixing  the  joints  above  and  below  the  fracture.  It  only 
requires  ten  or  twelve  days  for  firm  union  to  occur." 

Ruge  states  that  dislocation  of  the  hip  in  obstetric  operations  is  exceed- 
ingly rare,  he  having  not  found  one  in  three  hundred  autopsies  of  the  new- 
born. Kiistner,  however, 
mentions  that  Goschen  relates 
a  case  in  which  this  injury 
occurring  in  birth  was  success- 
fully treated  in  a  girl  thirteen 
years  old  by  Langenbeck,  and 
that  Stromeyer  had  met  with 
twenty  cases.  "  The  only  pos- 
sible way  in  which  this  dislo- 
cation could  occur  would  be 
by  sudden  and  violent  force 
drawing  down  the  limb,  and 
then  the  head  of  the  bone 
might  be  thrown  upon  the 
ilium." 

An  unusual  position  of 
the  lower  limbs  is  observed 
for  several  days  after  labor 
in  that  variety  of  pelvic  pres- 
entation in  which  the  thighs 

are  flexed  upon  the  abdomen  and  the  legs  extended  upon  the  chest,  described 
by  French  obstetricians  as  presentation  du  siPge  decoinjj/rfe,  mode  des  f esses. 
The  liml)s  for  a  time  remain  in  the  same  attitude  which  they  occupied 
during  pregnancy  and  in  labor,  and  it  is  in  vain  to  attempt  placing  them 
in  any  other.     (Fig.  6.) 


Position  for  some  days  after  birth  of  lower  limbs  in  child 
born  as  described  in  text. 


INFANT-FEEDING-WEANING. 

By  T.  M.  EOTCH,  M.D. 


In  reviewing  the  immense  amount  of  literature  which  has  accumulated 
on  the  subject  of  infant-feeding,  we  find  that  the  superiority  of  breast- 
feeding is  acknowledged  so  generally  that  it  may  be  said  to  have  become  a 
scientific  truth. 

On  the  other  hand,  the  opinions  expressed  regarding  artificial  feeding 
are  so  diverse,  and  so  opposed  to  one  another,  that  it  is  evident  that  much 
which  has  for  years  been  taught  must  be  unlearned,  or  rather  admitted  to 
be  untrue,  before  we  can  exjDCct  to  make  any  intelligent  advance  in  this 
most  difficult  subject. 

The  great  number  of  artificial  foods,  used  by  physicians  according  to 
the  fashion  of  the  day,  only  proves  that  bottle-feeding  has  not  as  yet 
arrived  at  that  state  of  perfection  where  it  can  compete  with  breast-feeding. 
The  difficulty  in  approaching  the  study  of  the  subject  has  been  in  the 
method,  which,  with  physicians  as  a  class,  has  been  too  purely  from  a 
clinical  stand-point.  We  know,  for  instance,  how  easily  we  may  be  misled 
by  the  apparently  good  effects  of  a  medicament  where  perhaps  on  further 
investigation  or  in  the  light  of  some  new  discovery  we  learn  that  the 
improvement  in  the  case  was  due  not  to  the  drug,  but  rather  to  circum- 
stances entirely  apart.  The  same  applies  equally  well  to  the  case  of  many 
foods  and  methods  of  feeding. 

The  analyses,  the  opinions  involving  expert  chemical  knowledge,  and 
much  valuable  general  advice,  in  the  following  pages,  were  received  from 
Dr.  Charles  Harrington,  Instructor  of  Materia  Medica  and  Hygiene  and 
Assistant  in  Chemistry  in  the  Medical  Department  of  Harvard  University. 

The  feeding-problem  is  one  which  is  hedged  about  with  many  difficulties, 
on  account  of  the  great  diversity  of  individual  circumstances  and  idiosyn- 
crasies. 

Certain  infants,  for  instance,  may  thrive  on  peculiar  mixtures  not  adapted 
to  infants  as  a  class.  Many  will  not  thrive  on  that  food  which  nature  has 
provided,  and  the  well-being  of  an  infant  will  depend  much  upon  the  cir- 
cumstances by  which  it  is  surrounded,  such  as  affluence  or  poverty,  country 
or  city  life. 

In  those  cases  where,  for  one  reason  or  another,  hinnan  milk  is  not 
270 


INFANT-FEEDIXG WEANING.  271 

available,  the  question  of  feeding  is  this  :  What  may  be  given  to  take  the 
place  of  nature's  food  ?  In  supplying  a  substitute  we  should  copy  in  every 
possible  way  the  physical  and  chemical  characteristics  of  the  food  which  is 
universally  acknowledged  to  be  the  best. 

In  our  endeavor  to  copy  nature  we  may  hope  that,  as  our  scientific 
knowledge  advances,  more  and  more  light  will  be  thrown  upon  those  points 
which  are  now  obscured  by  ignorance. 

The  recent  discoveries  in  bacteriology,  for  instance,  throw  light  on  the 
reason  for  the  old  and  well-deserved  popularity  of  boiled  milk  in  digestive 
disturbances,  and  plainly  point  out  to  us  that  had  we  in  the  past  better 
understood,  the  significance  of  the  sterility  of  breast-milk,  we  should  have 
made  more  rapid  advances  in  the  management  of  the  infant's  diet. 

What  is  of  the  first  importance  is  that  we  should  recognize  our  ignorance, 
and,  keeping  our  eyes  opened  to  all  possible  scientific  advancement,  be  ready 
to  sweep  aside  preconceived  ideas  not  resting  upon  established  facts.  Young 
animals  at  birth  begin  to  receive  their  nourishment  immediately,  and  a  cor- 
responding increase  in  their  weight  takes  place  from  almost  the  first  day  of 
life.  The  human  infant,  in  like  manner,  should  begin  with  its  nursing 
early,  getting  what  it  can  from  the  breast  until  the  full  supply  of  milk  has 
come.  In  this  way  it  will  not  be  so  likely  to  have  a  large  initial  loss  of 
weight  to  recover,  by  which  it  is  often  handicapped  at  the  very  beginning 
of  its  career,  when  there  is  most  danger  to  be  anticipated  from  a  depression 
of  its  nutrition.  Every  day,  every  hour,  is  of  the  utmost  imj^ortance  in 
the  early  days  of  life,  and,  provided  it  can  be  done  without  detriment  to 
the  condition  of  the  mother,  the  sooner  the  child  is  put  to  the  breast  the 
better  it  will  be. 

Under  rather  exceptionally  favorable  circumstances  we  see  the  breast- 
fed infant  steadily  gaining  in  weight  during  the  first  year  of  its  life,  starting 
with  the  average  initial  weight  of  from  three  thousand  to  four  thousand 
grammes,  showing  a  small  physiological  loss  of  one  or  two  hundred 
grammes  ^  according  as  the  first  weight  is  taken  before  or  after  the  bath  and 
passage  of  meconium,  and  attaining  at  the  completion  of  its  first  year  a 
weight  of  from  nine  to  ten  kilogrammes. 

Instances  of  continual  weekly  gains  during  the  first  year  occasionally 
come  under  our  notice,  and  the  following  chart  gives  the  exact  weights  of 
a  healthy  male  infant  fed  by  a  wet-nurse  for  over  a  year,  and  will  serve  as 
an  example  of  how  an  infant  can  thrive  on  good  breast-milk  :  the  analysis  of 
this  breast-milk  is  given  on  page  284,  Anabses  YIII.,  IX.,  X.  The  baby 
was  evidently  gaining  so  steadily  that  the  weighing  was  omitted  in  certain 
weeks,  which  fact  is  unfortunate,  as  the  weights  would  })r()bnbly  liave  shown 
the  same  steady  gain.  A  weekly  gain  is  also  shown  in  the  chaft  of  a  male 
and  a  female  infant,  brother  and  sister,  nursed  by  their  motlier.  Tlie  double 
line  represents  the  boy's  weights  in  the  first  twenty-nine  weeks  of  his  life, 

1  C.  W.  Townsend,  Bust.  Med.  and  Surir.  .Jour.,  Feb.  17,  1887. 


272 


INFAXT-FEEDIX( 


-WEAXING. 


and  the  dotted  line  the  girl's  weights  for  twenty-one  w^eeks.  This  continual 
increase  in  weight  is  of  great  importance  in  the  first  year,  as  it  is  the  chief 
index  by  which  we  note  the  progress  of  nutrition  and  judge  concerning  the 
desirability  of  continuing  the  food.     An  average  gain  of  from  twenty  to 


en  cs 


000 
750 
600 
.250 
.000 
.750 
.500 
.2.50 
.000 
.750 
.,500 
.250 
.000 
.750 
.,500 
.250 
.00( 
.7,50 
,500 

?icS=i=l?o=5oioio5c5 

2 

£ 

o  Si 

^:  ^c  T 

^^  5^ 

~       ~v  ^ 

"^^  ^v           - 

%       '^^^ 

-^.         -^^ 

^^     ^^s.^    : 

_ 

^*.           5^   . 





:        :         '^^       'S.. 

— 

_ 

■^         s. 

s 

— 

— 



— ^~ 

"^^^ 

t 

_ 

J 

^^ 

s, 

S;^ 

\ 

^ 

s; 

^^ 

1 

^^ 

±                     "^- 

^^^ 

t 

K'- 

^                ^i^^ 

-^                 ^ 



_ 

\                   ^^ 

^^                     s 

S^                        X 

^^                   X 

^^                    X 

K                         \ 

L 

1 

^ 

J                 i 

A 

I                                                                             V. 

lEi,, 

,, 

\ 

\ 

1 

\ 

\ 

\ 

\ 

^ 

\ 

1 

1 

1 

: 

_ 

Name,  F.  S 
Date  Birth, 
Initial  W't, 


,,  Hale. 
June  20, 18? 
4500  gram. 


ictualWt.  Bate  of  W'g 


4.500 
4,612 
4,916 
5,332 
5,684 
6,004 
6,292 
6,644 
6,852 
7,172 
7,476 
7,802 
7,994 
8,170 
8,362 
8,586 
8,912 
9,136 
9,376 


14 1 
15 
16 
17 1 
18 
19 
20( 

21 1  9,968 
22 1  10,112 
23' 
24  i 
25' 

26:  10,912 
27, 
281 
29 1 
30' 
31' 
32 
33 
34 

35:  11,680 
.36  11,904 
37 1  12,032 
38' 
39] 
40 
41 

42  12,544 
■43 
44' 

45  12,640 
46 
47 
48 
49 
50 

51    13,104 
52:  13,376 


June  27. 
July  4. 

"    11. 

"     18. 

"  25. 
Aug.  1. 

"      8. 

"     15. 

"     22. 

"  29. 
Sept.  5. 

"     12. 

"     19. 

"  26. 
Oct.  3. 

"   10. 

"   17. 

"   24. 

"   31. 

Nov.  14. 
"      21. 


Feb.  20. 

"     27. 

March  5. 


April  9. 
April  30. 


June  10. 
"     20. 


thirty  grammes  a  day  in  the  first  four  or  five  mouths  and  ten  to  fifteen 
grammes  a  day  through  the  rest  of  the  year  makes  a  successful  line  of  nutri- 
tion, and  may  be  used  as  a  working  basis  for  the  management  of  the  food. 

Nature's  feeding-apparatus  is  one  which,  by  collapsing  as  it  is  emptied, 
avoids  the  formation  of  a  vacuum,  with  its  consequent  exhaustion  of  the 
infant  and  prolongation  of  the  nursing-time. 

A  healthy  baby  empties  the  breasts  with  easy  and  almost  uninterrupted 
sucking  in  about  fifteen  minutes.  The  quantity  ingested  is  determined  by 
various  methods,  such  as  by  careful  weighing  before  and  after  nursing,  and 
by  the  determination  of  the  actual  capacity  of  the  average  stomach  at  difier- 
ent  ages  and  with  different  weiglits.  These  results  are  of  great  practical  im- 
portance, and  will  be  stated  later  when  we  come  to  speak  of  artificial  foods. 


INFANT-FEEDING WEANING. 


273 


The  intervals  of  feeding  constitute  a  very  much  more  important  factor 
in  breast-feeding,  Avhere  the  quantity  is  regulated  by  the  breast  itself.  It  is 
sufficient  for  the  present  to  state  that  the  activity  of  gro^\i:h  in  the  stomach's 
capacity,  according  to  Frolowsky/  can  be  represented  by  the  ratio  of  one 
for  the  first  week  to  two  and  one-half  for  the  fourth  week  and  three  and 
one-fifth  for  the  eighth  week,  while  it  is  only  three  and  one-third  for  the 
twelfth  week,  three  and  four-sevenths  for  the  sixteenth  week,  and  three  and 
three-fifths  for  the  twentieth  week.  The  first  month  being  the  most  critical 
period  for  the  infant's  nutrition,  as  it  is  the  time  when  the  equilibrium  of 
its  metabolism  is  being  established  and  its  chance  for  life  the  least,  especial 
value  should  be  attached  to  the  series  of  careful  investigations  made  at  the 
Children's  Hospital  in  St.  Petersburg  by  Ssnitkin^  to  determine  the  amount 
of  food  which  should  be  given  in  the  first  thirty  days  of  life,  and  from 
which  is  deduced  the  rule,  "  the  greater  the  weight  the  greater  the  gastric 
capacity."  Ssnitkin's  general  results  show  also  that  one  one-hundredth  of 
the  initial  weight  should  be  taken  as  the  figure  with  which  to  begin  the 
computation,  and  to  this  should  be  added  one  gramme  for  each  day  of  life. 
The  following  table  represents  merely  approximate  average  figures,  which 
are  the  results  of  computations  made  by  a  number  of  observers  in  different 
parts  of  the  world,  and  of  my  own  investigations,  both  clinical  and  anatom- 
ical, during  the  past  ten  years. 

TABLE  I. 

The  average  initial  weight  of  infants  is  3000-4000  grammes  ^  ahout  6.6-8.8  pounds. 
The  average  normal  gain  per  day  in  the  first  five  months  is  20-30  grammes,  or  about 
two-thirds  to  one  ounce. 

General  Rules  for  Feedxnrj. 


Age. 

Intervals  of 
Feeding. 

Number  of  Feedings 

in  twenty-foub 

Hours. 

Average  Amount  at 
EACH  Feeding. 

Average  Amount  in 

Twenty-Four 

Hours. 

1st  week .  .  . 

2  hours. 

10 

1  ounce. 

10  ounces. 

1-6  weeks .  . 

1\  hours. 

8 

1^-  to  2  ounces. 

12  to  16  ounces. 

6-12  weeks, 
and  possibly 
to  5th  or  Cth 
month  .... 

3  hours. 

6 

3  to  4  ounces. 

18  to  24  ounces. 

At  6  mos. .  . 

3  hours. 

6 

6  ounces. 

36  ounces. 

At  10  mos.  . 

3  hours. 

5 

8  ounces. 

40  ounces. 

Vol.  I.— 18 


1  Inaugural  Diss.,  St.  Petersburg,  1876. 
'  Keitz,  Physiologic  des  Kindesalt.,  S.  40. 


274 


INFANT-FEEDING — WEANING. 


The  weight,  as  well  as  the  age,  is  necessary  to  determine  the  amount  for  each  feeding 
in  the  individual  infant,  the  rule  being  ji^  of  the  initial  weight  +  1  gramme  for  each  day 
during  the  first  month. 

Illustrations  of  the  above  rule  to  serve  as  guides  for  especially  difficult  cases. 


Initial  weight. 

Each  Feeding. 

Early  days.                     At  15  days.                         At  30  days. 

3000  grammes. 

30  grammes  (about  1 
ounce). 

30  -|-  15  =  45  grammes 
(about  Ij  ounces). 

30  +  30  =  60  grammes 
(about  2  ounces). 

4500  grammes. 

45   grammes    (about 
IJ  ounces). 

45  +  15  =  60  grammes 
(about  2  ounces). 

45  +  30  =  75  grammes 
(about  2\  ounces). 

6000  grammes. 

60  grammes   (about 
2  ounces). 

60  +  15  ^  75  grammes 
(about  2^  ounces). 

60  +  30  =  90  grammes 
(about  3  ounces). 

The  only  point  in  the  feeding-problem  where  artificial  feeding  seems  to 
have  the  advantage  of  the  breast  is  in  the  intervals  of  nursing,  Irregu-' 
larity  in  nursing,  frequent  nursing,  and  too  prolonged  intervals  often  so 
disturb  the  quality  of  the  human  breast-milk  as  to  transform  a  perfectly 
good  milk  into  one  entirely  unfitted  for  the  infant's  powers  of  digestion ; 
while  the  element  of  intervals  does  not,  of  course,  influence  the  question 
of  chemical  composition  in  a  properly-prepared  artificial  food.  Thus,  too 
frequent  nursing  lessens  the  water  and  increases  the  total  solids  in  human 
milk,  making  it  resemble  in  a  certain  way  condensed  milk ;  Avhile  too  pro- 
longed intervals  result  in  such  a  decrease  of  the  total  solids  as  to  render  an 
otherwise  good  milk  too  watery,  and  unfit  for  purposes  of  nutrition,  how- 
ever well  it  may  be  digested.  The  lesson  that  may  be  drawn  from  these 
facts  is  that  some  general  rule  for  the  feeding-intervals  should  be  enforced, 
such  as  is  represented  in  Table  I.,  in  order  that  the  mother  should  neither 
interfere  with  the  infant's  digestion  by  nursing  it  too  frequently  and  thus 
giving  it  a  too  concentrated  food,  nor,  by  neglecting  to  feed  it  often  enough, 
interfere  with  its  nutrition  by  giving  it  a  too  largely  diluted  food.  We 
must  recognize  two  distinct  elements  in  infant-feeding,  neither  of  which  can 
with  impunity  be  interfered  with  at  the  expense  of  the  other,  namely,  di- 
gestion and  nutrition,  it  being  possible  for  the  milk  to  be  easily  digested 
but  non-nutritious,  and  again  to  be  highly  nutritious  but  difficult  to  digest, 
and  it  is  the  equilibrium  of  these  two  elements  which  makes  up  a  perfect 
infantile  development. 

The  younger  the  infant,  the  greater  the  metabolic  activity,  and  hence  the 
greater  need  for  frequent  feeding ;  for  nutriment  is  required  not  only  for 
repair  of  waste,  but  also  for  the  rapid  proportionate  growth ;  and  we  thus 
see  that  the  intervals  of  feeding  according  to  the  age  as  shown  in  Table  I. 
become  essential  in  successful  feeding. 


INFANT-FEEDING WEANING.  275 

The  next  question  to  be  considered  is  the  quality  of  the  food  which  is  pro- 
vided for  the  human  infant.  The  later  analyses  and  those  upon  which  most 
reliance  is  to  be  placed  are  those  of  J.  K5nig,  Forster,  Meigs,  Harrington, 
and  others,  and  give  the  following  approximate  results : 

TABLE   II. 

Human  Milk. 

Keaction slightly  alkaline 

Specific  gravity 1028-1034 

Water 87-88 

Total  solids 13-12 

Fat 3-4 

Albuminoids 1-2 

Sugar 7.0 

Ash 0.2 

Human  milk  has  also  been  shown  to  be  sterile  by  Escherich,  who  experi- 
mented with  the  milk  of  twenty-five  healthy  women,  and  found  by  keeping 
it  in  sterilized  tubes  that  it  remained  unchanged  for  some  weeks.  We  have 
as  represented  in  Table  II.  a  fair  knowledge  as  to  the  normal  composition 
of  human  milk,  and  are  at  once  struck  with  its  simplicity  and  freedom  from 
a  multiplicity  .of  constituents.  We  must,  however,  allow  that  the  chemistry 
of  what  is  put  down  as  albuminoids,  which  is  a  general  name  including 
casein  and  an  albumen^  which  in  its  general  features  agrees  with  ordinary 
serum  albumen,  is  too  obscure  to  practically  and  clinically  consider  it  more 
minutely.  AVe  recognize,  however,  that  this  albumen  is  present,  in  small 
and  variable  quantities,  when  the  mammary  gland  and  its  secretion  are  in 
a  normal  condition,  except  at  the  time  when  the  glandular  function  is  being 
established,  when  it  becomes  proportionately  larger  in  amount  than  the 
casein.  It  is  also  wiser,  although  we  know  that  the  ash  is  made  up  of  a 
number  of  different  salts,  to  deal  with  this  constituent  as  a  whole,  for  the 
analyses  which  have  been  made  of  the  mineral  constituents  of  human  milk 
are  so  contradictory  in  their  results  that  collectively  they  are  of  no  value. 
On  this  point  we  know  only  that  the  ash  is  made  up  of  certain  salts  amount- 
ing to  about  0.20  per  cent,  of  the  milk ;  but  we  do  not  know  the  proportion 
of  each  compound  present. 

Reasoning  from  the  strong  analogy  which  must  exist  between  human 
milk  and  cow's  milk,  and  being  aware  of  the  great  variations  which  occur 
in  the  latter,  we  may  assume  that  human  milk  is  liable  to  vary  in  its  com- 
position considerably  with  different  milkings  on  the  same  day  and  also  with 
the  milking  of  the  same  hours  on  different  days,  so  that  we  at  present  are 
not  in  a  position  to  state  that  our  knowledge  of  human  milk  is  sufficiently 
exact  to  justify  an  attemj)t  to  formulate  a  table  to  show  the  composition  of 
woman's  milk  at  different  ages,  however  valuable  such  information  may  in 
the  future  prove  to  be. 

*  Forster's  Physiology,  p.  563. 


276  INFAXT-FEEDIXG WEANIXG. 

It  is  hardly  withiu  the  scope  of  this  article  to  discuss  minutely  the 
physiological  question  of  the  elimination  of  various  elements  by  the  mam- 
mary gland.  The  fact  that  such  elimination  does,  however,  take  place  is 
conceded,  and  at  times  becomes  of  a  good  deal  of  importance  in  the 
manao-ement  of  the  infant's  diet. 

In  the  early  days  of  the  milk-secretion  we  find  a  decided  difference  in 
the  character  of  its  composition.  From  our  knowledge  of  the  colostrum 
period  of  cows,  it  would  seem  from  analogy  that  the  mammary  gland,  in 
the  first  five  or  six  days,  is  in  part  at  least  an  organ  by  which  transudation 
from  the  blood  can  take  place ;  that  is,  that  the  colostrum  period  is  one 
where  the  mammary  gland  has  not  yet  reached  the  perfect  development  of 
its  function  for  producing  milk  from  its  own  cells,  and  that  the  milk  of 
this  early  period  is  very  deficient  in  casein  and  proportionately  rich  in 
albumen.  Under  these  conditions,  and  also  where,  as  at  times  is  the  case, 
the  milk  is  abnormal  from  some  defect  in  the  health  of  the  mother,  causing 
the  colostrum  period  to  be  prolonged  or  to  recur,  there  seems  to  be  a  direct 
transudation  from  the  blood  of  such  inorganic  substances  as  arsenic,  anti- 
mony, lead,  iodide  of  potash,  mercury,  and  others,  taken  by  the  mother. 
"Well-authenticated  cases  also  come  to  our  notice  from  time  to  time  where 
injury  has  been  done  to  the  nursing  infant  in  this  way,  and  where  even 
death  has  occurred  from  the  elimination  by  the  breast-milk  of  certain 
organic  substances,  such  as  colchicum  and  morphine. 

The  greatest  variety  of  substances  have  been  found  in  the  milk,  but  no 
definite  rule  as  to  the  amount  of  this  elimination  has  yet  been  established, 
so  that  our  knowledge  of  the  existence  of  this  process  is  valuable  as  a  pro- 
phylactic against  harm,  rather  than  as  a  means  of  direct  benefit  to  the 
infant  in  disease,  which  latter  point  will  not  be  discussed  here,  except  to 
draw  attention  to  the  fact  that  the  medicinal  treatment  of  infantile  disease 
through  the  breast-milk  is  exceedingly  inexact. 

We  must  also  recognize  the  clinical  fact  that  it  is  not  only  when  the 
milk  is  in  a  poor  condition  that  this  elimination  takes  place,  but  that  it 
may  occur  at  any  time  during  the  nursing  period  in  the  breasts  of  women 
who,  so  far  as  we  can  ascertain,  are  in  a  perfectly .  healthy  condition.  Thus, 
every  practitioner  has  at  times  doubtless  observed  the  laxative  effect  on  the 
infant  of  such  drugs  as  the  compound  licpiorice  powder  given  to  the  mother ; 
and  a  case  has  lately  come  to  my  notice  where  a  baby  vomited  for  weeks 
while  taking  the  milk  from  the  breast  of  its  mother,  who  was  unusually 
strong  and  well,  but  who  was  in  the  habit  of  drinking  a  considerable  daily 
quantity  of  porter :  the  vomiting  ceased  at  once  and  did  not  return  after  the 
porter  was  omitted. 

That  both  the  secretion  and  the  character  of  the  milk  are  strongly  influ- 
enced by  the  nervous  system  is  a  matter  of  common  clinical  experience,  but 
the  exact  nervous  mechanism  which  controls  it  has  not  yet  been  fully  worked 
out, — the  clinical  result,  however,  being  recognized,  that  emotional  mothers 
do  not  make  sood  nurses.     There  are  certain  other  facts  known  regarding 


IXFAXT-FEEDIXG WEANIXG.  277 

the  milk,  which  it  will  be  well  to  mention  here  as  having  a  bearing  of  more 
or  less  practical  importance  on  what  remains  to  be  said  concerning  breast- 
feeding. Bunge's  investigations  on  the  comparison  of  tissues  ^  show  that 
the  mammary  gland  abstracts  from  the  blood  just  about  the  amounts  of 
salts  found  in  the  tissues. 

According  to  Forster,^  "  milk  is  the  result  of  the  activity  of  certain  pro- 
toplasmic cells  forming  the  epithelium  of  the  mammary  gland.  So  far  as 
we  know,  the  fat  is  formed  in  the  cell  through  a  metabolisiu  of  the  proto- 
plasm. Microscopically,  the  fat  can  be  seen  to  be  gathered  in  the  epithelium- 
cell  in  the  same  way  as  in  a  fat-cell  of  the  adipose  tissue,  and  to  be  discharged 
into  the  channels  of  the  gland  either  by  a  breaking  up  of  the  cells  or  by  a 
contractile  extrusion  very  similar  to  that  which  takes  place  when  an  amoeba 
ejects  its  digested  food.  This  observation  is  thoroughly  supported  by  other 
facts.  Thus,  the  quantity  of  fat  present  in  the  milk  is  largely  and  directly 
increased  by  proteid  food,  but  not  increased,  on  the  contrary  diminished,  by 
fatty  food.  In  fact,  proteid  food  increases,  and  fatty  food  diminishes,  the 
metabolism  of  the  body.  A  bitch  fed  on  meat  for  a  given  period  gave  off 
more  fat  in  her  milk  than  she  could  possibly  have  taken  in  her  food,  and 
that,  too,  while  she  was  gaining  in  weight,  so  that  she  could  not  have  sup- 
plied the  mammary  gland  with  fat  at  the  expense  of  fat  previously  existing 
in  her  body.  We  also  have  evidence  that  the  casein  is,  like  the  fat,  formed 
in  the  gland  itself.  When  milk  is  kept  at  35°  C.  outside  of  the  body,  the 
casein  is  increased  at  the  expense  of  the  albumen.  When  the  action  of  the 
cell  is  imperfect,  as  at  the  beginning  and  end  of  lactation,  the  albumen  is  in 
excess  of  the  casein  ;  but  so  long  as  the  cell  possesses  its  proper  activity,  the 
formation  of  casein  becomes  prominent.  That  the  milk-sugar  also  is  formed 
in  and  by  the  protoplasm  of  the  cell  is  indicated  by  the  fact  that  the  sugar 
is  not  dependent  on  a  carbohydrate  food,  and  is  maintained  in  abundance  in 
the  milk  of  carnivora,  when  these  are  fed  exclusively  on  meat,  as  free  as 
possible  from  any  kind  of  sugar  or  glycogen.  We  thus  have  evidence  in 
the  mammary  gland  of  the  formation,  by  the  direct  metabolic  activity  of 
the  secreting  cell,  of  the  rej^resentatives  of  the  three  great  classes  of  food- 
stuffs, proteids,  fats,  and  carbohydrates,  out  of  the  comprehensive  substance 
protoplasm." 

With  the  aid  of  such  facts  as  have  been  stated  above,  Ave  can  now  judge 
more  intelligently  as  to  the  various  questions  which  arise  in  connection  with 
the  subject  of  infant-feeding.  The  general  rule  deduced  from  these  facts  is, 
manifestly,  that  a  healthy  woman  should  nurse  her  child.  The  younger  the 
infant  the  more  important  the  breast-nursing,  the  gastro-intestinal  canal 
being  in  a  more  active  state  of  development  and  certain  of  its  functions 
being  still  unprepared  for  use  in  the  early  months  of  life.  It  is  much 
more  difficult  to  adapt  an  artificial  food  to  the  sensitive  growing  infiuitile 
digestive  apparatus  at  tliis  early  age,  thus  accounting  in  a  measure  for  the 

»  Archiv  fur  Physiologie,  1886,  539.  ^  Physiology,  p.  5G4. 


278  INFANT-FEEDING WEANING. 

rule,  that  the  younger  the  child  the  greater  the  mortality.  There  is  no 
doubt,  however,  that  the  mother's  milk  in  a  considerable  number  of  cases 
met  with  in  the  practice  of  physicians  among  civilized  nations  appears  to  be 
entirely  unfit  for  her  offspring,  and  it  at  times  becomes  a  question  of  con- 
siderable judgment  as  to  whether  the  infant  shall  be  withdrawn  from  its 
mother's  breast  either  temporarily  or  entirely.  It  is  here,  in  my  opinion, 
that  in  the  future  the  careful  and  repeated  analysis  of  the  milk  will  play  a 
great  role  in  aiding  us  to  determine  wisely  this  question. 

I  am  fully  convinced  that  a  large  number  of  infants  are  deprived  of 
their  natural  food  and  placed  on  artificial  foods  on  insufficient  grounds. 
We  thus  assist  to  keep  up  the  resulting  high  mortality  figures ;  and  I 
believe  that  these  figures  will  be  sensibly  reduced  when,  in  consequence 
of  our  taking  a  more  enlightened  view  of  the  subject,  we  shall  increase  the 
number  of  infants  who  are  fed  from  the  breast  during  the  first  three  or  four 
months  of  life. 

A  particular  reason,  among  many,  for  waiting  at  least  four  or  five  months 
before  beginning  with  artificial  feeding  is  presented  by  the  fact  that  the 
stomach  after  a  rapid  growth  has  become  by  the  fifth  or  sixth  month  a  more 
perfect  receptacle  both  as  to  size  and  as  to  function. 

Among  numerous  instances  of  the  same  kind  which  have  come  to  my 
notice,  I  might  cite,  by  way  of  a  simple  illustration  of  weaning  for  insuffi- 
cient reason,  the  case  of  an  infant  three  months  old,  which  recently  was 
brought  to  me  from  a  neighboring  town  to  have  its  artificial  food  regulated. 
The  history  of  this  case  was  that  its  mother,  a  healthy  primipara,  about 
twenty-two  years  old,  had  nursed  the  infant  for  six  weeks,  during  which 
time  the  infant  was  fretful,  suffered  much  from  colic,  and  never  seemed 
satisfied.  For  these  reasons,  although  there  was  a  gain  in  weight  and  the 
napkins  showed  a  fairly  good  digestion,  it  was  by  the  advice  of  the  attend- 
ing physician  weaned  at  once.  On  careful  inquiry,  I  found  that  this  infant 
had  been  nursed  almost  continuously  night  and  day  with  intervals  usually  of 
only  one  hour,  and  it  was  evident  that  the  frequent  nursing  had  resulted  in 
producing  a  concentrated  milk,  which  the  infant's  gastro-intestinal  canal  was 
rebelling  against,  and  the  infant  at  six  weeks  of  age  was  deprived  of  its 
supply  of  breast-milk  in  July,  and  placed  upon  an  artificial  food  containing 
seventy-eight  per  cent,  of  starch,  simply  because  the  important  factor  of 
intervals  had  not  been  thought  of  as  a  means  of  improving  the  milk  and 
relieving  the  pain  and  the  apparent  hunger. 

On  the  other  hand,  the  general  health  of  the  mother  should  be  carefully 
investigated,  as  women  sufiering  from  constitutional  syphilis  or  chronic  con- 
sumption are  manifestly  unfit  for  nursing ;  and  at  the  same  time  we  should 
be  careful,  unless  decided  symptoms  of  disease  are  present,  not  to  set  aside 
the  milk  of  a  delicate-looking  woman  until  it  has  been  analyzed.  The  rapid 
progress  which  is  being  made  in  the  detection  of  the  bacillus  tuberculosus  • 
not  only  in  the  sputum  but  also  in  the  milk  and  in  other  secretions,  may 
in  the  future  be  of  much  practical  importance  in  the  determination  of  the 


INFANT-FEEDING WEANING.  279 

question  whether  a  woman  should  nurse  an  infant ;  but  the  present  state  of 
our  knowledge  is  only  sufficiently  advanced  to  allow  us  to  state  that  this 
bacillus  has  been  detected  in  the  secretion  of  the  mammarv  gland. 

A  case  of  considerable  interest  came  to  me  in  consultation  early  in  July 
[1888],  which  points  to  the  possibility  of  our  being  at  times  too  hasty  in  our 
decision  to  deprive  an  infant  of  its  mother's  milk.  The  mother,  a  rather 
delicate  primipara,  twenty-five  years  of  age,  was  delivered,  July  3,  of  a  boy 
seven  pounds  in  weight.  AVithin  four  hours  puerperal  convulsions  set  in, 
from  which  she  recovered,  but  was  left  with  albuminuria  (0.25  per  cent.)  and 
casts.  The  latter  disappeared  in  a  few  days,  but  the  albumen,  though  some- 
what diminished,  continued ;  and  the  patient,  though  naturally  of  a  calm 
disposition,  was  in  a  highly  nervous  condition,  fearing  that  she  could  not 
nurse  her  baby,  but  decidedly  opposed  to  having  a  wet-nurse.  The  milk 
appeared  in  considerable  quantity  on  the  fifth  day,  but  the  baby  did  not 
thrive,  and,  although  it  gained  somewhat  in  weight,  was  very  fretful,  slept 
very  little,  and  looked  badly,  so  that  the  attending  physician  became  alarmed, 
and,  after  treating  it  for  its  dyspepsia  without  much  success  until  it  was  five 
weeks  old,  and  finding  that  there  was  still  about  0.25  per  cent,  of  albumen 
in  the  mother's  urine,  decided  with  me  that  the  breast-milk  should  be  with- 
held until  we  could  determine  the  cause  of  the  trouble,  and  an  analysis  was 
accordingly  made,  with  the  following  result : 

ANALYSIS   I. 

Fat 1.62 

Sugar 6.10 

Ash 0.17 

Albuminoids 3.54 

Total  solids 11.43 

"Water 88.57 

100.00 

This  analysis  revealing  the  probability  that  the  large  amount  of  albumi- 
noids was  causing  the  disturbance  of  digestion,  and  that  the  small  amount 
of  fat  was  not  sufficient  for  nutrition,  the  attending  physician  was  very 
anxious  to  procure  a  wet-nurse ;  but,  while  we  were  endeavoring  to  get  a 
proper  one,  we  decided  to  empty  the  mother's  breasts  with  the  breast-pump  ^ 
every  day,  thus  relieving  her  from  the  worry  of  attempting  to  nurse  lier 
baby  and  of  seeing  it  fail  to  gain,  and  thus  also  giving  her  undisturbed 


»  During  the  past  three  months  of  June,  July,  and  August  [1888]  I  have  had  under 
my  care  a  baby  seven  months  old,  who  was  dying  of  starvation,  tis  I  had  been  unable  to 
prepare  for  it  an  artificial  food  which  it  could  digest  and  thrive  on.  This  infant  also  was 
totally  unable  to  nui-se  from  the  breast ;  but  the  breast-milk  of  a  wet-nui-se  that  I  procured 
agreed  with  it  perfectly,  and  this  nui-se  has  pumped  the  milk  from  the  breasts  and  fed  the 
baby  with  it  from  a  bottle  for  over  three  months  with  the  greatest  success,  the  infant  thriving 
and  now  being  in  such  a  healthy  condition  that  it  is  about  to  be  weaned.  This  case  .shows 
the  perhaps  exceptional,  but  at  times  very  great,  value  of  the  breast-pump. 


280  INFANT-FEEDING ^WEANING. 

nights  and  a  great  deal  of  out-door  life.  The  infant  was  in  the  mean  time 
placed  on  an  artificial  diet,  which  was  digested  very  well,  and,  as  it  ceased  to 
cry,  the  mother's  mind  became  tranquil,  and  the  albumen  in  her  urine  in  a 
few  days  was  reduced  to  a  trace.  This  treatment  was  carried  out  for  a  week, 
the  milk  continuing  to  flow  freely,  and  an  analysis  was  then  made  of  the 
mother's  milk  and  also  of  that  of  a  healthy  wet-nurse,  whose  own  baby  was 
thriving  on  her  milk ;  the  following  results  were  obtained  : 

ANALYSIS  II.       ANALYSIS  III. 
Mother.  Wet-nurse. 

Fat 3.20  3.04 

Sugar 6.40  6.60 

Ash 0.18  0.12 

Albuminoids 2.52  2.32 

Total  solids 12.80  12.08 

Water 87.70  87.92 

100;00  100.00 

The  two  milks  being  equally  good,  it  was  then  decided  to  allow  the 
infant  to  begin  to  take  one  nursing  daily  from  its  mother,  although  the 
albuminoids  were  still  about  one  per  cent,  higher  than  the  infant  seemed 
likely  to  digest:  it  was  consequently  given  to  its  mother,  nursed  well, 
seemed  satisfied,  digested  its  meal  without  trouble,  and  at  six  months  is 
still  being  nursed. 

However  great  may  be  the  variation  in  the  composition  of  animals' 
milk,  and  from  our  extended  knowledge  of  the  chemistry  of  cow's  milk  we 
know  that  this  variation  is  a  marked  one,  we  must  bear  in  mind  that  a 
far  greater  variation  probably  occurs  in  human  milk.  The  physiological 
influence  of  the  emotions  on  the  nervous  system,  with  its  resulting  changes 
in  the  mammary  secretion,  necessarily  has  a  much  wider  range  in  the  woman, 
subjected  as  she  is  to  the  worries  and  vicissitudes  of  civilized  life,  than  in  the 
animal  carefully  stabled  and  pastured.  This  variation  in  a  mother's  milk 
must  be  seriously  considered,  and  the  individual  milk,  rather  than  the  gen- 
eral superiority  of  mother's  milk,  investigated  in  each  case,  if  our  feeding  is 
to  be  successful.  Instances  not  infrequently  arise  where  such  continual 
shocks  are  brought  to  bear  upon  the  mother  in  her  daily  life,  or  where  her 
own  temperament  is  such  an  undisciplined  one,  that  her  milk,  ordinarily 
good,  becomes  totally  unfitted  for  her  infant,  and  at  times  acts  as  a  direct 
poison,  with  most  disastrous  results,  so  that  the  welfare  of  the  infant  in  such 
cases  unquestionably  demands  the  change  to  a  wet-nurse. 

A  nursing  mother  should  be  made  to  understand  that  these  variations 
are  liable  to  arise  however  good  her  general  health  may  be,  and  that,  while 
she  is  simply  fulfilling  a  duty  demanded  by  nature  from  those  who  bear 
children,  her  duty  when  once  she  has  undertaken  to  nurse  is  to  avoid  as 
much  as  possible  these  variations,  by  regulating  her  life  to  a  normal  standard 
and  avoiding  excitement.  Both  of  these  requisites  of  a  normal  lactation 
come  within  the  province  of  the  physician  to  explain  as  he  would  any  other 


INFANT-FEEDING WEANING.  281 

branch  of  rational  medicine,  for  many  a  mother  by  her  course  of  life  renders 
her  milk  unfit  for  the  proper  alimentation  of  her  infant  through  ignorance 
of  what  seem  to  the  physician  but  the  simple  dictates  of  common  sense,  and 
she  will  be  only  too  thankful  for  advice  on  this  subject.  Instances  of  this 
arise  where,  as  observed  by  Zukowski/  seasons  of  fasting,  with  their  accom- 
panying excitement  of  the  emotions,  have  induced  such  an  influence  on 
the  milk,  the  fat  especially  being  decreased  to  as  low  as  0.88,  that  many  of 
the  nursing  infants  became  sick  and  gave  evidence  of  imperfect  nutrition. 

We  must'  next  consider  the  question  of  the  variation  in  the  milk  which 
takes  place  from  natural  causes,  such  as  the  return  of  menstruation.  Does 
such  a  return  necessarily  contra-indicate  the  continuation  of  nursing  ?  As 
in  all  questions  of  this  kind,  we  cannot  adopt  and  follow  an  inflexible 
rule,  but  must  be  guided  by  what  seems  best  for  the  individual  case.  In- 
fants are  at  times  affected  so  seriously  by  the  alteration  in  the  constituents 
of  the  milk  which  occurs  once  in  four  weeks,  that  their  nutrition  is  markedly 
interfered  withj  and  a  change  to  a  more  stable  food  is  indicated.  Again,  the 
only  disturbance  which  may  arise  is  a  temporary  and  slight  digestive  attack 
for  a  day  or  two,  which  apparently  does  not  materially  affect  the  infant, 
and  makes  us  hesitate  to  run  the  risk  of  depriving  the  infant  of  a  food  on 
which  it  thrives  during  twenty-six  days  out  of  twenty-eight.  We  must 
also  not  be  too  hasty  in  concluding  from  the  bad  symptoms  in  the  infant 
that  we  should  at  once  withdraw  it  permanently  from  the  breast,  for  the  cata- 
menia  may  appear  once  and  then  not  again  for  a  number  of  months,  the 
infant's  powers  of  digestion  in  the  mean  time  becoming  so  much  more  fully 
developed  that  they  are  unaffected  by  the  catamenial  milk.  Even  where 
the  catamenia  recur  regularly,  the  disturbance  which  may  have  been  marked 
at  one  period  may  for  many  reasons  fail  to  recur  at  the  next :  so  that  tlie 
question  is  reduced  to  whether  the  composition  of  the  milk  shows  a  recovery 
of  the  equilibrium  of  its  constituents  within  a  fcAV  days,  or  remains  affected 
to  such  a  degree  as  to  endanger  the  integrity  of  the  infant's  nutrition. 

My  own  experience,  so  far  as  it  goes,  is  in  favor  of  allowing  the  infant 
to  continue  with  the  breast,  unless  it  is  decidedly  contra-indicated  by  cir- 
cumstances such  as  have  just  been  mentioned. 

I  have  seldom  met  with  cases  which  could  not  without  permanent  injury 
be  tided  over  the  small  amount  of  temporary  digestive  disturbance  which 
is  usually  met  with.  Within  a  few  days  I  have  seen  a  case  where  the 
catamenia  returning  produced  no  effect  whatever  on  the  inflmt ;  and  this  is 
only  an  instance  of  what  in  all  probability  often  occurs  where  mother  and 
infant  are  at  the  time  in  an  otherwise  normal  condition.  There  have,  as 
yet,  been  too  few  analyses  made  during  the  catamenial  period  to  justify  us 
in  drawing  any  definite  conclusions  as  to  the  chemical  status  of  the  ques- 
tion ;  but  the  probability  is  that  the  milk  will  be  found  to  be  deficient  in 
fat  and  to  have  its  albuminoids  increased,  following  the  general  rule  of  dis- 

*  Jacobi,  Intestinal  Diseases,  p.  4. 


282  INFANT-FEEDING— WEANING. 

turbed  mammary  secretion,  and  consequently  in  a  condition  to  interfere 
temporarily  with  both  digestion  and  nutrition. 

It  may  be  of  interest,  from  what  has  been  said  above  concerning  the 
variations  in  the  milk  which  may  arise  from  emotional  causes  and  menstru- 
ation, to  report  the  analyses  of  the  milk  of  a  mother  and  a  wet-nurse  where 
these  influences  appeared  to  produce  certain  chemical  changes.  The  mother, 
a  healthy  but  rather  delicate  primipara,  the  period  of  whose  pregnancy  had 
been  supervised  by  me  with  the  greatest  care,  and  whose  temperament  was 
subject  to  extremes  of  despondency  and  excitement,  was  delivered  in  March, 
after  a  short  and  easy  labor,  of  a  healthy  boy.  She  was  exceedingly  anxious 
to  mirse  her  infant,  but  within  a  few  hours  after  its  birth  she  was  seized 
with  an  uncontrollable  fear  that  she  would  be  unable  to  do  so.  In  spite  of 
all  the  assurances  which  could  be  given  her  to  the  contrary,  and  of  the 
plentiful  supply  of  milk  which  in  due  time  came  in  the  breasts,  she  remained 
in  a  very  nervous,  despondent  condition.  As  the  infant  began  to  show 
decided  signs  of  indigestion,  I  thought  it  best,  before  proceeding  further,  to- 
investigate  the  composition  of  the  milk.  This  resulted  as  follows,  and 
plainly  showed  the  necessity  of  not  persisting  further,  as  it  was  evidently 
much  altered  from  unavoidable  nervous  conditions  which  seemed  likely  to 
recur  through  the  whole  of  her  lactation  : 

ANALYSIS    IV. 
Mother's  Milk. 

Fat 0.62 

Sugar 5.80 

Albuminoids 4.21 

Ash 0.20 

Total  solids 10.83 

"Water 89.17 

100.00 

Under  these  circumstances,  although  there  was  an  abundant  supply  of 
milk,  a  healthy  wet-nurse,  whose  baby  was  strong  and  thriving,  was  pro- 
cured, and  the  infant  immediately  began  to  gain  in  weight  and  ceased  to 
show  any  digestive  disturbance.  After  a  month,  however,  the  infant  was 
found  not  to  have  made  its  weekly  gain,  to  be  unusually  restless,  and  to 
be  having  rather  more  frequent  faecal  discharges  than  usual.  It  was  then 
discovered  that  the  wet-nurse  was  menstruating,  and  an  analysis  of  her 
milk  was  made  on  the  second  day,  resulting  as  follows : 

ANALYSIS  V. 

Wet-Nurse. 

CAtamenial  Milk,  Second  Day. 

Fat 1.37 

Sugar 6.10 

Albuminoids 2.78 

Ash 0.15 

Total  solids .      10.40 

Water 89.60      . 

100.00 


INFANT-FEEDING WEANING.  283 

The  catamenia  lasted  only  about  four  days,  and  did  not  return  for  some 
months.  The  infant  after  the  first  twenty-four  hours  showed  no  disturbance 
whatever,  soon  began  to  gain  again,  and  was  not  affected  by  the  subsequent 
recurrence  of  the  catamenia.  An  analysis  made  one  week  after  the  cata- 
menia had  ceased  showed  a  decided  change  for  the  better, — that  is,  increased 
fat,  decreased  albuminoids  ;  and  forty  days  later  a  still  greater  improvement, 
as  was  anticipated  from  the  blooming  condition  of  the  infant. 

ANALYSES. 

Wet-Nurse. 

VI.  VII. 

Seven  Days  aftee  Forty  Days  after 

Catamenia.  Catamenia. 

Fat 2.02  2.74 

Sugar 6.55  6.35 

Albuminoids 2.12  0.98 

Ash 0.15  0.14 

Total  solids 10.84  10.21 

Water 89.16  89.79 

100.00  100.00 

A  much  more  serious  state  of  affairs  arises  when  the  nursing;  mother 
becomes  pregnant ;  for  here  the  almost  universal  clinical  experience  is  that 
,  the  infant,  for  various  reasons,  cannot  continue  to  be  fed  by  its  mother,  it 
being  unusual  for  a  woman  to  have  sufficient  vitality  to  nourish  properly 
her  living  child  and  growing  foetus.  The  danger  of  reflex  miscarriage 
from  the  continual  irritation  of  the  mammary  gland  by  nursing,  I  person- 
ally have  had  no  experience  with,  but  this  is  mentioned  as  one  of  the 
dangers  contra-indicating  the  continuation  of  nursing  by  a  pregnant  woman. 
We  must,  however,  here  also  not  judge  hastily,  but  take  all  the  circum- 
stances of  the  case  into  consideration  before  deciding  on  a  measure  of  such 
vital  importance  to  both  child  and  fcetus.  If  the  mother  remains  strong 
and  vigorous  and  the  analysis  of  her  milk  shows  no  deterioration,  while  the 
infant  is  a  delicate  one  just  beginning  to  thrive  on  its  rightful  supply  of 
natural  food,  or  if  it  is  during  a  hot  period  of  the  year,  and  especially  Avliere 
a  wet-nurse  cannot  be  procured,  it  will  often  be  wisest  to  take  some  risks 
and  continue  the  nursing  for  a  certain  time,  perhaps  six  or  eight  weeks, 
and  then  according  to  circumstances  gradually  substitute  an  artificial  food. 
Almost  every  case -will  differ,  in  the  questions  to  be  decided,  and  must  be 
judged  on  its  own  indications  and  contra-indications,  always,  however, 
recognizing  the  generally  accepted  rule  that  lactation  and  pregnancy  are 
incompatible. 

The  food  of  the  nursing  woman  is  closely  connected  with  tlic  food  which 
she  provides  for  her  infant.  We  liave  already  spoken  of  tlie  possibility  of 
the  elimination  of  various  substances  by  the  mammary  gland,  and  we  should 
impress  upon  nursing  women  the  importance  of  a  more  carefully  arranged 
regimen  than  when  they  are  not  nursing,  and  of  a  limited  use  of  drugs. 


284  INFANT-FEEDIXG WEANIXG, 

Saline  cathartics  may  at  times  not  only  act  unfavorably  on  the  infant,  but 
very  decidedly  lessen  the  flow  of  milk,  or  even  stop  it  altogether.  Certain 
veg^etables  and  fish  will  in  some  individuals  cause  discomfort  to  their  infants. 
A  plain  mixed  diet,  with  a  moderate  excess  of  fluid  and  albuminoids  over 
what  they  are  normally  accustomed  to,  will,  as  a  rule,  give  the  best  results. 

According  to  what  we  have  already  said  concerning  the  physiology  of 
lactation,  we  should,  in  cases  where  the  milk  is  found  to  be  poor  in  fat, 
reduce  slightly  the  amount  of  fatty  food  taken  by  the  mother  and  increase 
the  proteid  elements.  We  should  also  be  exceedingly  careful  in  suddenly 
changing  the  customary  diet  of  a  healthy  nursing  woman  on  purely  theo- 
retical grounds.  The  mistake  was  made  for  many  years  of  keeping  women 
on  too  low  a  diet  in  the  early  period  of  lactation,  with  a  consequent  delay  in 
the  establishment  of  a  sufficiently  nutritious  milk-supj)ly,  and  a  correspond- 
ing increased  initial  loss  of  weight  in  their  infants.  Where,  however,  we 
are  especially  likely  to  err  is  in  permitting  a  healthy  hard-working  wet- 
nurse,  accustomed  to  a  somewhat  coarse  but  nutritious  diet,  on  entering  a 
refined  home  to  adopt  totally  different  habits  of  exercise  and  an  unaccus- 
tomed diet,  rather  than  endeavoring  to  have  her  continue  in  her  natural 
mode  of  life.  This  sudden  change  of  life  frequently  results  in  ill  health 
to  the  nurse,  with  its  accompanying  deterioration  in  the  quality  of  her  milk, 
or  at  least  in  so  changing  its  quality  as  to  make  it  an  unfit  food  for  her 
foster-child, 

A  notable  instance  of  too  radical  a  change  of  diet  ^vas  brought  to  my 
notice  about  a  year  ago,  by  Dr.  J.  B.  Swift,  of  Boston.  A  wet-nurse  was 
procured  for  an  infant  seven  days  old,  and  her  milk  was  digested  well 
during  two  or  three  weeks,  while  she  was  fed  on  an  abundance  of  good 
food  and  rich  milk.  The  infant  then  began  to  vomit  thick  curds,  identical 
in  appearance  and  toughness  with  the  curds  of  cow's  milk ;  and  an  analysis, 
as  shown  by  the  following  figures,  presented  the  amount  of  total  solids 
increased  to  a  most  marked  degree,  the  percentage  of  albuminoids  cor- 
responding far  more  nearly  to  cow's  milk  than  to  woman's  milk.  The 
nurse  was  put  on  plainer  food  and  skimmed  milk,  and  the  infant  ceased  to 
vomit.  The  infant  and  nurse  then  continued  well  and  strong  during  the 
whole  year,  the  infant  making  a  weekly  gain.  The  third  set  of  figures  gives 
the  analysis  of  this  milk  in  the  twelfth  month. 

ANALYSES. 
Wet-Nurse. 
YIII.  IX.  X. 

Two  Days  before     Rich  Food  for     Food  regulated  and  Milk 
Change  of  Food.  a  Month.  agreeing  with  Infant. 

Fat 0.72  5.44  5.50 

Sugar 6.75  6.25  6.60 

Albuminoids    .    .  2..5B  4.61  2.90 

Ash 0.22  0.20  0.14 

Total  solids  .  10.22  16.50  15.14 

Water 89.78  83. -50  84.86 

100.00  100.00  100.00 


IXFAXT-FEEDIXG — WEAXIXG.  2&5 

This  case  will  be  of  considerable  interest  later  when  we  come  to  speak 
of  albuminoids  in  the  preparation  of  artificial  foods, 

I  have  little  confidence  in  galactagogues^  beyond  proper  food,  exercise, 
and  general  hygiene,  for  their  number  betrays  their  ineificiencv. 

It  not  infrequently  happens,  especially  among  women  of  the  upper  classes 
and  nursing  women  of  all  classes,  when  their  general  health  is  not  in  a  per- 
fectly normal  condition,  that  the  supply  of  milk  is  not  sufficient  to  satisfy  the 
infant,  and  the  question  arises  whether  the  mother's  milk  shall  be  entirely 
given  up  or  whether  it  shall  be  supplemented  by  some  other  food.  ]\Iy 
own  individual  experience,  both  in  private  and  in  hospital  practice, — and, 
so  far  as  I  can  ascertain,  this  experience  agrees  with  that  of  other  observers, 
— is  in  favor  of  assisting  the  mother  to  nurse  her  infant  during  the  earlier 
months  of  its  life.  I  have  found  that  where  the  artificial  food  is  careflilly 
regulated  by  frequent  analysis  until  the  infant  is  making  decided  progress 
in  its  weight  and  general  condition,  this  method  of  rearing  infants  is  far 
superior  to  withdrawing  the  mother's  milk  and  feeding  the  child  exclusively 
upon  artificial  food. 

We  have,  on  the  one  hand,  a  much  wider  range  for  regulating  the 
mother's  milk,  by  increasing  or  diminishing  the  number  of  the  artificial 
feedings,  and  on  the  other  hand,  if  the  mother's  milk  agrees  with  her  in- 
fant, an  excellent  opportunity  for  making  our  artificial  food  correspond 
to  what  nature  has  provided.  We  are  far  better  equipped  to  cope  intelli- 
gently with  the  feeding-problem  by  this  method  than  by  any  other  which 
is  known,  excepting  a  continual  change  of  wet-nurses  until  one  is  found 
M^hose  milk  both  chemically  and  clinically  fulfils  the  wants  of  the  individual 
infant, — a  proceeding  which  can  rarely  be  carried  out  in  the  present  status 
of  parental  prejudice,  though  it  has  in  my  hands  at  times  proved  to  be 
eminently  successful. 

In  regulating  the  administration  of  this  mixed  feeding  we  should  allow 
ourselves  to  be  guided  as  much  as  possible  by  known  physiological  laws ; 
never,  however,  persistently  following  out  these  laws  where  the  clinical 
result  does  not  correspond  to  them,  for  there  may  be  other  physiological 
factors  in  the  problem  which  as  yet  are  beyond  our  knowledge. 

It  is  a  fact  pretty  widely  acknowledged  that  the  mother's  milk,  as  a  rule, 
is  more  likely  to  be  suited  to  her  infant's  digestion  than  the  milk  of  another 
woman ;  but  here  again  we  have  as  yet  too  few  cases  where  direct  investiga- 
tion by  means  of  chemical  analysis  of  the  two  milks  has  been  made,  to  lay 
down  actually  as  a  fact  what  we  can  merely  grant  as  a  supposition,  that  an 
idiosyncrasy  in  the  mothei-'s  milk  will  find  an  analogue  in  her  infant's  diges- 
tive powers.  The  reverse  of  this  proposition  has  also  been  held  to  be  true, 
that  at  times  some  idiosyncrasy  in  the  mother's  milk  will  make  it  radically 
unfit  for  her  infant.  The  probability,  however,  is  either  that  analyses  will 
show  that  these  milks  are  poor  ones  or  that  we  shall  find  tiiat  the  infants 
have  unusually  weak  digestive  powers. 

From  what  has  already  been  said,  we  neetl  hardly  state  that  if  for  any 


286  INFANT-FEEDING — WEANING. 

reason  a  mother  cannot  nurse  her  child,  the  food  which  will  of  all  others  be 
most  likely  to  give  satisfactory  results  is  that  of  a  wet-nurse.  The  question 
as  to  whether  a  wet-nurse  shall  be  employed  is,  however,  one  of  serious 
import,  and  must  in  each  individual  instance  be  decided  by  giving  full 
weight  to  all  the  many  circumstances  which  are  involved  in  the  case.  It  is 
the  duty  of  the  physician  fully  to  explain  that  a  good  nurse  is  far  superior 
to  any  artificial  method  of  feeding,  while  the  reverse  of  this  statement  must 
always  be  kept  in  view,  that  a  poor  nurse,  whether  from  temperament,  or 
age,  or  general  health,  or  quality  of  her  milk,  had  better  be  set  aside  where 
the  conditions  are  favorable  for  a  successful  artificial  feMing.  It  is  perhaps 
better  that  the  nurse's  milk  should  correspond  in  age  somewhat  nearly  to 
that  of  the  infant  she  is  to  suckle,  but  a  difference  of  some  months  in  age 
need  not  necessarily  be  a  contra-iudication,  as  we  are  not  yet  in  a  position  to 
say  definitely  that  the  milk  differs  sufficiently  in  different  months  to  be  of 
vital  importance  in  choosing  a  nurse.  A  feeble  child  will  nurse  more  easily 
and  probably  have  better  care  from  a  multipara  than  from  a  primipara. 
The  preferable  age  of  the  nurse  is  between  twenty  and  thirty  years.  Her 
other  requisites  are  a  condition  of  good  health  and  a  quiet  temperament. 
It  will  save  much  trouble,  and  will  often  obviate  the  frequent  necessity  for 
changing,  if  we  have  before  her  engagement  a  chemical  analysis  of  her 
milk ;  in  fact,  all  the  points  which  have  been  above  referred  to  for  a  suc- 
cessful maternal  nursing  are  of  equal  significance  in  the  wet-nurse. 

Quite  a  number  of  nursing  women,  especially  those  in  the  higher  classes, 
find  that  at  variable  periods  in  the  course  of  their  year's  lactation  their  milk 
begins  to  fail,  and  they  are  forced  first  to  lessen  the  number  of  their  nursings 
and  then  to  wean  entirely.  The  time,  then,  when  the  infant  should  be 
weaned  almost  always  settles  itself,  without  our  intervention,  at  varying 
periods.  The  period  of  lactation,  however,  and  the  one  which  might  be 
called  physiologically  normal,  can,  when  the  breast-milk  remains  of  good 
quality  and  quantity,  be  carried  through  the  first  year  with  benefit.  We 
have  certain  guides  which  aid  us  in  determining  the  proper  time  for  begin- 
ning to  wean.  Physiologically,  we  are  told  that  certain  functions,  such  as 
that  which  converts  starch  into  glucose,  are  but  slightly  developed  in  the 
early  months  of  life,  and  that  they  exist  and  are  gradually  being  established 
during  the  first  year,  not,  as  a  rule,  being  perfected  and  in  a  condition  upon 
which  we  can  call  upon  them  with  impunity  until  the  last  two  or  three 
months  of  the  year.  Another  sign  which  aids  us  somewhat  as  an  index  by 
which  we  can  judge  of  the  progress  of  this  functional  development  is  the 
appearance  of  the  teeth,  calling  our  attention  to  the  fact  that  nature  is  pre- 
paring a  means  for  the  infant  to  digest  and  assimilate  a  different  form  of 
food  from  that  which  it  has  so  far  received  by  sucking,  the  presence  of  six 
or  eight  incisors  usually  in  the  normally-developed  infant  corresponding  to 
the  full  development  of  the  pancreatic  secretion. 

Again,  a  most  valuable  index,  which  assures  us  that  we  need  not  be 
anxious  to  change  the  infant's  food  during  the  first  year,  is  the  continuous 


INFANT-FEEDING — WEANING.  287 

increase  of  weight,  which,  with  the  general  blooming  condition  of  the 
infant,  represents  a  normal  lactation.  As  in  the  case  of  all  physiological 
rules,  however,  we  must  admit  of  certain  variations  which  in  the  especial 
case  are  as  important  for  the  infant's  welfare  as  the  rule  itself, — namely,  the 
curtailing  or  lengthening  of  the  period  of  lactation  by  a  month  or  two,  ac- 
cording to  the  season  of  the  year,  the  irruption  of  the  teeth,  or  the  condition 
of  the  child  (as  in  recovery  from  an  illness),  it  being  wiser  to  feed  the  infant 
from  the  breast  during  the  heated  portions  of  the  year,  and  to  wean  in  cool 
weather,  either  before  or  after  the  hot  season,  according  to  the  individual 
circumstances  of  the  case. 

An  interdental  period  also  is  preferable  to  a  dental  period,  on  account 
of  the  possible  disturbances  which  may  arise  in  the  latter  and  interfere 
with  the  proper  action  of  the  new  functions  which  are  being  called  upon  to 
perform  their  duties.  Where  there  is  any  uncertainty  as  to  the  character  of 
the  milk  which  the  infant  is  taking,  especially  in  the  latter  months  of  lacta- 
tion, a  chemical  analysis  should  be  made  at  once,  and  repeated,  with  an 
interval  of  some  days,  several  times ;  for  the  latter  months,  though  not  so 
difficult  to  manage  intelligently  as  the  early  period  of  the  infant's  life,  are 
much  more  likely  to  need  careful  supervision  than  the  middle  period,  which, 
from  its  usually  uninterrupted  tranquillity,  has  been  called  the  period  of 
normal  nutrition.  Where  the  infant  has,  through  an  insufficient  supply  of 
milk  in  the  mother,  become  for  some  time  accustomed  to  several  meals  of 
artificial  food  daily,  the  matter  of  weaning  becomes  a  very  simple  one,  for 
we  know  that  we  have  a  food  which  will  agree  with  it ;  but  where  we  have 
to  begin  to  wean  directly  and  to  adapt  a  food  to  the  infant's  digestive  capa- 
bilities, as  in  cases  of  sudden  failure  of  the  milk  or  sickness  in  the  mother, 
this  procedure  becomes  much  more  intricate,  and  is  at  times  fraught  with 
considerable  danger.  It  is  in  these  cases  that  an  analysis  of  the  milk  made 
when  the  mother  was  in  good  condition  often  proves  to  be  of  great  assist- 
ance, for  it  is  not  a  very  difficult  matter  to  make  an  artificial  food  which 
shall  correspond  to  this  analysis  in  its  percentage  of  fat,  albuminoids,  sugar, 
total  ash,  and  water. 

Unless  under  very  exceptional  circumstances,  sudden  weaning  is  to 
be  deprecated,  though  of  course  we  must  allow  that  it  is  often  done  Avith 
impunity.  The  safest  method,  so  long  as  we  can  never  judge  beforehand 
what  infants  v/ill  be  likely  to  be  unfavorably  affiacted  by  sudden  weaning,  is 
to  take  plenty  of  time,  and  gradually  ascertain,  perhaps  by  frequent  changes, 
which  form  of  food  is  best  adapted  to  the  case.  We  then  gradually  accus- 
tom it  to  this  food,  omitting  one  by  one  the  breast-feedings,  until  finally  we 
are  sure  that  we  have  an  artificial  food  on  which  the  infant  will  thrive,  with 
the  proportion  of  starch,  the  new  element  which  may  now  usually  be  intro- 
duced into  the  dietary,  carefully  adapted  to  its  amylolytic  function,  which 
has  but  lately  arrived  at  its  full  development,  and  Avhich  varies  in  diffiircnt 
infants.  When  this  change  has  been  accomplished,  the  breast  can  with 
safety  be  entirely  withdrawn. 


288  INFANT-FEEDING WEANING. 

The  danger  of  injudicious  weaning  was  strongly  impressed  upon  me 
some  years  ago  in  a  case  which  I  watched  for  several  days,  through  the 
courtesy  of  Dr.  Sinclair,  of  Boston,  and  which  it  seems  well  to  put  on 
record.  A  rather  delicate  nursing  infant,  fourteen  months  old  and  back- 
ward in  its  development,  having  cut  only  four  teeth  and  being  in  the  process 
of  cutting  four  more,  was,  without  the  advice  of  the  physician,  suddenly 
deprived  of  the  plentiful  supply  of  breast-milk  of  its  healthy  mother,  in 
the  latter  part  of  November,  and  fed  upon  oatmeal  gruel.  Vomiting  and 
prostration  immediately  began,  and  continued  until  the  oatmeal  was 
omitted  and  the  breast  resumed,  when  the  infant  again  began  to  thrive. 
Three  weeks  later,  the  mother,  through  ignorance  of  the  cause  of  the  first 
attack,  again  weaned  her  infant  suddenly,  and  again,  without  any  prepara- 
tion, fed  it  on  oatmeal  gruel.  On  the  following  two  days  the  infant 
vomited  incessantly  and  was  much  prostrated.  The  oatmeal  was  then 
changed  to  barley,  and  this  again,  as  the  vomiting  continued,  to  Mellin's 
Food.  The  symptoms,  however,  grew  worse,  and  the  now  thoroughly  terri- 
fied mother  again  put  the  baby  to  her  breast,  with,  however,  this  time  a . 
disastrous  result,  as  her  milk  from  nervous  influences  was  so  changed  in  its 
quality  that  it  acted  like  a  poison  on  the  infant,  which  fell  into  a  condition 
of  collapse.  Dr.  Sinclair  was  sent  for,  and  a  few  hours  later  I  was  consult- 
ing with  him.  A  wet-nurse  with  a  healthy  four-months  baby  was  immedi- 
ately procured,  and  after  several  days  of  complete  prostration  the  baby 
began  to  revive,  and  somewhat  later  was  gradually  weaned  without  trouble. 
It  may  be  well  to  add,  for  the  encouragement  of  those  who  may  in  their 
practice  be  so  unfortunate  as  to  have  cases  of  this  kind  to  deal  with,  that 
after  the  mother's  milk  had  poisoned  the  infant,  and  when  I  first  saw  it,  the 
skin  was  gray  and  cold,  the  fontanel  sunken,  and  the  eyes  fixed,  and  yet 
recovery  took  place. 

It  would  here  seem  not  inappropriate,  before  entering  upon  the  subject 
of  artificial  feeding,  to  speak  somewhat  more  fiilly  of  the  value  of  the 
chemical  examination  of  the  milk.  From  Avhat  has  already  been  said,  it 
will  be  seen  that  although  such  analyses  enable  us  to  work  more  intelli- 
gently, yet  the  conclusions  which  we  can  draw  from  them  are  far  from  being 
precise,  owing  to  the  extreme  variations  which  take  place  at  different  times, 
and  to  the  insufficient  number  of  reliable  analyses  which  have  so  far  been 
made.  We  should,  therefore,  be  extremely  guarded  in  drawing  conclusions 
for  the  present,  merely  looking  upon  our  figures  as  approximate.  On  the 
other  hand,  it  is  of  great  importance  that  when  reliable  analyses  are  made 
they  should  be  published,  and  thus,  as  our  material  increases,  enable  us  in 
the  future  to  arrive  at  what  cannot  but  be  important  facts  to  aid  us  in  the 
regulation  of  infant-feeding.  Thus,  we  already  are  led  to  expect  to  find  in 
the  poor  milks,  which  do  not  agree  with  the  infant,  an  excess  of  albu- 
minoids and  a  diminution  of  fat  beyond  what  we  have  so  far  been  able  to 
determine  as  the  normal  average  percentages  of  these  two  elements.  Again, 
where  a  variation  takes  place  in  the  milk,  it  is  more  likely  to  be  found  in 


INFANT-FEEDIXG WEANING.  289 

the  fat  aud  albumiuoids  than  in  the  sngar  and  total  ash.  "VVe  should  also 
advise  a  number  of  analyses,  rather  than  one,  in  order  that  the  error  of  an 
especial  and  temporary  variation  may  be  corrected.  The  importance  of  and 
assistance  which  can  be  gained  from  these  analyses  are  in  my  opinion  very 
great,  and  many  more  analyses  should  be  made  than  we  are  now  in  the 
habit  of  deeming  necessary. 

The  question  of  expense  should  not  for  a  moment  be  considered  by 
those  who  can  afford  to  have  analyses  made,  for  not  only  will  real  benefit 
come  to  their  own  children  through  money  spent  in  this  way,  but  these 
analyses,  by  being  published  aud  collated,  will  j)rove  of  great  value  for  the 
proper  regulation  of  the  feeding  of  infants  in  all  classes  of  society. 

The  mere  microscopic  examination  of  milk,  beyond  the  determination 
of  the  presence  or  absence  of  colostrum-corpuscles,  is  too  uncertain  and 
misleading  to  be  in  any  way  depended  on,  the  chemical  analysis  being  the 
only  practical  method  which  can  be  recommended. 

It  was  only  lately  that  a  physician  skilled  in  the  use  of  the  microscope, 
in  a  neighboring  town,  sent  me  a  specimen  of  woman's  milk  which  he 
stated  was  rich  in  fat,  but  which  Dr.  Harrington's  analysis  showed  to 
have  only  a  little  over  one  and  one-half  per  cent,  of  this  ingredient.  The 
presence  of  an  undue  amount  of  yellow  coloring-matter  is  also  at  times  very 
misleading. 

An  error  which,  however,  we  must  always  allow  may  interfere  with  the 
true  analysis  of  the  milk  which  the  infant  has  actually  received  into  its 
stomach  at  the  end  of  the  nursing,  and  which  must  necessarily  invalidate 
the  reasoning  from  our  analyses,  is  what  I  have  already  referred  to  in 
speaking  of  the  changes  which  from  slight  causes  may  arise  and  influence 
the  especial  specimen  which  is  being  analyzed.  Thus,  we  should  recognize 
that  the  milk  varies  considerably  in  its  percentage  of  fat  and  total  solids  in 
the  different  periods  of  a  milking,  and  that  the  composition  of  the  milk 
which  the  infant  has  in  its  stomach  may  differ  very  widely  from  the  compo- 
sition of  a  specimen  taken  directly  before  or  after  the  nursing. 

Harrington's  analysis  of  the  three  portions  of  a  milking  will  illustrate 
the  meaning  of  what  has  just  been  said.^ 

TABLE   III. 

Fat.     Total  Solids.  Water.  Ash. 

"Foremilk"       3.88  13.34  86.66  0.85 

"Middle  milk" 6.74  15.40  84.60  0.81 

"Stripping.?" 8.12  17.13  82.87  0.82 

The  experiments  and  analyses  of  J.  Reiset  and  Peligot^  also  are  of 
considerable  interest,  as  showing  not  only  the  increase  of  solids  at  the  end 
of  a  nursing,  but  also  that  this  increase  is  mostly  of  the  fat,  and  to  a  lesser 
degree  of  the  albuminoids,  and  also,  as  I  have  already  stated,  that  a  short 

1  Harrington,  8th  Annual  Report  Mass.  State  Board  of  Health.  1884,  p.  189. 
^  Hermann,  Handbuch  der  Physiologic,  Bd.  V.,  Theil  I.  ts.  404. 
Vol.  I.— 19 


290  INFANT-FEEDING WEANING. 

interval  of  nursing  increases  the  solid  constituents  in  proportion  to  the 

water,  the  reverse  of  this  being  found  to  be  true  where  the  intervals  are 

long. 

Heideuhain  explains  this  physiological  phenomenon  by  saying  that  his 

investigations  point  towards  the  fact  that  during  the  pauses  between  the 

milkings  the  cells  of  the  glands  are  growing  and  a  proportionately  small 

amount  of  solids  and  a  proportionately  large  amount  of  water  are  secreted, 

while  the  irritation  of  milking  causes  increased  activity  of  the  milk-cells, 

with  a  corresponding  increase  in  the  solid  secretion  and  lessening  of  the 

water.     Thus,  Peligot's  table  giving  the  analysis  of  an  ass's  milk  in  three 

different  portions  shows  the  relations  of  the  solids  both  to  the  water  and  to 

one  another. 

TABLE  IV. 

Ass's  Milk  {Peligot). 

1st  Portion.  2d  Portion.  3d  Portion. 

Butter 0.96  1.02  1.52 

Milk-sugar 6.50  6.48  6.50 

Casein 1.76  1.95  2.95 

His  second  table  shows  the  changes  of  proportion  according  to  the  inter- 
vals of  the  nursing. 

TABLE   V. 

Ass's  Milk  {Peligot).  Milking-Intervals. 

l]4  Hours.     6  Hours.     24  Hours. 

Butter 1.55  1.40  1.23 

Sugar 6.65  6.40  6.33 

Casein 3.46  1.55  1.01 

The  next  table  is  also  interesting,  and  should  be  recorded. 

TABLE   YI. 

Coiv's  Milk  [Peiset). 

Percentage  of  Solids  at 
Time  since  Last  Milking.  Beginning.  End. 

12    hours   . 9.33  16.04 

6    hours , 12.80  16.06 

2J  hours '.    .    .    .    .    12.84  13.08 

Harrington's  analyses  of  woman's  milk  showing  the  "  strippings"  of  a 

two-hours  interval  and  the  "  fore-milk"  of  a  twelve-hours  interval  are  also 

of  considerable  interest. 

TABLE  VII. 

"  Strippings,"  "  Fore-Milk," 

2  Hours'  Interval.  12  Hours'  Interval. 

Total  solids 15.32  10.14 

"Water 84.68  89.86 


100.00  100.00 


With  these  chemical  and  physiological  facts  before  us,  we  are  forced  to 
acknowledge  that  we  must  be  very  circumspect  in  the  conclusions  which  we 
deduce  from  such  analyses  of  human  milk  as  up  to  the  present  time  have 


INFANT-FEEDIXG WEANING.  291 

been  made.  An  error  in  these  conclusions,  where  a  correct  chemical  analysis 
has  been  made,  is  less  likely  to  occur  from  the  sugar  and  ash  than  from  the 
albuminoids  and  fat,  and  is  most  likely  of  all  in  both  frequency  and  degree 
in  the  latter. 

In  the  preceding  pages  ample  recognition  has  been  given  to,  and  great 
stress  has  been  laid  upon,  the  importance  of  feeding  infants  during  the  early 
months  of  life  by  means  of  human  milk.  We  know,  however,  that  in 
civilized  communities  the  necessity  of  supplying  the  infant  with  food  not 
from  the  human  breast  will  often  arise,  and  will  in  all  probability  be  a 
demand  which  will  increase  rather  than  decrease  as  our  civilization  advances. 
With  this  prospect  before  us,  and  appreciating  the  difficulties  which  in 
a  large  number  of  cases  are  liable  to  arise  when  we  attempt  to  adapt  an 
artificial  food  to  the  wants  of  an  infant,  it  manifestly  becomes  a  duty  to 
endeavor  to  reduce  the  high  mortality  figures  induced  by  artificial  feeding. 
With  this  purpose  in  view,  we  should  carefully  investigate  the  different 
methods  of  feeding  and  adopt  some  more  uniform  plan  for  starting  human 
beings  in  life ;  for  diversity  and  not  uniformity  is  now  the  rule.  With  the 
exception  of  the  very  small  proportionate  percentage  of  inherited  diseases 
which  occur  at  birth,  this  diversity  of  method  in  feeding  is  the  most  prolific 
source  of  disease  in  early  infancy.  The  grouj)  of  symptoms  which  for  want 
of  a  better  name  is  represented  by  dyspepsia,  difficult  digestion,  occurs  most 
frequently  in  the  three  periods  when  the  infant's  digestion  is  likely  to  be 
tampered  with, — namely,  in  the  early  weeks  of  life,  when  experiments  are 
being  made  to  determine  what  food  will  be  best  to  start  with ;  next,  when, 
in  addition  to  the  irritation  arising  from  the  beginning  of  dentition,  new 
articles  of  diet  are  added  to  the  original  food ;  and,  thirdly,  at  the  time  of 
weaning,  when  there  is  often  a  sudden  and  entire  change  in  the  character  of 
the  food.  The  proper  management  of  the  first  of  these  periods  is  of  the 
greatest  comparative  importance,  because  it  is  the  time  when,  as  before  stated, 
the  stomach  is  in  its  most  active  period  of  growth,  and  when  the  function 
of  digestion  is  being  established,  and,  following  the  rule  of  functional  estab- 
lishment, is  in  a  state  of  unstable  equilibrium.  This  demands  the  most 
careful  regulation  of  the  bulk  of  the  food  given  to  make  it  correspond  to 
the  rapid  increase  in  the  gastric  capacity.  We  thus  avoid  the  danger  of 
overtaxing  this  capacity  by  too  great  volume  in  the  beginning  of  nutrition, 
at  the  Same  time  providing  the  sensitive  developing  function  with  the  proper 
materials  for  nutrition,  and  thus  avoiding  by  prophylaxis  the  dyspepsia  of 
the  later  periods  of  infancy  and  childhood,  the  seeds  of  which  are  continu- 
ally being  sown  in  this  early  transitional  period.  We  therefore  have  not 
only  the  question  of  infantile  digestion  but  also  that  of  infantile  development 
to  deal  with.  We  should  recognize  tlie  fact  that  the  problem  of  artificial 
feeding  is  not  a  simple  one,  and  that  we  cannot  too  often  reiterate  that  the 
question  which  but  too  commonly  is  supposed  to  be  a  simple  one,  and  the 
one  which  in  the  great  majority  of  cases  is  alone  considered,  namely,  "  Which 
food  shall  we  give  to  the  infant  ?"  is  a  misleading  and  insufficient  one.    The 


292  INFAXT-FEEDIXG: WEANING-. 

problem  is  a  combination  of  factors  of  which  the  kind  of  food  is  only  one^ 
and  I  personally  have  long  been  convinced  that  the  neglect  to  investigate 
thoroughly  and  carry  out  in  detail  the  combination  of  these  by  no  means 
insignificant  general  factors  has  had  much  to  do  with  our  failures  with  arti- 
ficial feeding  in  the  past.  If  this  fact  be  more  uniformly  insisted  on  in  the 
future,  it  will  prove  to  be  of  great  value  in  the  reduction  of  the  moii:ality 
figures  in  the  first  two  years  of  life.  It  would  seem  also  that  the  present 
is  a  most  opportune  time  for  raising  a  note  of  warning  against  allowing  our 
enthusiasm  over  any  one  especial  theory  in  the  feeding-problem  to  warp  our 
better  judgment.  There  will  surely  in  the  future  be  a  reaction  which  will 
relegate  to  its  proper  place  every  theory  which,  because  of  being  lately 
advanced,  happens  to  enjoy  an  undue  amount  of  credit,  and  at  the  same 
time  is  actually  doing  harm  by  keeping  in  the  background  other  theories 
which,  each  in  its  own  sphere  as  a  significant  part  of  a  complete  whole, 
may  be  of  very  great  importance  in  the  successful  solution  of  the  general 
problem.  An  error  of  oversight  of  one-eighth  in  a  mathematical  problem 
is  not  so  great  as  one  of  one-fourth,  but  nevertheless  the  attention  to,  and 
correcting  of,  the  greater  error,  will  not  prevent  the  neglect  of  the  smaller 
from  completely  destroying  a  correct  result.  Until  lately  it  has  been  the 
qualit}^  of  the  food  which  has  been  monopolizing,  in  my  opinion  to  com- 
paratively too  great  a  degree,  the  attention  and  brains  of  the  medical  pro- 
fession ;  to-day  it  is  sterilization  which  in  feeding  has  become  prominent, 
representing  a  faint  picture  of  the  great  advances  in  rational  medicine  which 
it  is  hoped  are  to  follow  from  the  undoubtedly  brilliant  discoveries  which 
have  been  made  in  bacteriology.  Already  one  of  the  latest  German  writers^ 
on  artificial  feeding  has  stated  that  the  physiology  and  pathology  of  infantile 
digestion  depend  not  on  the  chemical  but  on  the  biological  character  of  the 
food,  and,  if  we  are  not  on  our  guard,  this  tendency  to  exaggeration  will 
spread,  and  by  its  influence  will  blind  us  to  much  good  work  which  in 
other  directions  has  already  been  done,  and  which  we  cannot  afford  to 
ignore.  IN^ot  that  I  would  for  a  moment  be  understood  to  underrate  the 
value  of  sterilizing  an  infant's  food,  for  it  has  for  j^ears  proved  of  very 
great  benefit  in  my  practice  and  that  of  others  to  have  the  food  thoroughly 
boiled  before  giving  to  the  infant,  but  I  predict  that  just  so  much  as  we 
enhance  the  value  of  this  one  important  part  of  the  whole  at  the  expense 
of  others  which  possibly  may  be  proved  to  be  of  less  individual  importance, 
just  so  much  further  shall  we  be  from  an  intelligent  comprehension  of  the 
subject. 

To  feed  an  infant  one  month  old  with  vsix  ounces  of  acid  cow's  milk 
every  four  hours,  no  matter  how  thoroughly  such  a  mixture  has  been 
sterilized,  would  be  a  radical  offence  against  well-known  anatomical  and 
physiological  laws.  It  therefore  seems  to  me  that  time  will  be  well  spent 
in  the  discussion  of  the  subject  of  artificial  feeding,  if  we  investigate  and 

1  Hochstetter,  AUgemein.  Wien.  Med.  Zeit.,  No.  15,  1888. 


IXFANT-FEEDING WEAXIXG.  293 

endeavor  to  copy  each  in  its  turn  the  various  devices  which  nature  makes 
use  of,  for  we  must  admit  that  we  are  not  in  a  position  to  try  to  improve 
on  nature's  method. 

It  is  certainly  wiser  and  more  economical  not  to  spare  expense  and 
trouble  in  arranging  the  infant's  diet,  for,  as  has  been  explained  above,  the 
period  of  active  growth  of  an  organ  is  the  time  when  its  function  is  readily 
weakened,  and  when  once  weakened  the  digestive  function  is  a  prolific  source 
of  annoyance  and  expense  in  childhood  and  adolescence.  Cheap  foods  and 
cheap  methods  of  feeding,  unless  they  are  the  best  that  can  be  procured, 
should  not  be  tolerated  more,  and  in  fact  not  nearly  so  much,  in  the  early 
feeding  of  infants  than  in  adult  life ;  we  often,  however,  see  a  food  recom- 
mended for  a  young  infant  because  it  is  cheap  and  easily  prepared,  and  yet 
when  its  well-known  lack  of  nutritive  ingredients  would  with  adults  at  once 
stamp  it  as  unfit  for  use. 

In  discussing  the  treatment  of  disease  we  advocate  what  is  best,  without 
reference  to  what  it  costs,  and  then,  in  the  especial  case  where  expense  is  an 
element  which  has  to  be  taken  into  consideration,  we  endeavor  to  adapt  our 
treatment  to  these  considerations,  but  always  approaching  as  nearly  as  possi- 
ble to  our  first  standard.  In  like  manner  I  believe  that  we  are  doing  wrong 
to  the  public  if  we  allow  ourselves  to  be  handicaj)ped  in  such  a  difficult 
question  as  infant-feeding  by  the  cry  of  expense.  Infant-feeding  is  an 
expense  which  is  vital  to  the  welfare  of  the  human  race,  and  we  can,  without 
being  accused  of  extravagance,  safely  relegate  to  the  province  of  the  manu- 
facturers of  patent  foods  the  recommending  to  the  public  of  foods  which  if 
judged  by  the  amount  that  is  offered  in  bulk  are  cheap,  but  which  when 
judged  by  their  nutritive  properties  are  extremely  expensive. 

Our  scientific  knowledge  and  clinical  investigations  have  not  yet  enabled 
us  to  follow  nature  exactly,  and  we  therefore  have  not  yet  obtained  an  ideal 
method  of  artificial  feeding.  We  must,  nevertheless,  go  as  far  as  the  present 
state  of  our  knowledge  will  allow,  thus  gaining  a  little  ground  every  year ; 
and  we  must  be  especially  careful  not  to  be  led  astray  by  the  fictitiously 
brilliant  results  which  are  reported  from  time  to  time  in  favor  of  certain 
foods.  Instances  are  continually  occurring  where  one  food  will  fail  and 
another  when  substituted  for  it  succeed  ;  and  yet  these  successes  are  merely 
temporary,  and  the  mortality  always  remains  far  above  that  from  human 
breast-milk. 

In  nature's  method  of  feeding  we  have  first  a  receptacle,  the  hmnan 
breast,  which  provides  a  fresh  supply  of  food  at  proper  intervals,  absolutely 
prevents  fermentation  of  the  food  before  it  enters  the  infant's  mouth,  incites 
to  action  the  necessary  digestive  fluids,  avoids  a  vacuum  by  collapsing  as  it 
is  gradually  emptied,  thus  allowing  the  food  to  flow  continuously,  and 
finally  is  practically  self- regulating  as  to  the  amount  of  daily  food  accord- 
ing to  the  infant's  age.  Secondly,  the  food  itself  is  adapted  to  the  infant's 
digestive  function,  and  for  its  development,  by  its  temperature,  98°  to 
100°  F.,  its  alkaline  reaction,  and  its  chemical  constituents.     Given  these 


294 


INFANT-FEEDIXG WEANIXG. 


factors^  how  nearly  can  we  approach  them  artificially  ?  Human  ingenuity 
has  not  yet  been  able  to  devise  anything  which  approaches  the  perfection 
of  nature's  receptacle,  and  the  best  that  we  can  do  to  offset  this  complex 
mechanism  is  to  adopt  that  which  is  exactly  the  reverse, — namely,  a  recep- 
tacle of  absolute  simplicity, — and  thus  combat  the  tendency  to  fermentation 
by  preventing,  through  perfect  cleanliness,  the  receptacle  from  becoming  a 
source  of  fermentation. 

To  illustrate  to  my  class  of  medical  students  my  ideas  as  to  a  proper 
receptacle  for  the  sterilization  and  administration  of  an  artificial  food,  I 
had  made  in  the  spring  of  1887  what  are  practically  enlarged  test-tubes, 
which,  being  open-mouthed  beyond  what  is  usually  provided  in  the  ordi- 
nary nursing-bottle,  and  having  no  angles,  are  readily  cleaned.  I  also 
devised  at  the  same  time,  and  for  the  same  purpose,  a  simple  sterilizer  for 
household  use,  which  can  be  made  at  any  tinsmith's  at  small  expense. 
The  rubber  nipple  takes  the  place  of  that  of  the  breast,  and  a  small  hole 
near  the  end  of  the  feeding-tube  prevents  a  vacuum  being  formed  and 
regulates  the  rapidity  of  the  flow,  while  it  allows  it  to  be  continuous ;  this 
is  done  by  rolling  up  the  edge  of  the  rubber  nipple  from  the  hole  with  the 
finger,  or  letting  it  cover  the  hole,  according  to  the  demand  shown  by  the 
infant.  The  artificial  receptacle  is  not  self-regulating,  and  hence  we  must 
determine  anatomically  the  amount  of  food  in  bulk  which  nature  provides 
for  the  average  infant  at  different  ages,  and  from  these  averao;e  fio-ures 
deduce  the  proper  amount  for  the  especial  infant.  The  feeding-tubes  are 
graduated  for  the  more  important  periods  of  growth,  for  the  purpose  of 
continually  impressing  upon  the  mother  and  nurse  what  the  physician  often 
only  has  the  opportunity  of  telling  them  at  the  beginning  of  the  nursing 
period, — namely,  that  the  error  is  in  giving  too  much  food  rather  than  too 

little,  an  error  also  which 
naturally  results  when,  as  is 
commonly  the  case,  the  usual 
eiffht-ounce  nursing-bottle 
is  provided  as  the  recepta- 
cle at  the  very  beginning 
of  infantile  life. 

Fig.  1  represents  the 
stomach  of  an  infant  five 
days  old,  in  life-size,  which 
was  prepared  for  me  by  Dr. 
C.  W.  Townsend,  of  Boston. 
It  was  found  to  hold  twenty- 
five  cubic  centimetres,  and 
Dr.  Townsend  draws  attention  to  the  fact  that  in  measuring  the  capacity 
of  these  stomachs  it  should  be  done  before  the  stomach  is  separated  from 
its  mesenteric  attachment,  as  otherwise  it  is  easily  stretched  by  the  introduced 
fluid,  so  as  to  show  a  greater  capacity  than  would  be  possible  during  life. 


Fig.  1. 


INFANT-FEEDIXG WEAXIXG. 


295 


Fig.  2. 


Fig.  2  represents  the  actual  size  of  the  tube,  which  is  sufficiently 
large  for  each  feeding  during  the  first  week ;  and  when  we  consider  the 
space  which  would  be  needed  to  represent  the  fiiU-sized 
nursing-bottle,  these  two  diagrams  express  better  than 
can  be  explained  by  words  the  disproportion  between 
the  size  of  the  infant's  stomach  and  the  amount  Avhich 
the  mother  supposes  it  should  hold  to  keep  her  child 
from  being  stan'ed. 

Referring  again  to  Frolowsky's  investigations,  al- 
ready mentioned  on  page  273,  we  see  that  there  is  a 
veiy  rapid  increase  in  the  gastric  capacity  in  the  first 
two  months  of  life,  while  in  the  third,  fourth,  and  fifth 
months  the  increase  is  slight.  Guided  by  these  data, 
which  we  find  correspond  closely  Avith  the  results  of 
clinical  investigations  bearing  on  this  point,  Ave  should 
rapidly  increase  the  quantity  of  the  food  in  the  first 
six  or  eight  Aveeks,  and  then  gi\-e  the  same  quantity  up 
to  the  fifth  or  sixth  month,  unless  the  infant's  appetite 
evidently  demands   more,  w^hen  of  course  a  gradual 

increase  should  be  made.     A  considerable  increase  in  

the  quantity  needed,  also,  usually  takes  place  betAA'een 
the  sixth  and  tenth  months. 

Of  the  different  causes  Avhich  regulate  the  gastric  capacity,  the  weight  of 
the  infant  has  the  greatest  influence,  and  it  is  perfectly  possible  for  a  poorly- 
developed  infant  of  small  Aveight  to  haA'e  a  gastric  capacity  no  greater  than 
a  normally-developed  infant  of  half  the  age.  This  possibility  must  be  taken 
into  account  AAdien  Ave  attemjjt  to  regulate  the  bulk  of  an  artificial  food  to 
the  age  of  the  infant.  An  infant  of  six  Aveeks  has  been  brought  to  me, 
whose  general  development  and  weight  corresponded  so  closely  to  those  of 
the  normal  aA^erage  infant  of  tAveh'e  Aveeks  that  it  Avas  self-eA'ident  that 
the  tAvo  ounces  of  food  Avhich  Avould  ordinarily  haA^e  been  the  proper  alloAV- 
ance,  so  far  as  its  age  was  concerned,  was  not  sufficient,  and  that  its  weight 
indicated  a  gastric  capacity  for  an  alloAA^ance  of  four  ounces,  AA'hich  in  fact  it 
took  and  digested  with  the  greatest  ease,  Avhile  Avith  any  amount  less  than 
the  four  ounces  it  Avas  never  satisfied. 

Fig.  3  represents,  in  life  size,  the  stomach  of  a  female  infant  tAveh'e 
months  old.  This  infant's  weight  Avas  4289  grammes,  Avhich  corresponded 
to  about  the  AA^eight  of  the  average  normal  infant  at  two  months.  The 
gastric  capacity,  120  cc.  (4  ounces),  corresponded  to  the  Aveight  rather  than  to 
the  age. 

Another  \'ery  important  influence  on  the  gastric  capacity  is  the  kind  of 
nourishment  Avhich  the  infant  has  received.^  The  breast-fed  infant  in  the 
early  months  of  life  has  a  uniformly-dev'eloped  stomach,  and,  as  a  rule,  of 


'  Fleischmann,  Die  Emahrung  des  Saiiglingsalters,  p.  17. 


296 


INFANT-FEEDIX< 


-WEANING. 


smaller  capacity  than  the  stomach  of  the  artificially  fed, — the  muscular  fibres 
of  the  fundus  in  the  latter  stomach  being  weak  and  its  form  abnormal. 

It  is  common  in  the  artificially  fed,  where  the  quality  of  the  food  is  poor 
and  the  quantity  too  large  for  the  age  and  development,  and  where  rachitis 


Fig.  3. 


has  been  a  consequence,  to  find  the  stomach  dilated  to  a  capacity  entirely  out 
of  proportion  to  the  infant's  age  and  weight. 

Fig.  4  represents,  in  life-size,  the  dilated  stomach  of  an  artificially 
fed,  rachitic  infant  seven  months  old.  The  gastric  capacity  in  this  case  was 
300  cc.  (10  ounces),  corresponding  to  the  average  infant  of  twelve  months, 
and  the  shape  of  the  dilated  stomach,  with  its  very  much  increased  greater 
curvature  and  its  lessened  smaller  curvature,  is  very  significant. 

Allowing,  then,  that  owing  to  the  disteusibility  of  the  stomach  these 
measurements  of  the  gastric  capacity  are  only  approximate,  we  can  never- 
theless see  from  the  above  anatomical  diagrams,  which  have  been  prepared 
with  great  care,  that  the  figures  in  Table  I.  provide  us  with  a  fair  working 
basis  by  which  we  can  determine  the  amount  of  food  to  be  given  at  different 
ages  so  as  to  correspond  to  the  marked  periods  of  the  stomach's  gro"\\i:h. 
Figs.  5,  6,  7,  and  8  represent  feeding-tubes  drawn  on  a  scale  of  about  one- 
third,  and  have  the  proper  capacity  for  the  amount  of  food  which  should 
be  given  to  the  infant  during  these  periods. 

Fig.  5  is  a  tube  of  small  calibre,  graduated  to  hold  two  ounces,  and 
intended  to  be  used  for  feeding  during  the  first  six  weeks  of  life  and  later 
as  a  measure  for  the  larger  tubes  in  preparing  the  artificial  food  in  its 
varying  proportions. 

The  smaller  tube.  Fig.  6,  holds  four  ounces,  has  a  calibre  of  one  and 
five-eighths  inches,  and  a  height  of  six  inches ;  it  is  to  be  used  from  the 
sixth  week  to  the  fifth  or  sixth  month,  and   is  intended  to  correspond  to 


INFANT-FEEDING WEANING. 


297 


the  above-described  rapid  growth  of  the  stomach  in  the  first  two  mouths 
and  its  insignificant  further  increase  in  size  up  to  the  fifth  or  sixth  month ; 


Fig.  4. 


it  is  represented  in  the  diagram  with  the  nipple  adjusted  for  use.  The 
large  tube,  Fig.  8,  has  a  calibre  of  one  and  six-eighths  inches,  a  height 
of  eight  and  three-fonrths  inches,  and  corresponds  to  the  common  half- 
pint  nursing-bottle ;  it  is  represented  in  the  figure  without  the  nipple,  and 
shows  the  air-hole,  which,  together  with  the  mouth  of  the  tube,  is  stopped 
with  cotton.  Another  medium-sized  tube  has  been  made  to  go  with  the  set, 
and  this  has  a  calibre  of  one  and  six-eighths  inches,  a  height  of  seven  and 
three-fourths  inches,  and  holds  six  ounces.  It  of  course,  is  not  a  necessity, 
but  is  intended  to  be  used  between  the  sixth  and  tenth  montlis,  merely  to 
enunciate  the  importance  of  careful  supervision  of  quantity  throughout  the 
first  year,  as,  where  a  food  qualitatively  correct  is  being  used,  the  error,  as  a 
rule,  is  in  giving  too  great  an  amount.     It  is  represented  in  Fig.  7. 


298 


INFANT-FEEDING ^WEANING. 


A  few  words  regarding  the  process  of  sterilization  and  the  connection  of 
bacteriology  with  the  feeding-problem  will  here  be  necessary,  as  explanatory 
of  what  will  be  said  later  about  especial  artificial  foods.  The  practical 
utility  of  destroying  the  developed  bacteria  in  the  milk  in  certain  intestinal 


Fig.  8. 


Fig.  5. 


Fig.  7. 


Fig.  6. 


00 

0^ 


disorders  has  long  been  recognized  clinically.  Jacobi  many  years  ago 
recommended  that  the  milk  to  be  used  for  the  infant  during  the  day  should 
be  boiled  as  soon  as  received,  and  kept  in  tightly-stoppered,  inverted  bottles 
on  ice.  Lister  has  shown  that  cow's  milk  as  it  comes  from  the  udder  is 
sterile,  and  that  it  quickly  becomes,  infected  in  various  ways,  as  by  the  hands 
of  the  milkers,  the  air  of  the  stables,  etc.  Professor  Soxhlet,  of  Munich, 
found  that  calves  one  week  old,  when  taken  from  the  udder  and  fed  with 
their  mother's  milk  from  a  trough,  were  aifected  with  diarrhoea,  which 
disappeared  on  their  being  fed  again  directly  from  the  udder.  Soxhlet's 
experiments  also  showed  that  under  the  same  conditions  of  temperature  the 
milk  of  three  cows  as  ordinarily  milked  turned  sour  in  about  half  the  time 
that  the  same  milk  did  when  the  udders  and  milkers'  hands  were  carefully 
washed  and  other  precautions  for  cleanliness  were  taken  before  the  milking. 
After  the  true  significance  of  sterilization  had  been  explained  by  various 
bacteriologists.  Professor  Soxhlet  undertook  a  series  of  experiments  to  de- 
termine the  length  of  time  milk  would  remain  sweet  after  sterilization. 
His  method  was  to  immerse  the  milk,  contained  in  stoppered  bottles,  in 
boiling  water ;  and  he  found  that  thirty  to  forty  minutes  of  this  immersion 


INFANT-FEEDING WEANING. 


299 


Fig.  9. 


practically  sterilized  the  milk  and  enabled  it  to  be  kept  sweet  for  varying 
intervals  of  time  according  to  the  variations  in  the  process  of  the  steriliza- 
tion. Soxhlet  also  devised  an  apparatus  for  sterilizing  and  for  feeding, 
and  this  apparatus  is  already  being  used  by  a  large  number  of  families 
in  Munich.  His  feeding-arrangements  are,  however,  clinically  imperfect 
and  unsatisfactory,  his  use  of  the  long  rubber  feeding-tube  being  especially 
objectionable,  and  much  of  his  apparatus  unnecessary. 

Soxhlet  published  the  results  of  his  investigations  in  the  Muncliener 
Medicinische  Wochenschrift,  Nos.  15-16,  April,  1886. 

Dr.  Harold  C  Ernst,  Demonstrator  of  Bacteriology  in  the  Harvard 
Medical  School,  had  already  been  successfully  feeding  sick  infants  on  steril- 
ized food  as  early  as  the  summer  of  1884,  when  in  the  spring  of  1887, 
attention  having  been  drawn  by  him  to  the  subject  of  sterilization,  I  was 
led  to  devise  the  feeding-tubes  for  sterilization  already  described,  and  the 
steamer  represented  in  section  below. 

A  paper  which  embodied  my  work  on  this  subject  was  read  by  me  at 
the  May,  1887,  meeting  of  the  Obstetri- 
cal Society  of  Boston,  and  was  published 
in  the  Archives  of  Pediatrics,  August, 
1887,  Soxhlet's  article  at  that  time  not 
having  been  heard  of  by  me.  My  idea 
was  that  if  sterilization  was  necessary  or 
advisable  we  should  adopt  as  simple  a 
method  as  possible  for  family  use.  This 
was  in  a  measure  accomplished  by  steril- 
izing in  a  receptacle  from  which  the 
infant  could  be  directly  fed,  without 
pouring  from  one  vessel  to  another  and 
running  the  risk  of  fresh  infection. 

Following  Dr.  Ernst's  advice,  I  ster- 
ilized by  exposure  to  steam  for  twenty 
minutes,  and  thus  destroyed  the  devel- 
oped bacteria.  A  single  steaming,  how- 
ever, may  not  destroy  the  spores,  which 
may  be  developed  later  unless  the  process 
is  several  times  repeated. 

For  purposes  of  feeding,  the  first 
sterilization  or  killing  of  the  germs  is 
in  all  probability  all  that  is  practically 
necessary. 

Fig.  9  represents  the  sterilizer,  with 
the  water  boiling  under  the  litre  fiask,  which  is  stopi)crcd  with  cotton,  and 
the  four-ounce  feeding-tube,  with  its  mouth,  its  nipple,  and  its  air-hole 
tightly  enclosed  in  the  rubber  cot,  as  dcscrilied  on  the  following  page.     A 
gas-flame  is  preferable  to  that  of  an  alcohol  lamp.     Tiiis  steamer  answers 


300  IXFANT-FEEDIXG WEAXIXG. 

very  well  for  sterilization  such  as  is  necessary  in  infant-feeding.  It  is  simply 
a  tin  pail  eight  or  nine  inches  in  diameter  and  nineteen  to  twenty  inches 
deep,  raised  on  three  legs  sufficiently  high  to  allow  a  Bunsen  burner  to  stand 
under  it.  Four  inches  from  the  bottom  of  the  cylinder  is  a  perforated  tin 
•diaphragm,  on  which  the  feeding-tubes  stand  while  being  sterilized.  There 
is  a  small  vent  for  the  escape  of  the  steam  in  the  cover.  Water  is  placed  in 
the  bottom  of  the  steamer  to  the  depth  of  about  an  inch,  and  in  about  ten 
minutes  after  lighting  the  gas-jet  the  water  begins  to  boil.  The  food  is  then 
poured  into  one  of  the  feeding-tubes,  and  an  ordinary  rubber  nipple  adjusted 
as  on  any  nursing-bottle.  Over  the  nipple,  as  an  extra  precaution  for  the 
exclusion  of  contamination,  a  non-perforated  rubber  cot  is  di'awn  tightly 
down  on  the  tube.  As  soon  as  the  water  has  been  boiling  for  a  minute  or 
two,  the  tube  is  placed  in  the  steamer,  the  cover  applied,  and  the  steaming 
•continued  for  twenty  minutes.  The  tube  can  then  be  removed,  allowed  to 
cool  until  of  a  proper  temperature,  98°  to  100°  F.,  and  on  removing  the 
rubber  cot  and  putting  the  nipple  in  the  infant's  mouth  the  food  is  received 
as  sterile  as  from  the  human  breast,  so  far  as  the  developed  bacteria  are  con- 
cerned. Food  sterilized  in  this  way  can  be  kept  for  a  number  of  days,  and 
can  be  utilized  when  the  infant  is  to  be  taken  on  a  journey.  Where  longer 
journeys  are  to  be  taken,  such  as  an  ocean  voyage  or  across  the  continent, 
the  sterilization  should  be  repeated  several  times  with  intervals  of  a  day, 
and  the  flasks  used  for  the  sterilization  hermetically  sealed.  Food  prepared 
in  this  way  will  keep  sweet  for  many  weeks.  Where  the  steamer  just 
described  can  for  any  reason  not  be  obtained,  a  simple  colander  with  a  lid, 
placed  on  the  teakettle,  makes  an  effective  sterilizer.  The  food  can  also  be 
sterilized  by  Soxhlct's  method  of  immersion  in  boiling  water,  or  by  directly 
boiling  the  food  itself. 

The  question  as  to  whether  the  milk  should  be  boiled  or  steamed  is  one 
which  is  not  of  a  great  deal  of  significance,  and  can  be  settled  according  to 
the  fancy  of  the  individual  practitioner,  the  object  of  sterilization  being 
accomplished  in  either  case.  The  remarks  on  this  subject,  however,  made 
by  Dr.  Charles  W.  Townsend  at  the  June,  1887,  meeting  of  the  Obstetrical 
Society  of  Boston,  may  be  of  interest  to  those  who  are  using  boiled  milk  as 
a  food  for  infants.     Dr.  Townsend  said, — 

"  The  process  of  boiling  milk  of  course  sterilizes  it,  destroying  not  only 
the  putrefactive  bacteria  and  disease-germs  which  may  be  present,  but, 
according  to  jSTewton  and  AYallace,^  changing  and  driving  off  tyrotoxicon,  one 
of  the  poisonous  ptomaines  produced  by  these  bacteria.  This  takes  place 
at  a  temperature  of  180°  F.  Boiling,  however,  brings  about  other  changes 
than  those  caused  by  sterilization  by  steam.  The  odor  and  taste  of  boiled 
milk  are  decidedly  different  from  the  odor  and  taste  of  raw  milk.  Boiling 
expels  about  three  per  cent,  of  gases,  CO2,  N,  and  O.  As  the  boiled  milk 
cools  in  contact  with  the  air,  a  scum  forms,  whicli  is  the  albumen  coagulable 

1  Phila.  Med.  News,  Sept.  25,  1886. 


INFANT-FEEDING WEANING.  301 

by  heat,  entangling  in  its  meshes  a  certain  amount  of  fat.  Tiiis  coagulable 
albumen,  according  to  Winter  Blythe,  equals  one-fifth  of  the  casein  in 
amount. 

"  Boiled  milk  does  not  become  sour  as  quickly  as  raw  milk,  due,  of 
course,  largely  to  the  fact  of  its  sterilization. 

"  As  to  the  effect  boiling  has  ou  the  digestibility  of  milk,  there  is  a  diifer- 
ence  of  opinion.  There  is  a  general  impression  that  boiled  milk  is  more 
constipating  than  new  milk,  which  is  probably  derived  from  the  fact  that 
milk  sterilized  by  boiling  is  less  likely  than  raw  milk  to  cause  diarrhoea. 

"According  to  Schreiner^  and  to  Randolph,^  boiled  milk  is  more  quickly 
coagulated  by  acids  than  raw  milk,  while  the  reverse  is  the  case  with  regard 
to  the  action  of  rennet.  Thus,  raw  milk  at  the  body-temperature  coagu- 
lates firmly  almost  immediately  on  the  addition  of  a  neutral  rennet  solution, 
whereas  boiled  milk  under  the  same  conditions  does  not  clot  for  a  far  long-er 
period,  and  the  coagula  are  not  so  firm. 

"The  investigations  concerning  the  relative  digestibility  of  raw  milk 
and  boiled  milk,  found  by  siphoning  out  the  contents  of  the  stomach,  are  so 
contrary  in  their  results  that  they  need  not  be  mentioned  here,  Randolph^ 
and  Reichmau^  came  to  exactly  opposite  conclusions,  and  Dujardiu-Beau- 
metz*  disagrees  with  both  of  these  writers,  saying  that  there  is  "no  differ- 
ence. He,  however,  refers  to  Pinard  as  saying  ^that  prolonged  boiling 
peptonizes  a  part  of  the  albuminoid  substances  contained  in  the  milk.'  " 

My  own  experiments  comparing  steamed  with  boiled  milk  show  that 
the  odor  and  taste  of  boiled  milk  are  present  when  milk  is  steamed,  but 
to  a  much  less  degree  than  with  boiled  milk ;  also  that  while  a  thick  scum 
is  formed  on  milk  boiled  for  twenty  minutes,  which  is  tenacious  and  does 
not  disappear  on  shaking,  only  a  very  thin  scum  forms  on  milk  steamed  for 
twenty  minutes,  and  this  is  not  tenacious,  and  almost  entirely  disappears 
on  shaking. 

Soxhlet  did  not  make  any  direct  bacteriological  study  of  the  subject, 
but  simply  took  the  curdling  of  the  milk  as  a  sign  of  infection.  Measured 
by  this  standard,  his  milk  kept  about  three  weeks.  According,  however, 
to  Jeffries,  milk  becomes  full  of  bacteria  and  seriously  altered  before  cur- 
dling occurs,  and  certain  species  of  bacteria  do  not  curdle  milk. 

Dr.  J.  Amory  Jeffries,  of  Boston,  published  in  the  American  Journal  of 
the  Medieal  Seienoes  for  May,  1888,  a  paper  entitled  "The  Sterilization  of 
Milk  and  Food  for  Infants."  Dr.  Jeffries  very  aptly  remarks  "  that  it  is  a 
curious  fact  that,  while  older  people  are  chiefly  fed  on  sterilized  food, — that 
is,  cooked  food, — infants  are  fed  on  food  peculiarly  adapted  by  its  compo- 
sition and  fluid  state  to  offer  a  home  for  bacteria."  Jeffries's  work  is  more 
distinctly  bacteriological   than   Soxhlet's ;   agar-agar   cultures  were   made 

1  Loc.  cit. 

2  Phila.  Med.  Npws,  June  21,  1884. 

»  Zeitschr.  fiir  Klin.  Med.,  1885,  ix.  565. 

*  Boston  Med.  and  Surg.  Journ.,  Aug.  5,  188G. 


302  INFANT-FEEDING WEANING. 

before  and  after  the  diiferent  fluids  were  sterilized,  and  the  colonies  of 
bacteria  counted.  His  results,  however,  coincide  with  those  of  previous 
experimenters, — namely,  that  steaming  for  fifteen  minutes  is  sufficient  to  kill 
the  developed  bacteria,  while  a  second  steaming  is  necessary  for  complete 
sterilization.  Out  of  one  hundred  and  twenty  lots  of  milk  steamed  but  once, 
all  but  four  or  five  showed  distinct  signs  of  change  within  a  month,  while 
the  majority  of  those  steamed  twice  did  not  change  at  all. 

Jeffries's  experiments  also  show  that  spores  develop  slowly  and  indeed 
rarely  form  in  milk,  which,  as  he  says,  is  an  excellent  medium  for  growth, 
while  spore-formation  among  bacteria,  like  seeding  among  higher  plants,  is 
a  phenomenon  of  impaired  growth.  He  also  explains  the  preservation  of 
some  of  the  milk  steamed  but  once  by  the  absence  of  any  enduring  spores 
from  the  start.  In  an  article  of  very  great  interest  and  value  to  the  prac- 
tising physician  "  On  the  Bacteria  of  the  Alimentary  Canal"  in  the  Boston 
Medical  and  Surgical  Journal,  September  6,  1888,  Jeffries  has  reviewed  the 
work  done  by  the  various  bacteriologists  up  to  the  present  time,  and,  as 
much  of  this  work  has  a  direct  bearing  on  the  subject  of  feeding,  I  have 
taken  the  liberty  of  quoting  extensively  from  his  article,  and  acknowledge 
to  him  my  indebtedness  for  the  assistance  which  I  have  received  from 
his  laborious  work : 

"  Miller,  De  Barry,  and  Escherich  have  shown  that  living  bacteria  are 
to  be  found  in  the  stomachs  of  man  and  animals,  and  the  former  author 
has  also  clearly  proved  that  bacteria  can  pass  through  the  stomach  into  the 
intestines  and  live  for  a  considerable  time."  Jeffries  goes  on  to  say,  "  Of 
the  morphology  and  biology  of  the  forms  found  in  the  stomach,  little  is 
known.  The  field  is  a  new  one,  and  the  species  have  not  been  sufficiently 
described  to  enable  others  to  recognize  them  with  certainty.  Miller  has 
found  five  kinds  which  give  off  carbonic  dioxide  and  hydrogen  gas,  lactic, 
acetic,  and  butyric  acids  being  formed."  "  Of  the  flora  of  the  intestines 
much  more  is  known  than  of  that  of  the  stomach.  The  researches  of  Brie- 
ger,^  Yignal,^  Stahl,^  and  Escherich*  have  now  proved  that  a  large  number 
of  species  may  occur  in  the  fajces.  Brieger  isolated  two  new  kinds,  one  a 
micrococcus  which  turns  grape-  or  cane-sugar  into  ethylalcohol,  with  a 
trace  of  acetic  acid ;  the  other  the  well-known  Brieger's  bacillus.  This  spe- 
cies occurs  in  the  faeces  in  vast  numbers,  ferments  sugars,  and  decomposes 
albumens.  Vignal  isolated  ten  species  from  the  fseces,  six  of  these  also 
being  found  in  the  mouth.  Of  these,  some  produced  acid  fermentations 
and  gas,  but,  unfortunately,  they  were  not  sufficiently  studied  to  show  their 
effects  on  digestion."  "  Escherich  studied  especially  the  fseees  of  infants, 
and  found  a  large  number  of  kinds  of  bacilli, — among  them  a  small  bacillus 

1  Brieger,  Zeitschr.  f.  Physiol.  Chem.,  1884,  p.  306. 

2  Vignal,  Arch,  de  Physiol.,  1884,  p.  492. 

'  Stahl,  Verhandl.  des  III.  Congress  f.  innere  Medicin,  1884. 

*  Escherich,  Die  Darmbacterien  des  Sauglings  und  ihre  Beziehungen  zur  Physiologie 
der  Yerdauung,  1886. 


INFANT-FEEDING WEANING.  303 

capable  of  converting  milk-sugar  into  lactic  acid,  carbonic  dioxide  and 
hydrogen  gas  being  evolved,  either  in  the  presence  or  absence  of  air, — a 
facultative  anaerobic  species,  his  Bacillus  ladis  aerogenes.  .  .  .  Escherich  estab- 
lished, by  the  examination  of  a  large  series  of  cases,  the  fact  that  the  kinds 
occurring  in  the  faeces  vary  with  the  food,  that  is,  the  intestinal  contents." 
Jeffries  again  says,  "  Starting  at  birth  with  the  sterile  meconium,  consist- 
ing of  mucus,  epithelium,  and  the  like,  infection  by  the  mouth  and  rectum 
quickly  occurs,  and  in  a  short  time  almost  any  form  may  be  found,  but 
chiefly  such  putrefying  forms  as  Proteus  vulgaris. 

"  With  the  suckling  of  the  infant  and  the  substitution  of  the  refuse 
of  the  milk  and  secretion  of  the  digestive  tract  for  the  meconium,  a  sharp 
transition  occurs.  Instead  of  the  generally  distributed  forms  causing  de- 
composition, only  two  kinds  are  regularly  found, — Bacillus  lactis  aerogenes 
and  Brieger's  bacillus,  the  first  chiefly  in  the  upper  parts  of  the  intestine, 
the  second  in  the  lower  parts.  Passing  on  to  the  period  of  mixed  diet, 
quite  a  number  of  forms  appear,  among  them  the  Streptococcus  coli  gracilis, 
the  putrefying  green  fluorescing,  a  tetrad  coccus,  and  several  kinds  of  yeast. 
This  brings  us  to  the  pith  of  the  subject :  why  are  the  flora  so  limited  in 
the  milk-eating  infants  and  so  diverse  in  others  ?  What  drives  the  forms 
found  in  the  meconium  out  ?  That  they  can  live  there  is  clear,  as  shown 
by  their  presence  the  day  before.  Again,  what  prevents  forms  so  common 
with  meat  diet  from  gaining  a  footing  ?  It  is  not  the  milk  alone,  for  milk 
is  an  almost  universal  food  for  bacteria,  and  all  the  kinds  found  in  the 
intestines  thrive  in  it. 

"  Escherich  answers  as  follows :  the  Bacillus  lactis  aerogenes  and  the 
milk  diet  keep  out  the  other  forms. 

"  Formerly,  even  before  the  nature  of  ferments  and  putrefactive  pro- 
cesses were  clearly  understood,  the  significance  of  this  question  was  seen. 
The  chyme  is  a  mass  admirably  adapted  for  putrefaction  or  fermentation, 
yet  ordinarily  but  little  of  either  occurs.  It  is  an  alkaline  or,  as  in  the 
milk-fed,  acid  mixture  rich  in  albumens,  fats,  and  the  starch  group,  amply 
provided  with  water  and  warmth.  Such  a  mixture  outside  the  body  at  an 
equal  temperature  would  quickly  decompose.  It  was  generally  held  that 
some  preservative  action  was  exerted  by  the  digestive  juices  :  Bidder's  and 
Schmidt's  dogs  with  biliary  fistulae  were  held  to  explain  the  whole.  These 
dogs,  deprived  of  their  bile,  became  emaciated,  and  suffered  from  diarrhoea 
and  decomposition  of  the  intestinal  contents.  Thus  it  seemed  clear  that  in 
the  absence  of  the  bile  decomposition  occurred  ;  that  is,  that  the  bile  was  a 
powerful  germicide  or  germ-inhibitor.  During  the  last  few  years,  however, 
different  results  have  been  obtained  in  cases  of  biliary  fistula.  Rohmann's  ^ 
dogs  did  not  suffer  from  diarrhoea  or  putrefaction  in  the  intestines :  hence  it 
is  clear  that  the  bile  is  not  the  cause  of  prevention.  The  diarrhoea,  if 
present,  is  due  to  the  large  amount  of  fat  passed  on  to  the  lower  intestines. 


1  Kdhinann,  Beobachtunsen  an  Hunden  mit  Gallenfistel,  Breslau,  1882. 


304  INFANT-FEEDING WEANING. 

"Maly^  and  Emich^  ascribed  value  to  the  bile  acids,  especially  the 
taurocholic,  basing  their  results  on  crude  methods;  and  Lindenberger,^ 
really  leaving  the  subject,  attributed  the  action  to  the  organic  acids  in 
combination  with  the  bile. 

"All  this  argument  and  belief  in  the  decided  germicidal  action  of  the 
bile  occurred  in  the  face  of  the  well-known  fact  that  bile  itself  will  decom- 
pose. 

"  From  a  bacteriological  stand-point,  Miller  has  shown  that  a  ten-per- 
cent, solution  of  bile,  if  anything,  favors  growth.  JSIacfadyen  has  studied 
bile,  bile  salts,  and  bile  acids  in  varying  strengths.  The  only  positive 
results  were  got  with  the  acids,  these  arresting  development  of  bacteria  if 
sufficiently  strong,  especially  taurocholic  acid.  Xeither  acid  had  much  eifect, 
and  least  of  all  on  the  forms  causing  putrefaction.  Proteus  vulgaris  was  only 
arrested  by  a  strength  of  from  one  to  two  per  cent.  The  pathogenic  forms 
were  arrested  by  a  much  smaller  quantity,  from  one  to  one-half  per  mille. 

"  It  is  thus  clear  that  other  causes  must  be  sought  for.  One  of  these 
is  to  be  found  in  the  lack  of  oxygen  in  the  intestines,  as  pointed  out  by 
Escherich  and  strangely  forgotten  by  others.  There  is  certainly  very  little 
free  oxygen  in  the  chyme,  if  any ;  not  only  is  it  scarce  in  the  food  at  the 
start,  but  is  taken  up  by  the  chemical  changes  during  digestion,  and  also  by 
the  intestines.  This  clearly  must  be  a  potent  factor,  for  the  majority  of 
bacteria  require  a  fair  supply.  Accordingly,  many  bacteria  are  found  in 
the  faeces  which  will  not  grow  in  the  air,  as  shortly  stated  by  Macfadyen, 
and  the  mass  of  those  isolated  in  the  air  are  able  to  grow  without  it. 

"  This  apparent  contradiction,  the  absence  of  oxygen  in  the  intestines, 
and  the  presence  of  both  aerobic  and  anaerobic  bacteria,  is  probably  ex- 
plained by  the  ability  of  the  aerobic  kinds  to  draw  oxygen  from  oxyhsemo- 
globin.  They  thus  breathe  through  the  intestines,  as  it  were,  when  in  close 
contact  with  the  walls,  while  the  anaerobic  kinds  live  in  the  mass  of  the 
chyme,  and  do  not,  so  far  as  we  know,  reduce  oxyhasmoglobin. 

"  Escherich,  though  he  points  out  the  absence  of  oxygen,  does  not  seem 
to  give  it  full  value,  or  rather  forgets  the  subject  in  treating  of  the  action  of 
his  IxictiG  acid  bacillus.  As  before  stated,  this  form  is  regularly  found  in 
great  numbers  in  the  upper  part  of  the  intestines  of  milk-fed  children. 
Here  it  converts  a  considerable  part  of  the  milk-sugar  into  lactic  acid 
(Baginsky  *  says  acetic  acid,  but  has  given  no  proof),  and  thus  prevents  the 
other  forms  from  growing,  most  forms  being  susceptible  to  an  acid  reaction, 
and  especially  to  the  organic  acids.  The  action  of  salicylic  acid  is  known 
to  all,  and  recent  experiments,  of  which  Macfadyen's  (the  last)  are  the  best, 
show  acetic,  butyric,  and  lactic  acids  to  be  efficient  germ-inhibitors  in 
strengths  of  from  one  to  one-half  per  mille  according  to  the  species. 

^  Maly,  Hermann's  Physiologie,  v.  184. 

2  Emich,  Sitzungsbericht.  d.  Akad.  d.  Wissenschaft,  Wien,  1882. 

'  Lindenberger,  Upsula  Forbandlingar,  1884. 

*  Baginsky,  Deutsch.  Med.  Wochenschrift,  1888,  Nos.  20  and  21. 


IXFAXT-FEEDIXG WEANING.  305 

"  In  milk-fed  infants  another  point  is  the  comparative  inability  of  bac- 
teria to  attack  casein,  so  that  the  bacteria  are  literally  starved. 

"  To  sum  up,  we  may  conclude  that  the  bile  acids,  lack  of  oxygen,  lack 
of  suitable  albumens,  and  the  presence  of  organic  acids  are  the  causes  of 
immunity  from  the  putrefying  and  fermenting  kinds  of  bacteria  to  which 
we  are  exposed.  Certain  forms  are  probably  limited  by  the  lack  of  water, 
that  is,  fluid  state,  doing  poorly  if  unable  to  swim  freely  about.  It  must 
not,  however,  be  supposed  that  bacteria  are  scarce  in  the  intestines ;  on  the 
contrary,  they  form  a  large  part  of  the  dry  substance  of  the  faeces. 

"  The  ferments  act  by  the  production  of  various  acids,  chiefly  from  the 
milk-sugar.  In  small  amounts,  as  in  the  case  of  Bacillus  lactis  aerogenes, 
the  acid  seems  to  be  of  benefit,  and  certainly  does  no  harm,  as  it  regularly 
occurs  in  healthy  breast-fed  infants.  In  large  amounts,  however,  it  must 
tend  to  over-acidify  the  contents  of  the  intestines  and  interfere  with  the 
action  of  the  digestive  fluids." 

The  remaining  factor  of  the  feeding-problem — formulated  on  page  293, 
and  which  has  not  yet  been  considered — is  the  chemical  constituents  of  the 
artificial  food :  what  shall  they  be  ?  Taking  the  average  human  breast- 
milk  as  the  safest  standard,  we  are  impressed  with  the  fact  that  the  helpless 
young  of  all  animals  and  of  human  beings  are  carnivorous ;  also,  that 
although  a  vegetable  diet  would  often  seem  far  the  easiest  method  of  pro- 
curing nourishment  for  young  infants,  yet  nature  has  persisted  in  providing 
an  animal  diet.  We  should  therefore  be  very  cautious  about  endeavoring 
to  introduce  into  our  artificial  diet  a  vegetable  element,  which,  as  judged 
by  our  standard,  must  be  a  foreign  element.  Milk  is  the  food  which  our 
reason  tells  us  should  be  given  to  the  young  infant,  and  a  milk  which  will 
approach  as  nearly  as  possible  to  the  average  human  milk.  That  of  various 
animals  has  from  time  to  time  been  recommended  as  the  best  substitute  for 
human  milk,  the  recommendation  being  based  on  their  analyses  approaching 
more  or  less  nearly  the  composition  of  human  milk.  The  milk,  however, 
of  all  animals  has  to  be  modified  to  correspond  to  human  milk  ;  and  Avhen 
we  begin  to  modify,  it  is  as  easy  to  change  the  proportions  of  the  dilfcrent 
constituents  to  a  great  degree  as  to  a  small.  The  fact  that  one  animal's 
milk  approaches  in  its  analysis  more  nearly  to  human  milk  than  another  is 
not  of  much  significance,  other  considerations  being  far  more  important  . 
and  it  is  most  important  of  all  that  we  should  use  one  which  can  be  obtained 
everywhere  all  over  the  world  by  the  people  at  large.  This  at  once  settles 
the  question  that  it  is  the  milk  of  the  cow  to  which  avc  must  turn  our  atten- 
tion. Cow's  milk  may  differ  in  its  composition  from  human  milk  to  a 
greater  degree  than  does  the  milk  of  tlie  ass  or  tlie  mare,  whose  milk  ap- 
proaches, so  far  as  is  shown  by  analyses,  most  nearly  of  all  animals  to  that 
of  woman  ;  but  this  in  all  probability  is  for  the  very  reason  that  cow's  milk 
is  so  universally  used  as  a  food  for  human  beings  of  all  ages. 

If  the  ass  and  tlie  mare  sliould  become  domesticated  as  a  food-supply  to 
the  same  extent  that  the  cow  has  been,  there  is  every  reason  to  suppose  that 
Vol.  I.— 20 


306  INFANT-FEEDING WEANING. 

their  milk  might  change  in  its  composition  and  their  comparatively  unde- 
veloped mammary  glands  increase  in  size,  just  as  has  been  the  case  with  the 
cow,  an  animal  which  for  thousands  of  years  has  been  used  for  the  produc- 
tion of  milk,  and  which  probably  did  not  in  the  beginning  give  such  an 
over-production  of  the  mammaiy  secretion  as  is  the  case  now.  In  fact, 
in  Egypt,^  where  formerly  there  was  either  no  trade  in  milk  or  very  little, 
we  find  represented  on  the  monuments  cows  with  only  slightly-developed 
udders,  while  the  generative  organs  of  the  male  animals  are  clearly  de- 
picted,— a  fact  of  some  significance  when  we  remember  the  well-known 
tendency  of  the  Egyptians  to  realistic  representations.  It  is,  then,  from 
the  public  demand  and  by  breeding  that  cows  have  been  made  to  produce 
so  much  more  milk  than  is  necessary  for  the  support  of  their  young.  Not 
only  quantitative  but  qualitative  differences  exist  in  animals  according  to 
the  development  of  their  mammary  glands ;  and,  as  Martiny  '^  has  shown  in 
his  collection  of  statistics  on  this  subject,  the  condition  which  determines 
the  quantity  and  quality  of  the  milk  depends  on  the  development  of  the 
organ  which  produces  it.  The  question  of  artificial  feeding,  then,  is  prac- 
tically reduced  to  some  modification  of  cow's  milk,  for  this  is  the  milk 
which  is  most  easily  procured  everywhere,  and,  as  the  milk  of  all  animals 
must  be  modified  for  the  human  infant,  it  is  as  easy  to  deal  with  cow's  milk 
as  with  any  other. 

A  further  exemplification  that  cow's  milk  is  practically  the  universal 
source  of  the  artificial  food-supply  for  infants  in  most  civilized  communities, 
is  the  fact  that  the  various  foods,  patent  or  not,  all  depend  for  their  basis 
on  cow's  milk,  and  that  without  this  addition  of  milk  they  would  show  but 
an  insignificant  percentage  of  many  of  the  most  important  ingredients  of 
the  food  :  so  that  logically  we  should  not  speak  of  the  various  foods  as  such, 
but  merely  as  adjuvants  to  cow's  milk,  for  if  this  is  thoroughly  understood 
it  will,  in  many  minds,  do  away  with  much  misapprehension  regarding  the 
apparently  successful  results  of  innumerable  foods  which,  in  reality,  when 
given  to  the  infant,  are  merely  a  means  of  modifying  the  almost  universal 
representative  of  the  artificial  foods,  cow's  milk.  Cow's  milk,  therefore, 
should  be  carefully  compared  with  the  standard  human  milk,  in  order  that 
we  should  know  how  nearly  it  resembles  it ;  and  Table  VIII.  is  a  com- 
parison of  the  average  human  milk  and  the  average  cow's  milk,  the  figures 
representing  the  later  and  more  reliable  analyses. 

TABLE   VIII. 

Cow's  TMir.K  AS  ordinarily   re- 
.       Woman's  Milk,  directly  from       ^^^^^^^    ^^^^^    Twenty-Four 
THE  Breast.  jjours  old. 

Reaction Slightly  alkaline Slightly  acid. 

Coagulable  albuminoids    .    .    Small  proportionately    .    .    .    Large  proportionately. 


1  Stumpf,  Deutsches  Archiv  fiir  Klinisch.  Medicin,  Jan.  18,  1882. 

"  B.  Martiny,  Die  Milch,  ihr  Wesen  und  ihre  Verwerthung,  Danzig,  1872 


INFANT-FEEDING WEANING. 


307 


Coagulation  by  acids 


Woman's  Milk  directly  from 
THE  Breast. 


Not  perceptible  in  test-tube 


Water  .  .  . 
Total  solids  . 
Fat  ...  . 
Albuminoid- 
Milk-sugar  . 
Ash  .  .  .  . 
Bacteria   .    . 


TABLE   y 111.— Continued. 

Cow's   Milk  as  oedinartly   re- 
ceived,     ABOUT     TWENTY-FOVK 

Hours  old. 
Marked  in  .test-tube ;  greatest 
with  pure  milk ;  less  with 
milk  diluted  with  water, 
and  when  1  to  5  is  not  per- 
ceptible. 

87-88 86-87 

12-13 13-14 

4 4 

1 4 

7 4.5 

0.2 0.7 

Not  present Present. 


We  must,  however,  recognize  that  infants  in  general,  as  represented  by 
those  who  live  in  cities  and  large  towns,  do  not  receive  their  supply  of  milk 
at  once  from  the  cow's  udder,  but  that  the  milk,  as  a  rule,  is  about  twenty- 
four  hours  old,  and  it  is,  therefore,  cow's  milk  twenty-four  hours  old  that, 
until  further  improvement  is  made  in  delivering  milk,  we  must  compare 
with  fresh  human  milk  and  modify  to  correspond  to  it. 

From  this  comparison  we  at  once  see  that  human  milk  and  cow's  milk 
differ  as  markedly  from  each  other  in  their  chemistry  as  they  do  in  their 
clinical  results  as  foods ;  and,  as  practically  we  must  use  cow's  milk  in  arti- 
ficial feeding,  our  wisest  course  is  to  modify  it  until  we  have  approached 
the  chemistry  of  human  milk  as  closely  as  possible.  There  is  no  doubt, 
however,  that  cow's  milk  unmodified  has  at  times  proved  to  be  clinically 
successful  in  the  rearing  of  infants.  In  parts  of  France,  notably  in  Brittany, 
the  infants  among  the  peasantry  are  put  directly  to  the  cow's  udder,  and  with 
apparently  good  results. 

I  know  of  a  strong,  healthy  woman,  twenty-four  years  old,  who  is  one 
of  a  family  of  eight,  all  of  whom  in  their  infancy  never  tasted  any  milk 
but  that  which  they  received  from  their  parents'  cow,  sucking  it  directly 
from  the  udder.  The  great  w^eight  of  evidence,  however,  is  that  the  average 
infant  in  the  early  months  of  its  life  does  not  digest  unmodified  cow's  milk 
when  introduced  by  the  usual  methods. 

The  exceptional  instances  where  it  is  tolerated  have  their  counterparts 
in  the  success  of  many  other  foods  diverse  in  their  composition,  and  only 
serve  to  prove  that  human  digestion  can  at  times  be  tampered  with  with- 
out much  apparent  immediate  injury,  and  to  emphasize  the  {general  rule, 
that  the  chemistry  of  the  food  which  will  produce  the  best  average  result 
should  be  the  chemistry  of  human  milk. 

I  am  aware  that  Escherich  ^  has  announced  that  he  has  successfully  fed  a 
baby  ten  weeks  old  on  unmodified  cow's  milk  one  quart  per  day,  sterilized  ; 
but  it  is  only  necessary  to  refer  to  Analyses  VIII.,  IX.,  and  X.  on  page  284. 


'  Jahrb.  fiir  Kinderheilk.,  Oct.  1887. 


308  INFANT-FEEDING WEANING. 

to  show  that  sterilization  alone  is  not  sufficient  for  success,  which  statement 
indeed  is  merely  an  every-day  experience  of  those  who  clinically  have  much 
to  do  with  the  management  of  the  infant's  food.  The  milk  in  the  above- 
mentioned  Analyses  VIII.,  IX.,  and  X.,  being  directly  from  the  breast,  was 
certainly  sterile.  It  will  be  noticed  that  the  chief  difference  in  IX.  and  X. 
is  in  the  albuminoids.  The  infant  was  doing  perfectly  well  with  the  albu- 
minoids at  2.53.  The  nurse  was  fed  on  a  rich  diet,  and  the  infant  vomited 
curds  which,  so  far  as  could  be  judged,  were  identical  in  size  and  toughness 
with  the  thick  curd  of  undigested  cow's  milk.  The  analysis  then  showed 
the  albuminoids  4.61,  corresponding  to  the  percentage  of  cow's  rather  than 
woman's  milk.  The  vomiting  continued  until  the  woman  was  put  on  a  less 
nutritious  diet,  when  the  vomiting  ceased,  and  the  infant  continued  to  thrive 
on  the  milk  with  its  albuminoids  reduced  to  2.90. 

Before  speaking  of  the  various  modifications  of  cow's  milk  which  are 
necessary  to  make  it  correspond  to  human  milk,  it  will  be  well  to  say  a  few 
words  about  its  properties,  as  represented  in  Table  VIII. 

The  reaction  is  stated  to  be  slightly  acid ;  and  this  is  the  case  whether 
it  has  stood  twenty-four  hours  with  ordinary  care  or  whether  it  is  tested 
directly  from  the  udder.  This  I  have  determined  by  direct  experiment :  so 
that  practically  the  same  amount  of  modification  will  be  correct  for  the  first 
twenty-four  or  thirty-six  hours,  so  far  as  the  reaction  is  concerned. 

Of  the  total  nitrogenous  constituents  of  the  milk  which  are  classed 
under  the  general  term  of  albuminoids,  and  of  which  the  casein  and  the 
albumen  are  parts,  the  coagulable  albuminoids  are  proportionately  larger  in 
amount  in  cow's  milk  than  in  human  milk,  so  that  under  the  same  condi- 
tions a  larger  curd  will  be  formed  with  the  former  than  with  the  latter. 

In  conjunction  with  Dr.  Harrington  and  Dr.  Townsend,  I  have  recently 
made  some  careful  experiments  as  to  the  relative  coagulability  by  acids  of 
woman's  milk,  cow's  milk,  and  cow's  milk  diluted  with  lime-water  and 
barley-water  in  various  proportions.  The  coagulation  by  rennet  was  not 
found  to  be  a  satisfactory  or  reliable  test. 

Table  IX.  gives  the  results  of  these  experiments,  which  may  prove  to 
be  of  considerable  value. 

TABLE   IX. 

Equal  volumes  of  fluid  in  test-tubes.  Ten  drops  of  acetic  acid  added  to  each  test-tube. 
Each  test-tube  inverted  slowly  three  times,  so  as  to  insure  thorough,  equal,  and  uniform 
mixing  in  all. 

1.  "Woman's  milk No  curd  perceptible  to  the  eye. 

2.  Cow's  milk  raw Large  curds. 

3.  Cow's  milk  boiled Same  as  2. 

4.  Cow's  milk  sterilized  by  steam Same  as  2. 

5.  Cow's  milk 2    parts  |  pj^^^r  than  2. 

water 1    part    ) 

6.  Cow's  milk 2    parts  1   o  r 

^  .  I  Same  as  5. 

Lime-water 1    part    ) 

7.  Cow's  milk 2    parts  "I   qt  r, .i     ij        ,i        r      j  a 

,^  '  y  Slightly  finer  than  5  and  6. 

Water 1 J  parts  /       "      -^ 


INFANT-FEEDING WEANING.  309 

TABLE   IX.—Contmued. 

8-  CoWs  milk 2    parts  |  g^^^^  ^^  ^ 

Barley-water 1    part    J 

9-  Cow's  milk 1    part    |  Fj^^e,.  than  7  and  8. 

Water 4    parts  J 

10.  Cow's  milk 1    part 

Cream 2    parts 

Solution  of  milk-suo;ar,  1  oi*  ^  i     n        ^^        r. 

^,       >    .    .    6    parts   Y  A  very  fine  curd  ;  finer  than  9. 
18  drachms  to  the  pmt  ) 


Lime-water,  1 


parts 


Water,  3  / -    i^'    -  j 

11.  Cow's  milk 1    part    ")   r;  i  j  i.-vi    ^    ^u 

^  >  bame  as  1 ;  no  curd  perceptible  to  the  eye. 

^ater 5    parts  /  >  f       f  j 

When  a  few  drops  of  mercuric  nitrate  solution  were  added  to  woman's 
milk  and  to  cow's  milk  diluted  1  to  5,  a  fine  coagulum  was  produced  in 
the  woman's  milk  and  a  still  finer  one  in  the  cow's  milk. 

There  was  found  to  be  practically  no  difference  as  to  the  rapidity  of  the 
coagulation  of  the  different  fluids. 

Cow's  milk  taken  directly  from  the  udder  was  found  to  coagulate  in  just 
as  large  curds  as  when  twenty-four  hours  old. 

It  is  thus  seen  that  there  is  no  difference  in  the  coagulation  of  raw,  boiled, 
or  steamed  milk ;  also  that  practically  the  size  of  the  curd  depends  on  the 
dilution  of  the  albuminoids,  rather  than  on  any  especial  property  belonging 
to  the  substance  with  which  the  dilution  is  made.  AVith  lime-water  the 
result,  is  the  same  as  with  water  in  equal  amount,  and  barley-water  only 
shows  a  fractional  difference  from  the  results  with  plain  water. 

The  fat,  so  far  as  we  know,  is  both  in  amount  and  in  quality  the  same 
in  both  milks. 

The  albuminoids,  as  shown  in  the  table,  are  four  times  as  great  in  amount 
in  cow's  milk  as  in  woman's,  while  the  milk-sugar  holds  the  relation  of  7 
in  woman's  milk  to  4.5  in  cow's  milk.  The  ash,  on  the  contrary,  is  in 
woman's  milk  only  0.2,  while  in  cow's  milk  it  is  0.7. 

In  cow's  milk  as  commonly  used  for  food  we  must  recognize  the  presence 
of  bacteria. 

The  question  is  now  reduced  to  the  different  methods  employed  in 
modifying  cow's  milk..  This  may  be  done  by  diluting  it  with  water,  by 
concentrating  it  and  then  diluting  it  when  used,  or  it  may  be  modified  by  the 
various  patent  foods  or  by  any  other  adjuvant,  such  as  barley-water,  lime- 
water,  or  cream. 

In  order  to  ascertain  the  correctness  of  the  statement  so  oflen  made  that 
"  attenuants  act  mechanically  by  getting  as  it  were  between  the  particles  of 
the  coagulum  daring  coagulation  and  thus  preventing  tlieir  running  together 
and  forming  a  large  compact  mass,"  I  have  lately  experimented  as  follows 
with  various  substances. 

In  each  of  six  test-tubes  of  equal  calibre,  and  containing  5  cc.  of  hot 
water,  10  c  c.  of  milk  were  placed.     In  test-tubes  II.,  III.,  IV.,  V.,  and 


310 


INFANT-FEEDING WEANING. 


VI.  were  added  equal  portions  respectively  of  Melliu's  Food,  Robinson's 
Barley,  Imperial  Granum,  cracker-crumbs,  and  bread-crumbs.  The  albu- 
minoids were  then  coagulated  as  before  with  acetic  acid,  and  the  following 
results  were  obtained : 

Test-tube  I.  hot  water  and  milk, — finest  curd  of  all. 


II. 
III. 
IV. 

V. 
VI. 


and  Mellin's  Food, — not  so  fine  as  I. 
"    Eobinson's  Barley, — about  like  II. 
"    Imperial  Granum, — not  so  fine  as  II.  and  III. 
"    cracker-crumbs, — not  so  fine  as  IV. 
"    bread-crumbs, — not  so  fine  as  V. 


There  is  no  doubt  that  where  no  attenuant  was  added  the  curd  looked 
decidedly  finer,  while  where  attenuants  were  used  there  was  not  a  great  deal 
of  diiference  between  the  substances  employed,  except  the  possibly  rather 
larger  curd  according  as  the  attenuant  contained  a  larger  percentage  of 
starch. 

We  may  conclude,  then,  until  something  more  definite  is  known  con- 
cerning this  rather  theoretical  method  of  treating  the  curd,  that  dilution 
with  plain  water  is  the  most  practical  and  efficient  means  at  our  command. 

Table  X.  has  been  prepared  to  show  the  analysis  of  the  different  modifi- 
cations as  they  are  given  to  the  infant,  and  serve  as  a  reference  table  to  the 
physician,  who  by  this  means  can  readily  see  how  near  to  or  far  from  the 
standard  human  milk  he  is  getting  when  he  decides  to  use  one  of  these 


modifications  in  feeding. 


TABLE   X. 


Comparison  of  Wo?7ian's  Milk  with  Cow's  Milk  and  Cow's  Milk  tnodijied. 
(The  figures  are  approximate  and  represent  general  averages.) 


Reac- 
tion. 

Starch. 

w.^pT,    Total 

Fat. 

Albu- 
min- 
oids. 

StTGAR. 

Ash. 

Woman's  milk .    .    .    .    > 

Slightly 
alkaline. 

0 

88 

12 

3-4 

1-2 

7 

0.1-2 

Cow's  milk I 

Slightly 
acid. 

0 

86.8 

13.2 

4 

4 

4.5 

0.7 

Cow's  milk,  2  parts  .    .   \ 
Water,  1  part    .    .    .    .   j 

Slightly 
acid. 

0 

91.20 

8.80 

2.67 

2.67 

3 

0.46 

Cow's  milk,  1  part  .    .   \ 
Water,  1  part    .    .    .    .    | 

Slightly 
acid. 

0 

93.40 

6.60 

2 

2 

2.25 

0.35 

Cow's  milk,  1  part  .    .   \ 
Water,  2  parts  .    .    .    .    ( 
Cow's  milk,  1  part  .    .   \ 
Water,  4  parts  .    .    .    .   j 
Condensed  milk    .... 

Slightly 
acid. 

Slightly 
acid. 

Neutral. 

0 

0 
0 

95.60 

97.36 

28 

4.40 

2.64 

72 

L33 

0.8 
10 

1.33 

0.8 
10 

1.50 

0.9 
50 

0.23 

0.14 
2.0 

Condensed  milk,  1  part^  1 
Water,  9  parts  .    ,    .    .   / 

Neutral. 

0 

90.31 

9.69 

1.35 

1.35 

6.73 

0.26 

Condensed  milk,  1  part^  \ 
Water,  15  parts    .    .    .   j 
Loefland's        sterilized  \ 

milk / 

Loefland's        sterilized  \ 

Neutral. 
Acid. 

0 
0 

93.92 

62.87 

6.08 
37.13 

0.83 
10.85 

0.83 
10.27 

4.35 
13.78 

0.17 
2.23 

milk,  1  parti                 l 

Acid. 

0 

94.02 

5.98 

1.75 

1.65 

2.22 

0.36 

Water,  6  parts  ....  J 

1  By  volume. 


INFANT-FEEDING WEANING. 


311 


TABLE   X. — Continued. 


Nestle' s  Food. 

Fat  ...    .      1.911 
Albuminoids    8.23 
Su^ar  .    .    .    38.92  -    1 
Ash  ....      1.59 
Starch  .    .    .    40.10 
Water 10 

Imperial  Granum. 

Fat  ...    .      1.01]       1 
Albuminoids  10.51 
Sugar  .    .    .    trace 
Ash  ...    .      1.16 
Starch  .    .    .    78.93 

Milk '32 

Water 64 


Reac- 
tion. 


Neutral. 


99 


MelUn's  Food. 


Fat  ...  .  0.15 
Albuminoids  5.95 
Sugar  .  .  .  48.20 
Ash  ....  1.89 
Starch  .    .  present. 

Milk '48 

Water 48 

99 


Carnrick's  Soluble  Food. 

Fat  ....  5.001 
Albuminoids  18.22 
Dextrin  .  .  67.74 
Water  .  .  .  6.14 
Ash  ...  .  2.99 
Water 96 


Starch. 


3.65 


Slightly 
acid. 


Slightly 
acid. 


99 


Barley-  Water. 


As    usually    made "] 
with   Robinson's  | 
Barley,  contains  V    1 
starch  1.4.  J 

Milk 2 


Neutral 


2.36 


91.75 


Tot  A  I, 
Solids. 


8.25 


92.88 


Present. 


Acid. 


Unchanged 
starch  is 
present  to'  a 
very  consid- 
erable ex- 
tent. (Dex- 
trin 2  p.  c. 
claimed  by 
the  makers.) 


0.47 


91.74 


.12 


8.26 


Biederfs  Cream  Mixture. 
(for  infant  of  3  months). 
Cream  .    .    .51 


Milk 

Water  .    .    .  ^-, 

Milk-sugar  .  3;  1 


.53 


J. 


Acid. 


97.22 


90.75 


91.56 


2.78 


9.25 


8.44 


Fat. 


o.r 


Albxt- 

MIN  - 

cms. 


0.03 
1.33 


1.36 


0.004 
2.0 


2.004 


2.66 


2.7 


Sugar. 


0.75 


0.31 
1.33 

1.64 


0.17 
2.00 

2.17 


3.54 


Ash. 


0.14 


Trace. 
1.5 

1.5 


0.15      0.54 


2.66 


1.8 


1.44 

2.25 

3.69 


3.0 


3.8 


0.03 
0.23 

0.26 


0.05 
0.35 

0.4 


0.09 


0.46 


0.14 


312 


INFANT-FEEDING — WEANING. 


TABLE   X.— Continued. 


52 


Meigs  Mixture. 
Cream   (14  to  16  \ 
per  cent,  fat) .  j 

Milk 

Lime-water    .    .    . 
Sugar- water : 
Milk-sugar, 

Pi  17|. 
"Water,  1  pint.  J 


S8J 

Mixture  recommended.^ 

Cream  (centrifu-T 

gal  cream,  20.1 

per    cent,    fat  [ 

diluted  4^or^).  J 

Milk 

Lime-water  (di-  "t 

luted  I).  i 

Milk-sugar  .53|\ 
Water     ..53/ 


§1 

"9  ^ 


58J 


Reac- 
tion. 


Strongly 
alkaline. 


Slightly- 
alkaline. 


Starch. 


Water. 


^.35 


Total 

SOIJDS. 


11.62 


11.58 


3.. 50 


Albu- 
min- 
oids. 


1.21 


1.11 


Sugar. 


6.66 


6.26 


Ash. 


0.25 


0.21 


1  The  figures  in  this  case  were  ohtained  by  actual  analysis  of  a  mixture  as  made  by  one  of  my 
patients  from  the  ordinary  milk  and  cream  supply. 

Note. — To  prepare  1  pint  of  food  for  use  in  24  hours :  take  milk  and  cream  (20  per 
cent.)  as  soon  as  it  comes  in  the  morning,  and  mix  as  follows : 

.  Milk,     I  2  ; 
Cream,  ^^  3 ; 
Water,  5  10 ; 
Milk-sugar,  2  measures. 
Place  in  flask  in  -steamer  and  steam  for  twenty  minutes ;  then  remove  the  flask  from 
the  steamer  and  when  still  slightly  warm  add  lime-water  5  1 ;  place  on  ice,  and  give  the 
proper  amount  at  the  proper  feeding-times. 

In  considering  the  preparation  of  the  various  foods  with  reference  to 
making  them  correspond  in  their  analyses  as  nearly  as  possible  to  human 
milk,  the  question  is  somewhat  simplified  if  we  recognize  the  fact  that 
although  the  percentages  of  the  ingredients  of  human  milk  vary  under  cer- 
tain circumstances,  yet,  as  has  already  been  explained  in  an  earlier  part  of 
this  paper,  so  far  as  the  age  is  concerned,  in  the  early  months  there  is  so 
little  difference  that  a  variation  is  as  likely  to  occur  between  different  milks 
of  the  same  age  as  in  the  same  milk  at  different  ages,  so  that  we  probably 
are  doing  wisely  not  to  change  the  percentage  of  the  ingredients,  but  as 
the  infant  grows  older  give  a  food  qualitatively  uniform,  but  of  varying 
quantity. 

It  will  at  once  be  seen  by  referring  to  Table  X.  that  no  matter  how  cow's 
milk  is  diluted  it  cannot  be  made  by  dilution  alone  to  correspond  to  human 
milk.     It  is  well,  however,  to  remember  that  clinical  experience  has  shown 


INFANT-FEEDING WEANING.  313 

that  infants  seem,  even  in  the  early  clays  of  life,  to  digest  the  albuminoids 
well  enough,  provided  that  they  are  sufficiently  diluted, — that  is,  about  four 
times,  which  reduces  them  to  one  per  cent. ;  and  this  will  be  of  significance 
when  we  come  to  prepare  a  food  ^^'hich  shall  correspond  to  human  milk. 
If,  however,  we  reduce  cow's  milk  so  that  the  percentage  of  albuminoids  is 
one,  the  fat  and  sugar  fall  so  far  below  the  standard  that,  although  the  ash 
has  the  proper  percentage,  yet  we  have  an  acid  food  markedly  deficient  in 
its  nutritive  quality  and  with  its  total  solids  represented  by  3.25  instead 
of  12. 

There  is  a  very  large  number  of  patent  foods,  but  they  all  claim  about 
the  same  advantages,  and  closely  resemble  one  another  in  their  constituents, 
and  in  their  endeavor  to  make  cow's  milk  easily  digestible,  and  also  to  make 
their  resulting  analysis  agree  as  closely  as  possible  with  that  of  human  milk. 
There  are,  however,  certain  differences  by  Avhicli  we  can  divide  them  into 
classes,  and  we  can  speak  of  individual  foods  as  representing  their  class, 
and  thus  illustrate  the  composition  of  all  foods  which  have  so  far  been 
devised  for  infant-feeding. 

My  own  opinion  in  regard  to  patent  foods,  as  a  whole,  is  that  they  must 
necessarily  be  unreliable ;  they  are  thrown  on  the  market  in  such  numbers 
that  the  competition  is  extreme,  and  when  ance  they  have  made  a  reputation 
I  cannot  but  feel  that  irregularities  and  changes,  slight,  perhaps,  in  the  eyes 
of  the  makers,  may  unintentionally  creep  in  and  carry  their  composition 
still  further  from  that  of  the  standard  human  milk. 

Analyses  show  that  there  is  a  lack  of  uniformity  from  year  to  year,  and 
that  original  claims  are  apparently  forgotten  or  are  allowed  to  give  way  to 
cheaper  production.  In  fact,  as  my  experience  in  the  feeding  of  infants 
increases,  and  as  I  examine  year  by  year  the  different  foods,  old  and  new, 
as  they  are  actually  given  by  myself  and  others,  I  am  strongly  impressed 
with  the  belief  that,  with  our  present  physiological,  chemical,  and  clinical 
knowledge,  all  the  patent  foods  are  entirely  unnecessary.  Their  claims  are 
not  supported  by  intelligent  and  unprejudiced  investigation.  Their  manu- 
facturers are  not  in  a  position  to  judge  correctly  concerning  them.  The 
merit  of  their,  at  times,  apparent  success  does  not  belong  to  them,  but  to 
other  accompanying  circumstances.  They  do  great  harm  by  impressing 
upon  the  public  that  a  cheap,  easily-prepared  food  is  being  manufactured 
for  the  good  of  the  infant  and  is  better  than  anything  that  can  be  pro- 
cured elsewhere.  They  vary  too  greatly  in  their  analyses  to  keep  even 
within  the  acknowledged  varying  limits  of  human  milk. 

It  is  high  time  for  us,  as  physicians,  to  appreciate  exactly  how  inefficient 
in  themselves  and  how  misleading  in  their  claims  are  these  artificial  foods, 
and  also  in  what  a  false  position,  as  protectors  of  and  advisers  to  the  public, 
we  are  placed  in  doing  anything  but  ignoring  them.  They  have  a  place  in 
this  article  simply  because  there  is  no  d()ul)t  that  they  are  kept  in  the  market 
by  the  physician  rather  than  by  the  manufacturer.  The  latter  is  only  doing 
what  any  capitalist  interested  in  a  business  venture  would  do.     The  former, 


314  INFANT-FEEDING WEANING. 

it  seems  to  me,  is  acting  somewhat  blindly,  and  is  unintentionally  aiding 
the  business  interests  of  others  at  the  expense  of  his  own  future  reputation 
as  a  scientist,  and  of  his  ability  for  adapting  the  truths  presented  to  him  by 
physiology  and  chemistry  to  his  clinical  every-day  practice  among  infants. 
It  makes  but  little  difference  to  us  as  physicians  as  to  what  these  foods  are 
claimed  to  contain  when  put  on  the  market.  It  makes  a  great  deal  of 
difference  to  us  what  the  mixture  contains  when  given  by  the  mother  to  the 
infant  according  to  the  directions  on  the  label.  For  instance,  a  food  may 
show  by  its  analysis  a  fair  percentage  of  fat  or  sugar,  and  the  analyst  may 
state  this  in  an  article  on  the  results  of  his  investigations  or  in  a  report  to 
the  manufacturer,  and  yet  this  same  food  when  diluted  for  the  infant's 
feeding  may  have  these  constituents  reduced  far  below  the  reasonable  limits 
of  nutrition. 

I  repeat  that  I  am  about  to  mention  certain  representatives  of  the 
different  classes  of  patent  foods,  merely  to  furnish  the  practising  physician 
with  a  ready  means  of  seeing  at  a  glance  exactly  what  he  is  giving  when  he 
uses  these  foods,  and  not  because  I  consider  that  their  mention  will  be  of 
any  direct  benefit  to  the  subject  of  infant-feeding. 

I  have  already  published  in  the  Archives  of  Pediati^ics  (August,  1887) 
part  of  Table  X.,  and  I  would  here  state  that  in  the  figures  for  diluted 
condensed  milk  in  that  article  a  correction  should  in  justice  be  added  to 
each  calculation,  on  account  of  the  greater  specific  gravity  of  condensed 
milk  (the  mixture  being  made  by  volume),  while  tlie  other  foods  on  account 
of  a  lower  specific  gravity  have  their  percentage  rated  somewhat  higher 
than  they  really  deserve. 

An  examination  of  Table  X.  will  at  once  show  how  all  of  these  foods, 
when  prepared  for  and  given  to  the  infant,  widely  differ  from  the  standard 
food,  woman's  milk,  which  is  represented  in  the  upper  line  of  the  table ;  it 
will  also  explain  how  difficult  it  is  to  make  the  artificial  foods  correspond 
to  human  milk  by  the  methods  which  are  usually  employed,  and  also  the 
errors  in  percentage  which  result  from  these  methods ;  it  is,  in  fact,  a  series 
of  figures  which  represent  the  element  of  nutrition  rather  than  of  digestion, 
and  the  merits  of  every  food  should  be  determined  in  this  way  before  sub- 
mitting it  to  the  test  of  clinical  experience,  for  our  common  sense  must 
certainly  be  better  satisfied  if  we  know  not  only  that  the  infant  is  digesting 
the  food,  but  also  that  the  food  itself  is  similar  (or  as  nearly  so  as  we  can 
make  it)  in  its  proportions,  ingredients,  and  reaction  to  the  standard  which, 
in  its  results,  shows  the  lowest  rate  of  mortality. 

The  patent  foods  can  practically  be  divided  into — first,  those  which  are 
manufactured  from  cow's  milk  modified  by  cereals,  and,  secondly,  those 
which  are  not.  The  first  class  contains  the  starch  of  the  cereal  unchanged, 
or  converted  either  into  dextrin  or  glucose. 

We  can  take  as  examples  of  the  different  classes  of  patent  foods  especial 
foods  which  will  represent  large  numbers  of  other  foods  so  far  as  illustrating 
their  good  or  bad  qualities  is  concerned.     We  have,  then, — 


INFANT-FEEDING WEANING.  315 

I.  Condensed  milk  with  the  addition  of  about  fifty  per  cent,  of  cane- 
sugar  ;  represented  by  "  Anglo-Swiss  Condensed  Milk." 

II.  Condensed  milk  without  anything  added  to  it,  simply  cow's  milk 
evaporated  to  one-fourth  of  its  volume  and  then  sterilized ;  represented  by 
"  Loefland's  Sterilized  Milk." 

III.  Peptonized  milk. 

IV.  Condensed  milk  mixed  with  a  cereal  and  its  starch  unchanged ; 
represented  by  "  Nestle's  Food." 

V.  A  cereal  food  with  its  starch  converted  into  glucose ;  represented  by 
"  Mellin's  Food." 

VI.  Equal  parts  of  powdered  milk  and  wheat,  the  milk  partially  pep- 
tonized and  the  starch  converted  into  soluble  starch  and  dextrin ;  represented 
by  "  Carnrick's  Food." 

In  making  this  division  of  the  foods,  and  in  discussing  their  analyses, 
I  do  not  here  enter  into  the  question  of  whether  these  especial  analyses 
are  correct.  They  are  taken  directly  from  the  advertisements  of  the  foods 
themselves,  and  the  directions  for  preparing  each  food  are  taken  from  its 
own  printed  labels  and  circulars. 

Condensed  milk  represents,  in  its  production,  its  chemistry,  and  its  clin- 
ical results,  a  very  fair  illustration  of  what  has  been  said  on  the  subject  of 
patent  foods.  It  has  strong  advocates  and  strong  opponents,  but  a  simple 
consideration  of  its  vital  properties  will  easily  explain  its  successes  and  its 
failures.  It  is  a  preparation  which  varies  greatly  in  its  composition,  at  times 
being  a  mixture  which  has  evidently  been  made  from  skimmed  milk.  Con- 
densed milk  is  not  a  sterile  food,  which  might  be  supposed  from  the  process 
of  its  manufacture  to  be  the  case,  cultures  having  been  made  directly  from 
the  can  by  both  Gautier^  and  Jeffries.^  Any  food,  however,  which  is  mixed 
with  water  would  at  any  rate  have  to  be  resterilized  when  mixed  for  the 
infant's  use.  In  Table  X.  the  percentage  of  the  ingredients  of  condensed 
milk — when  diluted,  as  it  commonly  is,  nine  times — is  given,  and  we  at 
once  see  why  it  is  easily  digested  but  non-nutritious,  for  the  albuminoids, 
ash,  and  sugar  have  been  reduced  to  the  proper  amount,  but  the  fat  is  far 
from  attaining  the  proper  percentage. 

When  again,  as  seen  also  in  the  table,  and  as  is  very  often  done  by  phy- 
sicians, the  dilution  is  made  fifteen,  all  the  ingredients  excepting  the  ash 
are  so  far  reduced  below  a  reasonably  nutritious  food  that  we  can  well 
understand  the  bad  results  which  have  so  often  been  reported  concerning 
condensed-milk-fed  infants. 

The  large  amount  of  cane-sugar  used  in  preserving  condensed  milk  is  a 
point  rather  against  than  in  favor  of  this  preparation,  and  will  be  referred 
to  later,  in  discussing  the  proper  kind  of  sugar  which  should  be  put  into  an 
artificial  food. 


1  Semaine  Medicale,  1887,  20. 

2  Amer.  Jour,  of  the  Med.  Sciences.  May,  1888. 


316  IXFAXT-FEEDIXG WEAXIXG. 

Clinically,  then,  condensed  milk  represents  a  food  easily  digested  but  not 
sufficiently  nutritious  :  the  former  explained  by  its  low  percentage  of  albu- 
minoids and  ash,  its  neutral  reaction,  its  antiferment  properties,  and  its 
proper  percentage  of  sugar ;  the  latter,  by  'its  great  lack  of  fat.  Among 
the  poorer  classes  and  in  infant  asylums  it  is  a  fav^orite  food  for  the  physi- 
cian to  prescribe,  because  the  infants  digest  it  so  easily ;  but  the  testimony 
of  those  clinical  observers  who  look  beyond  the  temporary  digestion  to  the 
subsequent  nutrition  of  the  child  supports  the  view  that  condensed  milk, 
even  if  we  set  aside  the  objections  to  which  all  patent  foods  are  subject, 
must  be  modified  by  more  than  the  addition  of  water  before  it  can  safely  be 
given  as  a  continuous  food  to  the  average  infant.  For  preparing  the  way 
for  other  more  nutritious  foods  in  cases  of  difficult  digestion,  for  conve- 
nience in  travelling,  and  where  for  any  reason  the  intelligence  or  the  proper 
desire  to  take  trouble  about  the  food  is  lacking  in  the  parents,  condensed 
milk,  from  its  simplicity  in  preparation  as  well  as  from  its  other  attributes 
mentioned  above,  is  a  valuable  addition  to  other  more  rational  methods 
of  artificial  feeding.  The  commonly  accepted  opinion  that  condensed  milk 
contains  too  much  sugar  is  an  error,  for  by  referring  to  the  table  it  will  be 
seen  that,  as  usually  given,  the  sugar  in  the  mixture  is  below  the  proper 
percentage,  and  we  have  merely  the  fat  to  deal  with,  and  the  reaction,  which 
should  be  made  alkaline.  We  must,  then,  modify  this  condensed-milk  mix- 
ture ;  and  not  only  is  the  fat  an  important  part  of  this  modification,  but  the 
proper  amount  of  fat ;  for,  although  it  is  admitted  that  a  large  percentage 
of  surplus  fat  is  frequently  found  in  the  fseces  of  infants  whose  digestion 
and  nutrition  are  normal  and  whose  food  is  breast -milk,  yet  we  have  no 
more  right  to  conclude  from  this  that  a  small  percentage  of  fat  is  sufficient 
for  nutrition,  or  that  a  large  percentage  will  be  taken  care  of  by  this  outlet, 
than  we  have  to  assume  that  there  is  too  much  oxygen  in  the  blood  because 
we  find  that  a  certain  surplus  of  oxygen  is  found  in  the  arterial  blood  and 
returned  to  the  lungs  in  the  pulmonary  veins.  In  fact,  it  is  far  more  prob- 
able that  nature  introduces  a  certain  percentage  of  fat  into  human  milk  with 
a  purpose  which  can  only  be  accomplished  by  that  percentage,  and  that  it 
is  an  error  to  vary  this  percentage  beyond  the  variation  which  commonly 
occurs  in  average  human  milk. 

The  production  of  animal  heat  is  so  very  important  a  part  of  the 
young  infant's  well-being  that  it  is  not  surprising  that  we  should  find  so 
large  a  percentage  of  fat  and  sugar  in  the  food  which  is  provided  for  it. 
AVe  should  remember  also  that,  while  the  sugar  is  the  more  digestible  of  the 
two,  the  fat  contains  more  potential  energy  (that  is,  heat-producing  power), 
in  a  given  weight,  than  the  sugar,  and  that  its  presence  in  the  milk  is  not 
only  for  the  purpose  of  nutrition,  but  also  as  a  means  for  the  maintenance 
of  the  bodily  heat.  This  function  of  the  fat  cannot  with  impunity  be 
trifled  with,  and  is  essential  for  that  active  metabolism  spoken  of  in  an  ear- 
lier part  of  this  paper,  with  its  corresponding  rapid  increase  in  gro^^'th,  so 
well  exemplified  in  the  very  organ,  the  stomach,  which  receives  this  heat- 


IXFAXT-FEEDIXG WEANIXG.  317 

producing  food.  A  proper  amount  of  fat  is  prol)ably  of  great  aid  in  the 
regulation  of  the  fsecal  discharges.  From  what  has  been  said  above,  we 
should  naturally  expect  that  unless  the  standard  percentage  of  fat  was 
attained,  or  at  least  a  near  approach  to  it,  trouble  would  be  likelv  to  arise  • 
and  tliis  corresponds  to  my  individual  experience  in  the  cases  where  the 
especial  ingredient  Avhich  was  disturbing  the  success  of  the  food  was  the 
fat.  I  have  found  clinically  that  under  the  proper  percentage  of  fat  the 
nutrition  suffers,  the  digestion  is  not  so  good,  and  there  is  a  tendency  to 
constipation,  while  where  the  fat  percentage  is  decidedly  above  the  standard 
the  digestion  is  verv  much  affected,  there  is  a  tendency  to  diarrhoea,  and  in 
consequence  a  resulting  poor  nutrition. 

Unless,  then,  it  is  impossible  to  be  more  exact  in  arranging  the  percent- 
age of  fat  in  condensed  milk,  as  is  often  the  case  among  the  poorer  classes, 
where  cod-liver  oil  is  used  as  a  cheap  expedient  for  rectifying  this  source  of 
error,  the  addition  of  indefinite  amounts  of  fat  to  a  food  is  to  be  deprecated, 
just  as  it  is  unwise  to  add  indefinite  amounts  of  sugar,  and  we  should  seek 
for  a  better  combination  than  is  offered  to  us  in  condensed  milk. 

It  is,  however,  practically  a  very  simple  matter  to  increase  the  percentage 
of  fat  in  a  mixture  such  as  condensed  milk  and  water,  by  means  of  the 
proper  amount  of  cream  of  a  given  fat  percentage,  such  as  will  be  explained 
later.  Thus,  by  referring  in  Table  X.  to  condensed  milk  diluted  nine  times, 
we  see  that  in  one  hundred  parts  of  such  a  mixture  there  is  only  1.35  per 
cent,  of  fat,  and  to  raise  this  percentage  to  the  proper  4  per  cent,  w^e  must 
add  sufficient  20-per-cent.  cream  to  make  up  2.65  per  cent,  of  fat  in  the 
condensed-milk  mixture  :  this  is  easily  done  by  the  rule  of  three  : 

100  parts  cream  (20  p.  c.)  :  20  : :  a;  :  2.65. 
20  a;  =  265.     a'=  13j  c.c.  of  cream  to  be  added  to  each  100  cc.  of  con- 
densed milk  diluted  nine  times :  this,  practically,  is  about  one  drachm  to 
every  ounce. 

The  second  kind  of  condensed  milk,  represented  in  the  table  under  the 
name  of  "  Loefland's  Sterilized  Milk,"  must  be  diluted  ten  times  in  order 
that  the  albuminoids  should  be  brought  within  proper  limits  for  digestion. 
This  reduces  the  total  solids,  fat,  and  sugar  to  such  a  minimum  percentage 
that  for  purposes  of  nutrition  a  considerable  amount  of  modification  would 
be  needed,  and  quite  as  much  as  for  fresh  cow's  milk. 

Peptonized  milk  is  cow's  milk  with  its  albuminoids  partially  or  entirely 
predigested  by  means  of  the  extract  of  pancreas  and  soda.  Now,  there  is  no 
doubt  that  the  albuminoids  of  cow's  milk  have  been  a  source  of  trouble  to  the 
infant's  digestive  apparatus,  and  under  certain  circumstances  can  with  great 
benefit  to  the  infant's  digestion  be  treated  by  predigesting  them  for  a  time  and 
thus  allowing  a  stomach  which  otlierwisc  digests  well  to  rest  and  recover 
itself.  It  is  of  use,  also,  where  a  decided  idiosyncrasy  of  the  individual 
precludes  the  digestion  of  these  ingredients  of  the  milk ;  but,  besides  that, 
the  indigestion  is  often  attributed  to  the  lack  of  power  to  digest  albuminoids 
at  all,  while  in  fact  the  stomach  is  simply  rebelling  against  an  amount  of 


318  INFANT-FEEDING ^WEANING. 

albuminoids  above  the  standard  percentage,  or  against  some  other  ingredient. 
It  would  seem  that,  for  the  average  infant  digestion,  this  predigesting  of  the 
albuminoids  or  any  other  constituent  of  the  milk  is  contrary  to  nature's  teach- 
ing. There  are  certain  natural  functions  which  should  be  allowed  to  act  as 
they  do  on  human  milk,  and  it  seems  irrational  and  contrary  to  the  laws  of 
physiology  not  to  encourage  all  the  functions  to  act  naturally,  each  in  its 
own  province,  instead  of  forestalling  their  action  and  allowing  them  to  fall 
into  disuse  and  thus  be  weakened.  The  baby's  stomach  is  intended  to  digest 
albuminoids,  and  not  to  have  the  albuminoids  digested  for  it.  Clinically, 
also,  the  use  of  peptonized  milk  supports  this  view,  for,  so  far  as  I  know,  no 
very  brilliant  results  have  been  obtained  from  its  use.  Peptonized  milk, 
then,  is  a  food  consisting  of  too  large  an  amount  of  digested  albuminoids, 
too  little  sugar,  and  a  very  large  over-proportion  of  ash. 

Any  food  which  introduces  an  element  foreign  to  the  ingredients  of 
human  milk  is  to  be  looked  upon  with  suspicion,  as  it  is  not  likely  that  we 
can  improve  on  nature's  method  of  adapting  the  food  to  the  infant's  digestive 
functions  :  we  should  therefore  consider  carefully  before  recommending  the 
various  classes  of  food  which  contain  starch,  which  by  referring  to  Table 
X.  will  be  seen  to  be  the  foreign  element  which  enters  into  the  represen- 
tative patent  cow's-milk  modifications, — Trestle's  Food,  Imperial  Granum, 
and  Carnrick's  Food.  As  has  already  been  said,  it  is  not  merely  neces- 
sary to  know  the  percentages  of  the  different  ingredients  as  they  occur  in 
the  printed  analysis  of  the  especial  food ;  to  us  the  important  question  is, 
what,  as  shown  in  the  table,  are  the  sums  total  of  cow's-milk  percentages 
and  the  patent  modification  percentages,  these  sums  total  being  what  the 
infant  receives.  Judged  by  this  standard,  ISTestle's  Food  provides  a. larger 
amount  of  starch  for  the  infant's  digestion  than  the  other  foods,  almost 
one-third  less  total  solids  than  woman's  milk,  practically  no  fat,  too  little 
albuminoids,  one-half  too  little  sugar,  and  a  fair  percentage  of  ash.  A 
mere  glance  at  the  figures  in  the  table  then  tells  us  whether  we  have  an 
easily  digestible  and  nutritious  food  to  deal  with.  For  instance,  the  success 
of  Imperial  Granum  is  evidently  in  its  correct  percentage  of  albuminoids 
and  ash  making  it  easily  digestible,  but  its  failures  are  readily  explained  by 
its  reaction,  its  foreign  ingredient,  and  its  very  low  percentage  of  fat  and 
sugar. 

Reference  has  been  made  above  to  the  capability  shown  by  even  very 
young  infants  to  digest  the  albuminoids  of  cow's  milk  when  it  is  reduced  to 
one  or  two  per  cent. ;  and  this  is  a  factor  which  probably  enters  to  a  greater 
degree  than  is  usually  recognized  into  the  easy  digestion  of  these  foods,  and 
possibly  too  much  credit  has  been  given  to  the  starch  as  a  means  of  making 
the  albuminoids  more  digestible.  At  any  rate,  it  is  a  question  worth  con- 
sideration, for  it  certainly  is  more  rational  not  to  introduce  a  foreign 
ingredient  like  starch  into  the  food  if  we  can  make  it  digestible  in  some 
other  way.  Examining  this  question  of  albuminoid  percentage  in  the  three 
large  classes  of  patent  foods  represented  in  Table  X.,  we  find  Imperial 


INFANT-FEEDIXG — WEANING.  31 9 

Graniim  1.64,  Melliii's  Food  2.17,  and  Nestle's  Food  0.74.  Now,  all  these 
correspond  very  closely  to  the  albLimiiioid  percentage  of  human  milk,  that 
of  Mellin's  Food  psrhaps  being  rather  high,  and  all  these  foods  are  found 
to  be  easily  digestible ;  so  also  where  barley-water  is  mixed  in  the  usual 
way  with  milk,  one  to  two,  the  albuminoids  of  the  resulting  mixture  are 
notably  diminished  in  amount  and  naturally  are  more  easily  digested  than 
when  they  stand  at  a  higher  percentage,  as  in  cow's  milk  undiluted.  This 
has  already  been  shown  in  Table  IX.,  where  the  question  of  the  beneficial 
effect  of  the  starch  itself  on  the  albuminoids  is  seen  to  be  somewhat  prob- 
lematical. This  brings  us  at  once  to  the  consideration  of  whether  starch 
should  be  made  a  part  of  the  infant's  food.  Physiologically,  we  know  that 
during;  the  first  ten  or  twelve  months  of  life  the  function  of  convertino- 
starch  into  sugar  is  in  the  process  of  development.  It  is  also  known  that 
a  partial  conversion  of  the  starch  can  be  performed  at  quite  an  early  age, 
and  by  exceptional  cases  to  a  much  greater  extent  than  by  the  average 
infant.  But,  besides  the  well-known  fact  that  the  presence  of  a  function 
does  not  necessarily  mean  that  it  must  be  used,  it  is  also  rational  to  suppose 
that  when  a  function  is  being  developed  it  should  not  be  taxed  with  a  trial 
of  the  use  which  will  later  be  demanded  of  it.  That  is,  a  function  develops 
more  perfectly  if  its  power  is  not  too  early  exerted  to  its  utmost.  With 
these  facts  before  us,  we  judge,  as  indeed  we  could  also  do  without  them  by 
simply  referring  to  the  best  known  food  for  infants,  woman's  milk,  that 
starch  should  not  form  a  part  of  the  infant's  artificial  food.  Although  it 
may  perhaps  not  be  of  a  great  deal  of  significance  in  connection  with  this 
discussion  of  starch,  I  might  mention  that  I  have  had  a  number  of  infants 
in  the  early  months  of  life  fed  for  twenty- four  hours  entirely  on  the  prepa- 
ration of  barley-water  represented  in  Table  X.,  and  in  every  case,  except 
one,  starch  was  found  in  the  faeces ;  and  this  will  be  of  considerable  interest 
when  we  consider  that  the  very  low  percentage  (0.47)  of  starch  in  the  mix- 
ture does  not  provide  much  material  for  conversion  into  sugar. 

The  especial  merit  which  is  claimed  for  the  next  representative  patent 
modification  of  cow's  milk  on  page  315,  No.  V.  (Mellin's  Food),  is  that 
it  contains  almost  fifty  per  cent,  of  converted  starch :  the  manufacturers, 
recognizing  that  starch  is  not  a  proper  ingredient  physiologically  for  an 
infant's  food,  have  had  this  starch  converted  into  glucose.  It  is  difficult  to 
understand  why,  except  perhaps  for  financial  reasons,  expensive  machinery 
should  be  made  for  the  workino-  of  a  material  which  should  not  exist  in  an 
infant's  food,  and  for  the  purpose  of  chemically  converting  this  into  sugar, 
which  might  as  such  be  directly  added  to  the  food  in  the  beginning.  In 
addition  to  this,  the  resulting  sugar  is  glucose,  whicli  is  not  the  sugar  of 
woman's  milk,  l)ut  the  final  product  of  the  milk-sugar  digestion  ;  and  thus 
again  tlie  natural  function  of  converting  milk-sugar  into  glucose  is  allowed 
to  fall  into  disuse,  which  is  objectionable,  just  as  in  peptonized  milk  such 
disuse  of  a  function  is  unwise. 

Referring  to  the  table,  we  next  see  that  the  percentages  in  the  mixtures 


320  INFANT-FEEDING WEANING. 

which  are  derived  from  Mellin's  Food  itself  are  exceedingly  insignificant, 
the  fat  being  inappreciable,  the  albuminoids  so  low  as  to  be  of  little  value 
for  nutrition,  the  ash  only  half  the  amount  of  the  smaller  figure  represent- 
ing woman's  ash,  and  even  the  sugar  being  only  about  one-fifth  as  large  in 
amount  as  in  woman's  milk.  The  resulting  percentages  where  the  cow's 
milk  has  been  added  give  us  a  mixture  containing  one-half  too  little  fat,  a 
somewhat  too  high  amount  of  albuminoids,  almost  one-half  too  little  sugar, 
and  an  ash  just  double  the  highest  figure  representing  the  ash  percentage  in 
woman's  milk.  It  will  be  noticed  that  starch  is  entered  in  the  table  as 
present,  though  it  is  claimed  to  be  entirely  converted  into  sugar.  This 
starch,  as  found  by  Dr.  Harrington  in  a  number  of  different  specimens, 
though  perfectly  appreciable  was  not  sufficient  in  amount  to  be  of  any  great 
importance.  Cow's  milk  being  acid,  we  should  naturally  expect  to  find  the 
resulting  mixture  with  any  of  these  foods  acid ;  and  this,  as  seen  in  the 
table,  is  the  case. 

The  next  patent  modification  of  cow's  milk,  Carnrick's  Food,  is  not 
assisted  in  its  nutritive  properties  by  additional  cow's  milk,  and  conse- 
quently presents  by  its  own  analysis  a  mixture  which  practically  amounts 
to  a  two-per-cent.  solution  of  dextrin  and  water.  Fifty  per  cent,  of  a  cereal 
has  been  introduced  in  the  food,  and  it  is  claimed  that  its  starch  is  imme- 
diately converted  into  dextrin.  By  this  procedure  the  infant's  undeveloped 
function  is  called  upon  to  exercise  its  power  many  months  before  nature  has 
intended  it  to  be  used.  The  reverse  of  this,  the  allowing  a  developed 
function  to  fall  into  disuse  by  having  its  work  done  for  it,  might  be  said  to 
occur  in  the  predigesting  of  the  albuminoids ;  but  the  table  shows  us  that 
there  is  only  about  one-half  per  cent,  of  these  albuminoids  left  by  the  dilu- 
tion to  digest.  The  manufacturers  claim  in  their  circular  that  in  the  process 
used  by  them  the  starch  is  first  converted  into  soluble  starch  and  then  into 
dextrin ;  but  careful  examination  by  Dr.  Harrington  has  shown  that  a  very 
great  proportion  of  the  starch  is  unchanged  and  insoluble,  and  that  the 
great  bulk  of  the  food  is  not  capable  of  solution.  The  name,  therefore,  of 
"  Soluble  Food"  is  a  misnomer. 

The  total  solids,  when  prepared  according  to  direction,  outside  of  the 
"dextrin"  percentage,  are  represented  by  0.77 ;  the  fat  is  scarcely  appre- 
ciable, the  ash  slightly  under  the  lowest  figure  representing  woman's  ash. 
Where  woman's  milk,  then,  contains  certain  ingredients  amounting  in  all  to 
twelve  per  cent.,  the  same  ingredients  in  Carnrick's  Food  when  mixed 
according  to  the  directions  on  the  label  are  represented  by  0.77. 

From  what  has  already  been  shown  in  Tables  IX.  and  X.  it  will  be 
understood  that  the  dilution  of  cow's  milk  with  barley-water  will  be  but 
very  little  more  satisfactory  than  with  plain  water,  and,  as  the  resulting 
mixture  with  barley-water  is  acid,  the  addition  of  lime-water  in  sufficient 
amount  to  produce  the  proper  degree  of  alkalinity  will  be  preferable,  the 
barley-water  supplying  a  percentage  of  starch  of  no  nutritive  value  to  the 
mixture,  and  its  assistance  in  digesting  the  albuminoids  being  much  over- 


INFANT-FEEDING WEANING.  321 

rated,  if,  indeed,  it  exists  at  all.  Lime-water,  on  the  other  hand,  is  the  most 
simple  adjnvaut  which  we  can  use  for  making  cow's  milk  alkaline,  for  so 
small  is  the  amount  of  lime  contained  that  its  addition  in  even  considerable 
quantity  to  cow's  milk  does  not  materially  alter  the  amount  of  the  total  ash, 
while  it  will  render  cow's  milk  alkaline  when  added  in  such  small  amount 
as  one-sixteenth  part,  so  that  simply  for  this  purpose  alone  (making  an  acid 
milk  correspond  in  its  reaction  to  woman's  milk)  it  is  very  valuable,  for  it 
apparently  does  not  produce  any  other  changes  in  the  milk.  The  question 
next  arises  as  to  whether  cow's  milk  can  be  modified  without  the  use  of 
patent  foods  or  foreign  ingredients  and  made  to  correspond  to  the  percentage 
given  in  the  upper  line  of  Table  X.  This  has  been  accomplished,  with 
more  or  less  success,  by  the  addition  of  milk-sugar,  of  fat  in  the  form  of 
cream,  and  of  lime-water. 

Biedert,  having  come  to  the  conclusion  clinically  that  the  young  infant 
could  digest  easily  a  mixture  containing  one  per  cent,  of  albuminoids, 
devised  what  he  called  his  cream  mixture,  which,  as  seen  in  the  table, 
contains  the  proper  amount  of  albuminoids  and  ash,  but  entirely  too  little 
fat  and  sugar.  This  mixture  also,  though  a  step  in  the  right  direction,  is 
far  from  exact  in  the  method  of  its  preparation,  either  as  originally  recom- 
mended by  Biedert  or  in  the  condensed  patent  "  Cream  Preserve"  which 
under  his  name  has  appeared  in  the  market,  and  is  open  to  all  the  criticisms 
Avhich  have  been  made  on  patent  foods  in  general. 

Dr.  J.  F.  Meigs,  of  Philadelphia,  having  found  in  a  very  extensive 
practice  among  infants  that  certain  proportions  of  milk,  lime-water,  cream, 
and  milk-sugar  appeared  to  suit  the  average  infant's  digestion  and  nutrition 
better  than  anything  else  that  he  had  experimented  with,  advised  his  sou, 
Dr.  A.  V.  Meigs,  to  determine  chemically  how  near  this  mixture  approached 
to  the  analysis  of  average  human  milk.  The  younger  Meigs,  having  already 
determined  chemically  that  the  average  woman's  milk  contains  but  one  per 
cent,  of  albuminoids,  found  in  the  analysis  of  his  father's  mixture  that  it 
also  presented  one  per  cent,  of  albuminoids.  He  then  perfected  the  mix- 
ture still  further  by  using  a  definite  amount  of  milk-sugar,  seventeen  and 
three-quarters  drachms  to  a  pint  of  water,  and  a  cream  of  about  sixteen  per 
cent.  fat.  With  these  ingredients  in  the  proportion  of  one  part  milk,  two 
parts  cream,  two  parts  lime-water,  and  three  parts  sugar-water,  he  found 
the  almost  unvarying  analysis  to  be  an  alkaline  mixture  containing  about 
88.35  water,  3.50  fat,  1.21  albuminoids,  6M  sugar,  0.25  ash.  This  mix- 
ture at  ouce  established  the  possibility  of  a  simple  method  of  making  the 
composition  of  a  mixture  correspond  to  that  of  woman's  milk,  and  gives  us 
as  definite  a  chemical  basis  to  work  with  as  we  are  justified  with  our  present 
chemical  and  physiological  knowledge  to  expect.  The  details  of  making  the 
mixture,  however,  form  a  very  important  part  of  its  practical  success,  and 
will  be  referred  to  later,  for  unless  these  details  are  precisely  carried  out  the 
mixture  is  no  better  than  those  which  have  already  been  mentioned. 

A  great  deal  has  been  said  and  written  about  "  cream  mixtures."     These 

Vol.  I.— 21 


322  INFANT-FEEDING — WEANING. 

have  met  with  many  alleged  successes  and  failures.  So  maay  of  the  suc- 
cesses and  so  many  of  the  failures,  however,  have,  in  all  probability,  had  so 
little  to  do  with  the  mixtures  as  "  cream  mixtures,"  that  it  cannot  be  said 
that  our  clinical  knowledge  has  so  far  accumulated  many  scientific  or  prac- 
tical facts  concerning  them.  It  would  indeed  seem  that  the  theory  of  the 
"  cream  mixture"  has  not  been  thoroughly  understood  by  the  general  prac- 
titioner or  practically  carried  out  by  him,  although  he,  as  a  rule,  is  the  one 
who  has  the  greatest  opportunity  for  doing  so.  It  is  better  not  to  use  the 
term  "  cream  mixture."  We  merely  add  the  cream  so  as  to  supply  a  fat 
which,  so  far  as  we  know,  corresponds  to  the  fat  of  woman's  milk,  and  to 
make  the  percentage  of  this  especial  ingredient  of  the  mixture  agree  with 
its  percentage  in  woman's  milk.  We  should  not  attach  so  much  importance 
to  this  or  to  any  of  the  ingredients  of  the  artificial  foods  as  to  name  the  food 
from  it,  but  should  give  all  the  ingredients  an  equal  share  of  importance, 
or,  as  I  have  stated  above,  we  inevitably  fall  into  the  error  of  neglecting 
some  of  them.  Tiie  intention  of  adding  cream  is  simply  to  add  fat :  we 
therefore  should  not  speak  of  cream  or  fat  mixture,  any  more  than  we 
should  of  sugar  mixture,  as  it  conveys  the  false  idea  to  the  average  practi- 
tioner that  it  is  the  cream  which  is  of  especial  importance.^  An  infant's 
artificial  food  must,  as  I  have  already  said  (until  our  knowledge  is  much 
more  extended  than  at  present),  consist  of  cow's  milk  modified.  Cream  is 
one  of 'the  modifying  elements,  and  may  be  counted  simply  as  fat.  The 
fat  is  an  important  part  of  the  whole,  but  only  so  far  as  it  is  in  the  proper 
amount  of  three  to  four  per  cent.,  for  in  excess  it  is  a  disturbing  element. 

The  "Meigs  Mixture,"  even  when  carefully  prepared,  has  not  given 
nearly  so  good  results  as  those  obtained  with  woman's  milk.  We  have, 
however,  gone  as  far  with  it  as  the  chemistry  of  to-day  will  permit,  so  far 
as  the  actual  percentages  are  concerned.  Much,  however,  can  be  added  to 
this  factor  of  correct  percentages  by  improvement  in  the  exact  application 
of  the  principles  involved ;  and  this  is  to  be  accomplished  by  a  more  ex- 
tended examination  of  this  mixture.  For  some  years  I  have  made  a  careful 
study  of  the  Meigs  mixture,  both  clinically  and  in  the  laboratory,  and  the 
following  are  the  results  of  my  investigations.  So  many  analyses  of  this 
mixture  have  been  made  for  me  by  Dr.  Harrington  with  uniformly  satis- 
factory results  that  I  have  assumed  that  so  far  as  the  question  of  percentage 
is  concerned  I  can  safely  accept  the  proportions  of  one  part  ordinary  mixed 
herd  milk,  two  parts  cream  twelve  to  sixteen  per  cent.,  two  parts  lime-water, 
and  three  parts  sugar-water. 

The  taste  of  the  lime-water  is  very  perceptible  in  the  Meigs  mixture, 
and  destroys  the  striking  similarity  in  taste  to  woman's  milk  which  is 
attained  by  using  a  smaller  amount  of  lime-water.     The  Meigs  mixture  is 

1  I  am  continually  meeting  with  physicians  who  speak  about  their  success  or  failure 
with  cream  mixtures,  and  who  are  feeding  the  infants  simply  on  cream  and  water, — that  is, 
diluted  fat,  just  as  Keed  &  Carnrick's  Food  is — even  if  we  accept  the  manufacturei-s'  figures 
— diluted  dextrin. 


INFANT-FEEDING WEANING.  323 

strongly  alkaline,  while  woman's  milk  is  very  slightly  alkaline  and  often 
neutral.  The  infant  at  times  does  not  like  the  taste  of  the  lime-water,  and 
the  parents  are,  therefore,  often  opposed  to  its  administration  in  such  large 
amount.  It  is  wiser  to  try  and  make  an  artificial  mixture  approach  as 
closely  as  possible  to  woman's  milk  in  both  taste  and  reaction ;  and  this  can 
easily  be  done  by  reducing  the  amount  of  the  lime-water,  for,  as  has  been 
explained,  it  is  useful  only  for  the  purpose  of  making  the  acid  mixture 
alkaline. 

Dr.  Harrington  has  made  an  estimate  by  actual  experiments  of  the 
amount  of  lime-water  which  was  needed  to  produce  an  alkalinity  in  the 
mixture  which  would  correspond  to  the  alkalinity  of  human  milk.  His 
results  were  as  follows  : 

Meigs  ]\Iixture  with  Reaction. 

25  per  cent,  lime-water Strongly  alkaline. 

12.5  per  cent,  lime-water Still  strongly  alkaline. 

6.25  per  cent,  lime-water Slightly  but  distinctly  alkaline,  and  corresponding 

to  woman's  milk. 

It  is  thus  seen  that  there  is  at  least  four  times  too  much  lime-water  in 
the  Meigs  mixture ;  and  we  accomplish  our  desired  result  of  making  the 
reaction  of  the  mixture  correspond  to  that  of  woman's  milk  by  adding,  in 
place  of  one- fourth  lime-water,  three-sixteenths  plain  water  and  one-sixteenth 
lime-water. 

Cream  varies  much  in  composition,  owing  to  the  different  methods  em- 
ployed in  the  process  of  skimming.  In  cities  or  towns  where  the  cream 
can  be  obtained  from  a  centrifugal  machine  the  question  of  the  fat  is  mucli 
simplified,  and  I  hav^e  practically  found  that  it  has  been  much  easier  to 
regulate  this  factor  in  the  food  for  infants  in  and  near  Boston  than  for 
those  who  live  at  a  distance  in  the  country,  although  the  latter  would 
naturally  be  provided  with  fresher  milk  and  cream  than  could  be  procured 
in  the  city.  In  the  country,  however,  the  milk  has  at  any  rate  to  stand 
some  hours  for  the  cream  to  rise,  while  the  cream  from  the  twenty-four- 
hours-old  city  milk  is  removed  by  the  machine  in  a  few  minutes,  so  that 
the  question  of  time  is  somewhat  obviated,  while  the  opportunity  of  ob- 
taining an  unvarying  percentage  of  fat  is  far  greater  in  city  cream  than  in 
country.  In  large  cities,  such  as  London  and  New  York,  Avhere  the  need 
for  exact  infant-feeding  is  felt  to  a  greater  extent  than  in  the  smaller  cities 
and  towns,  on  account  of  the  density  of  the  ])o])ulation,  a  cream  of  almost 
unvarying  percentage  in  fat  can  easily  be  provided  for  tlie  peoj)le  at  large, 
if  physicians  will  but  take  the  trouble  to  attend  to  it.  I  myself,  in  Boston, 
have  had  but  little  difficulty  in  arranging  this  (question  of  cream  with  one  of 
our  large  milk-dealers,  who  uses  centrifugal  machines.  This  dealer  has  two 
grades  of  cream,  a  very  thick  cream  which  he  sells  at  sixty  cents  a  quart, 
and  a  thinner  cream  which  he  calls  his  ordinary  cream  and  sells  at  thirty 
cents.  On  inquiry,  I  found  that  his  machines  arc  run  at  an  almost  unvary- 
ing rate  of  seven  thousand  rotations  of  the  wheel  to  the  minute,  the  result- 


324  INFANT-FEEDING WEANING. 

iug  cream  being  thin  or  thick  according  as  the  stopcock  supplying  the  milk 
to  the  machine  is  turned  on  to  a  greater  or  less  extent.  I  found  that  the 
ordinary  cream  keeps  sweet  longer  than  the  thick  cream.  I  next  had  a 
careful  analysis  made  of  the  ordinary  cream  every  day  for  two  weeks,  and 
found  that  the  average  and  almost  unvarying  percentage  for  the  fat  was 
twenty.  This  ordinary  cream,  then,  which  is  about  as  thin  as  the  dealer's 
machine  will  make  it,  is  really  of  very  good  quality,  and  we  can  count  on 
its  containing  about  twenty  per  cent,  of  fat. 

When  a  cream  of  sixteen  per  cent,  fat  has  been  used  in  the  Meigs  mix- 
ture, I  have  usually  found  that  the  resulting  percentage  of  fat  was  rather 
above  than  under  four,  so  that  by  diluting  the  ordinary  centrifugal  cream 
with  one-quarter  part  water,  and  then  calling  this  "  cream,"  I  have,  by 
adding  this  resulting  fifteen  per  cent,  cream  in  the  proportion  of  one-quarter 
to  the  mixture,  usually  obtained  a  satisfactory  resulting  fat  percentage  of 
from  three  to  four.  Where  centrifugal  cream  cannot  be  obtained,  what  Dr. 
Meigs  calls  ordinary  cream  will  often  give  a  very  fair  resulting  fat  percent- 
age ;  but  if  the  patients  cannot  afford  to  have  an  analysis  made  the  physician 
should  at  least  ask  to  see  a  specimen  of  the  cream  which  is  being  used,  since 
people  show  the  greatest  lack  of  intelligence  in  judging  what  is  good  ordi- 
nary cream,  thinking  that  if  it  comes  from  their  own  cow  in  the  country  it 
must  be  good,  while  really  it  may  be  a  very  poor  cream  so  far  as  evidence 
is  given  to  the  eye.  It  is  well,  however,  to  advise  people  not  to  use  the 
rich  cream  of  fancy  cattle,  but  the  cream  from  mixed  common  herd  milk, 
and  also  to  have  always  the  same  person  skim  the  milk,  and  to  have  the 
milk  stand  for  the  same  time  and  in  the  same  temperature,  for  the  percent- 
age varies  considerably  with  different  skimmers  and  according  as  it  has 
stood  for  a  longer  or  shorter  time  and  in  a  cool  or  a  warm  place. 

We  have  already  spoken  so  fully  concerning  the  albuminoids  and  ash 
that  it  is  hardly  necessary  to  refer  to  them  here  again,  except  so  far  as  is 
requisite  to  emphasize  the  importance  of  reducing  the  percentage  of  the 
albuminoids  in  the  mixture  to  one,  and  the  ash  to  0.1-0.2. 

The  proper  percentage  of  sugar  to  be  given  in  an  infant's  food  has  been 
stated  to  be  from  six  to  seven ;  and  the  method  of  obtaining  this  percentage 
has  been  shown  in  the  chemistry  of  the  Meigs  mixture. 

Regarding  the  kind  of  sugar  which  should  be  used  in  making  up  an 
artificial  food,  we  have  certain  questions  to  consider  which  would  seem  to 
be  not  altogether  unimportant.  Cane-sugar  has  been  in  the  past  and  is  still 
a  favorite  form  -with  which  to  regulate  this  part  of  the  solid  constituents  of 
the  food,  and  the  reasons  given  for  using  it  have  been  its  preservative 
(qualities,  as  seen,  for  instance,  in  the  manufacture  of  condensed  milk,  and 
the  theory  that  it  is  not  liable  to  set  up  excessive  so-called  lactic  acid  fer- 
mentation, with  its  consequent  disturbance  of  digestion,  as  is  supposed  to 
be  the  case  with  milk-sugar.  Cane-suerar  in  a  concentrated  form  as  it  is 
found  in  condensed  milk  seems  to  act  as  a  preservative  ;  when,  however,  it 
is  diluted,  as  in  its  administration  to  the  infant,  the  cane-sugar  ferments 


INFANT-FEEDIXG WEANING,  325 

verv  readilv,  and  under  these  circumstances  is  no  better  than  milk-suorar. 
Reasoning  from  analogy,  we  should  say  that  milk-sugar  being  the  form 
which  is  always  found  in  the  milk  of  all  mammals,  it  would  be  natural  to 
suppose  that  this  form  of  sugar  has  been  put  there  for  some  good  purpose, 
and  that  it  is  needed  for  the  accomplishment  of  some  process  which  takes 
place  after  the  food  has  been  swallowed  by  the  infant.  Both  cane-sugar 
and  milk-sugar  are  converted  into  glucose  in  the  intestine.  There  seems, 
however,  to  be  some  difference  in  the  degree  to  which  they  can  be  used  for 
purposes  of  nutrition  before  they  are  converted  into  glucose.  Caue-sugar, 
so  far  as  is  known,  is  merely  a  reserve,  and  cannot  be  directly  used  for 
nutrition ;  in  fact,  this  holds  true  in  whatever  it  exists,  whether  in  plants 
or  in  animals.  Milk-sugar,  on  the  other  hand,  is  probably  not  merely  a 
reserve,  but  may  possibly  be  utilized  as  such  in  the  economy.  Thus, 
Bernard^  has  shown  that  seven  grains  of  milk-sugar  dissolved  in  an  ounce 
of  water  could  be  injected  under  the  skin  of  a  rabbit  without  the  subsequent 
appearance  of  sugar  in  the  urine,  while  under  the  same  conditions  and  in 
the  same  amount  cane-sugar  was  found  to  be  eliminated  as  foi'eign  matter 
by  the  kidneys. 

Milk-sugar  undergoes  no  direct  alcoholic  fermentation,  but  readily 
undergoes  a  change  to  lactic  (possibly  acetic)  acid  in  the  presence  of  nitro- 
genous ferments,  \vhile  cane-sugar  easily  undergoes  alcoholic  fermentation, 
but  changes  to  lactic  acid  less  readily  than  milk-sugar  :  cane-sugar,  however, 
takes  on  the  butyric  acid  fermentation  more  readilv  than  milk-suffar.  On 
page  304  I  have  already  referred  to  the  Bacillus  lactis  aerogenes  (Escherich) 
as  being  present  in  normal  digestion  and  for  the  purpose  of  acting  on  the 
milk-sugar  to  produce  an  organic^  acid  which  will  drive  out  the  more  noxious 
forms  of  bacteria,  which  by  their  presence  would  interfere  with  normal 
digestion.  When  also  milk-sugar  is  converted  into  glucose,  we  physio- 
logically have  a  gradual  conversion  into  lactic  acid,  which  may  aid  in  the 
digestion  of  the  albuminoids,  thus  giving  us  a  very  valuable  addition  to 
the  means  at  our  command  of  rendering  modified  cow's  milk  digestible. 

Dr.  Jeffries  writes  to  me  concerning  this  question  as  follows  : 

"  In  reference  to  the  question  as  to  the  difference  of  the  various  kinds 
of  sugar  in  the  digestive  tract,  the  following  seems  to  be  of  interest.  Starch, 
dextrin,  inulin,  caue-sugar,  and  dextrose  afford  material  for  the  butyric  acid'"' 
fermentation  ;  milk-sugar  first  after  completed  hydration. 

"  Again,  Eschericli,*  in  speaking  of  Brieger's  bacillus,  says,  '  Milk  is 
coagulated  with  sour  reaction  first  after  several  days  (eight  to  ten)  at  the 


1  Flint,  Physiology,  1879,  p.  4G7. 

2  According  to  Escherich,  this  organic  acid  is  lactic ;  while  Bagiusky  holds  that  the 
Hacillns  lactis  a'eroffenes  turns  milk-sugar  largely  into  acetic  acid,  producing  only  minimal 
amounts  of  lactic  acid,  and  he  suggests  the  name  of  BacllluN  acctlrum  for  this  form  of 
bacterium. 

'  Fliigge,  Mikroorganismen,  1886,  p.  484. 
*  Darmbacterien  des  Saiiglings,  p.  67. 


326  INFANT-FEEDING — WEANING. 

body-temperature.  With  exclusion  of  air  this  bacillus  cannot  grow  either 
in  milk  or  milk-sugar  solution,  but  will  in  grape-sugar.' 

"  We  thus  see  that  the  milk-sugar  offers  less  danger  of  the  butyric  acid 
ferment,  which  we  know  makes  much  trouble  at  times  in  the  body,  and 
under  the  conditions  of  the  intestine  should  be  exempt  from  the  assaults  of 
Bi'ieger's  bacillus." 

When,  in  connection  with  what  has  been  said  above,  we  consider  that 
by  means  of  sterilization  we  can  practically  put  an  end  to  the  lactic  acid 
fermentation  which  may  have  begun  to  act  on  the  milk  before  it  enters  the 
stomach,  it  would  seem  that  we  are  justified  on  both  physiological  and  bac- 
teriological grounds  in  using  the  same  animal  sugar  in  our  artificial  mix- 
tures Avhich  is  found  in  the  infant's  natural  food,  instead  of  introducing  a 
vegetable  sugar,  which  in  any  milk  is  a  foreign  element. 

The  dangers  from  lactic  acid  are,  at  any  rate,  much  exaggerated  by 
writers  on  this  subject,  and  there  are  many  other  questions  which  if  more 
carefully  attended  to  would  render  the  supposed  evil  results  of  the  lactic- 
acid  bugbear  much  less  noticeable. 

We  can  now  discuss  the  best  method  of  preparing  the  food  for  house- 
hold use.  We  will  suppose,  by  way  of  illustration,  that  we  are  using  a  cen- 
trifugal cream  of  twenty  per  cent.  fat.  We  dilute  this  cream  one-quarter, 
and  make  this  diluted  cream,  containing  fifteen  per  cent,  of  fat,  one-quarter 
part  of  the  whole  mixture.  It  was'  found  by  Meigs  that,  as  already  stated, 
the  proper  percentage  of  sugar  in  the  mixture  was  obtained  from  a  solution 
of  milk-sugar  seventeen  and  three-fourths  drachms  to  one  pint  of  water. 
In  the  analyses  of  the  mixture  I  have  found  that  the  sugar  percentage  was, 
if  anything,  usually  somewhat  under  seven  per  cent. :  so  that,  to  simplify 
the  figures,  and  without  running  any  risk  of  appreciably  changing  the  per- 
centage from  seven,  I  have  added  eighteen  drachms  of  milk-sugar  to  the 
pint  of  water.  In  the  same  proportion  we  find  that  in  every  three  ounces 
of  water  there  should  be  three  and  three-eighths  drachms  of  milk-sugar,  and 
that  this  three  and  three-eighths  drachms  should  be  the  amount  for  every 
half-pint  of  the  mixture.  I  then  had  a  tin  measure  made  to  hold  three  and 
three-eighths  drachms  of  milk-sugar.  This  obviates  the  expense  of  having 
the  milk-sugar  put  up  in  packages  by  the  apothecary,  and  is  sufficiently 
exact  not  to  alter  the  sugar  percentage  in  the  mixture.  One  of  the  leading 
apothecaries  in  Boston  sells  a  pound  of  the  highest  grade  of  milk-sugar  for 
fifty  cents  and  gives  with  it  one  of  these  measures,  wliich  is  represented  in 

Fig.  10. 

Fig.  10. 


It  is  well  to  remember  also  that  the  pound  of  milk-sugar  contains  seven 
thousand  grains,  and  that  if  we  wish  to  have  it  divided  into  packages  of 
three  and  three-eighths  drachms  and  to  pay  about  one  dollar  and  a  quarter 


IXFAXT-FEEDING WEAXIXG.  327 

instead  of  using  a  measure  and  paying  fifty  cents,  we  can  order  thirty-five 
packages  to  be  made  from  the  pound  and  we  shall  still  have  the  resulting 
percentage  in  the  mixture  substantially  correct.  We  must  also  remember 
that  the  proportion  of  lime-water  should  be  one-sixteenth  part  of  the  whole 
mixture, — that  is,  one-half  ounce  for  the  half-pint.  Before  describing  the 
exact  manner  of  preparing  the  food  from  these  materials,  it  will  be  well  for 
me  to  state  the  result  of  my  experiments  wath  the  sterilized  Meigs  mixture, 
as  it  may  save  other  investigators  the  trouble  of  repeating  them. 

On  steaming  a  mixture  of  cream,  milk-sugar,  water,  and  lime-water  in 
the  usual  way  for  twenty  minutes,  it  was  found  that  the  liquid  had  become 
of  a  lio;ht-brown  color.  Dr.  Harrington  found  that  the  color  was  due  to 
certain  brown  products  formed  by  the  action  of  the  lime-water  on  the  milk- 
sugar  at  a  high  temperature.  This  color  in  itself  does  not  alter  the  value 
of  the  mixture ;  but  Dr.  Harrington  also  found  that,  while  at  the  beginning 
of  the  steaming  the  reaction  of  the  mixture  was  strongly  alkaline,  this 
reaction  as  the  steaming  was  continued  grew  gradually  less  and  at  the  end 
the  reaction  miglit  be  neutral.  This  change  in  the  reaction  Dr.  Harrington 
supposed  to  be  due  partly  to  the  formation  of  a  compound  of  lime  and 
sugar  and  partly  to  the  fact  that  on  heating  lime-water  much  of  the  lime  is 
thrown  down,  so  that,  as  the  object  of  the  lime-water  is  to  render  the  acid 
mixture  alkaline,  this  object  is  defeated  when  the  mixture  is  sterilized. 
The  lime-water  should  therefore  not  be  added  until  after  the  mixture  has 
been  steamed  and  partially  cooled. 

On  page  300  I  have  described  my  method  of  sterilizing  a  single  feeding 
for  the  infant,  and  my  four-ounce  tube  with  its  rubber  cot  is  represented  in 
Fig.  9  undergoing  sterilization.  Sterilizing  each  meal,  however,  is  con- 
sidered a  great  deal  of  trouble  by  many  mothers ;  and  "when  we  consider 
that  at  any  rate  the  milk  and  cream  should  be  sterilized  as  soon  as  they 
are  received  in  the  morning,  we  can  well  see  that  some  other  method  may 
be  preferable  in  these  cases. 

To  meet  this  demand,  I  have  lately  been  in  the  habit  of  having  the 
nurse  prepare  the  whole  quantity  of  food  which  is  to  be  used  by  the  infant 
in  twenty-four  hours,  by  mixing  it  as  soon  as  the  milk  and  cream  come  in 
the  morning,  pouring  it  into  the  litre  bottle  represented  in  Fig.  9,  steril- 
izing in  this  way  the  whole  twenty-four  hours'  food  at  once,  and  keeping 
it  in  the  ice-chest  to  be  used  when  necessary.  Giving  the  proportions  of 
the  various  ingredients  to  make  up  a  half-pint  of  the  mixture  is  sufiicient 
explanation  for  preparing  larger  quantities,  such  as  a  pint  or  a  (piart.  The 
directions  to  be  given  for  preparing  a  lialf-i)int  of  the  mixture  by  this 
method  are  very  simjjle,  and  can  be  carried  out  by  individuals  possessed  of 
a  very  small  amount  of  intelligence. 

Mix,  as  soon  as  received  in  the  morning, — 

Cream  (20  per  cent,  fat),  5I.I  ; 
Milk,5l; 
"Water,  50; 
Milk-sugar,  1  measure. 


328  INFAXT-FEEDING WEAXIXG. 

Steam  the  mixture  in  the  bottle  for  twenty  minutes,  the  mixture  being 
introduced  by  means  of  a  funnel,  in  order  that  the  neck  of  the  bottle  shall 
be  kept  dry.  The  bottle  is  to  be  stopped  tightly  with  a  cotton  plug.  After 
steaming,  remove  the  bottle  immediately  and  allow  it  to  cool  partially  ;  then 
add  half  an  ounce  of  lime-water,  and  keep  on  ice.  This  is  the  simplest  way 
of  preparing  the  food,  and  will  probably  prove  to  be  the  most  practical  and 
the  most  popular ;  but  of  course  it  is  open  to  the  objection  that  every  time 
the  infant  is  fed  the  cotton  has  to  be  removed  from  the  bottle,  with  the  re- 
sulting danger  of  contamination  of  the  remaining  fluid,  which  indeed  is  but 
slight.  Where,  however,  as  in  very  hot  weather,  this  objection  is  found  to 
be  a  valid  one,  small  bottles  for  each  feeding  should  be  used. 

I  have  arranged  this  latter  method  as  follows.     The  mixture  is  made 

in  the  morning  as  before,  and  is  then  poured  into  the  number  of  Erlmeyer 

Fig.  11.  flasks   corresponding    to   the    number   of  feedings.      The 

r^  flasks  are  to  hold  four  or  eight  ounces,  according  to  the 

r'^'\  amount  to  be  given  at  each  feeding.     Eight  or  ten  flasks 

^^^  are  usually  needed,  and  they  are  to  be  stoppered  with  cotton 

/      \  and  have  their  mouths  carefully  dried,  as  was  directed  for 

/        »  the  large  litre  bottle.     In  this  way  the  food  can  be  pre- 

/  \  pared  by  one  steaming  for  twenty-four  hours ;  and,  as  the 

/  \         cotton  is  not  removed  until  the  feeding-time,  the  mixture 

/  \        will  keep  indefinitely  and  need  not  be  put  on  ice.     Fig. 

1^       \       11  represents  a  four-ounce  Erlmeyer  flask.       When  this 

/     f-O^      \     ^^ethod  of  preparation  is  used,  the  proper  amount  of  lime- 

/  \    water  is  to  be  added  at  each  feeding. 

V  y  So  much  has  been  said  about  the  expense  of  preparing  a 

food  with  cream  and  milk-sugar  that  it  will  be  interestino- 
to  examine  into  the  actual  expense  incurred  in  using  this  mixture. 

The  cost  of  feeding  an  infant  three  or  four  months  old  will  represent 
approximately  the  cost  for  the  most  important  part  of  the  feeding-period 
and  the  one  which  is  most  difficult  to  manage. 

This  cost  amounts  to  about  twelve  cents  a  day ;  and  there  are  very  few 
parents  who  are  unable  to  pay  this  for  their  infant  during  the  early  mouths 
of  life.  The  expense  of  feeding  in  this  way  cannot  be  said  to  be  great  or 
beyond  the  means  of  the  people  at  large,  so  that,  although  the  food  and 
its  method  of  preparation  are  the  results  of  the  scientific  investigation  of 
what  is  best  without  regard  to  cost,  the  actual  daily  expense  happens  to 
compare  well  with  what  we  can  reasonably  demand  as  the  price  which  the 
poor  should  be  expected  to  pay  for  the  nourishment  of  their  oflspring. 

In  conclusion,  we  can  fairly  say  that  it  is  possible  in  artificial  feeding  to 
approach  the  standard  human  breast-milk  much  more  nearly  than  is  usually 
attempted,  and  there  is  no  reason  why  clinical  results  should  not  be  greatly 
improved,  if  physicians  will  only  take  additional  time  and  trouble  to  follow 
more  uniformly  nature's  teaching.  In  all  classes  of  life  a  much  greater 
amount  of  time,  expense,  and  thought  is  given  proportionately  to  the  prepa- 


INFAXT-FEEDIXG WEANIXG.  329 

ration  of  food  for  the  adults  of  the  family  than  for  the  infants.  This  is  a 
mistake  both  from  a  humanitarian  and  from  an  economical  point  of  view, 
for  the  infant  is  much  more  susceptible  to  irregularities  of  diet,  with  their 
resulting  suifering,  than  the  adult,  and  when  once  the  train  of  symptoms 
usually  called  dyspeptic  is  established,  infinitely  more  trouble  and  expense 
are  entailed  than  if  more  exact  methods  of  feeding  had  been  adopted  before 
the  digestion  was  disturbed.  In  the  early  weeks  of  lactation,  after  the 
mammary  function  has  been  fully  established  it  is  well  to  have  a  number  of 
analyses  made  of  the  mother's  milk,  and  to  keep  the  results  as  a  control 
record  to  act  as  a  guide  for  the  preparation  of  an  artificial  food  in  case,  as 
so  frequently  happens,  something  should  occur  to  end  the  nursing  at  an  early 
period.  It  is  highly  probable  that  the  digestive  function  of  the  individual 
infant  may  have  certain  idiosyncrasies  which  correspond  to  some  idiosyncrasy 
in  the  jjercentages  of  its  mother's  milk ;  and  in  cases  of  difficult  digestion 
where  the  artificial  food,  which  has  been  made  to  correspond  to  the  analysis 
of  average  woman's  milk,  fails  to  agree,  reference  to  this  control  record  may 
accomplish  the  solution  of  the  problem  sooner  than  if  we  have  to  ascertain 
experimentally,  by  changing  in  turn  the  percentages  of  the  different  in- 
gredients, in  which  particular  ingredient  the  idiosyncrasy  of  this  especial 
infant  is  to  be  found.  The  assistance  of  the  skilled  chemist  is  too  little 
sought  after  in  determining  these  questions  of  infantile  digestion  and  nutri- 
tion, and  in  the  future  must  necessarily  be  made  use  of  if  there  is  to  be  any 
advance  for  the  better  in  the  subject  of  artificial  feeding. 

Where  an  infimt,  then,  is  to  be  fed  with  artificial  food,  give  precise  direc- 
tions as  to  the  times  of  feeding,  the  amount  at  each  feeding,  and  the  feeding- 
apparatus  which  is  to  be  used.  See  that  the  analysis  of  the  food  corresponds 
as  closely  as  possible  to  that  of  human  milk ;  give  instructions  as  to  the 
proper  temperature  of  the  food ;  see  that  the  reaction  is  slightly  alkaline ; 
and  then,  if  there  is  any  difficulty  with  the  digestion,  sterilize  the  food.  If 
this  is  not  successful,  refer  to  the  control  record,  and  adapt  the  food  to  any 
maternal  idiosyncrasy  shown  by  this  record.  If  no  control  record  has  been 
kept,  experimentally  try  to  discover  the  especial  idiosyncrasy  of  the  indi- 
vidual infant  by  clianging  the  percentage  of  the  fat,  sugar,  albuminoids,  or 
ash. 


WET-NURSES. 

By   AYILLIAX   H.  PAEISH,  M.D. 


The  difficulties  attending  tte  selection  of  a  wet-nurse  are  of  sucli  a 
character  that  the  physician  must  bring  into  play  his  professional  knowl- 
edge and  must  exercise  the  greatest  care  and  shrewdness.  ]N^o  other  one 
should  assume  the  responsibility.  The  risks  to  the  infant  are  so  serious, 
and  it  is  so  difficult  to  avoid  them  fully,  that  some  experienced  practitioners 
disapprove  entirely  of  the  employment  of  a  wet-nurse.  Xot  only  must  the 
milk  be  nutritious  and  adapted  to  the  infant,  but  the  risk  of  the  infant's 
contractiuff  some  serious  and  it  mav  be  loathsome  disease  must  be  avoided. 
In  this  country  the  class  of  women  from  among  whom  wet-nurses  are 
chiefly  attainable  consists  largely  of  the  ignorant  poor  and  immoral,  those 
who  are  specially  liable  to  be  diseased  and  to  practise  deception.  Unfor- 
tunately, too,  the  number  of  available  women  from  among  whom  a  choice 
must  be  made  is  always  small,  and,  moreover,  the  demand  for  a  wet-nurse 
may  be  so  urgent  on  account  of  the  child's  failing  condition  that  delay  is 
deemed  impossible. 

Moral  Fitness,  etc. — The  moral  character  of  the  Avoman  must  be  con- 
sidered. While  most  probably  her  milk  cannot  influence  the  future  moral 
organization  of  the  growing  child,  yet  her  close  association  with  the  infant 
possibly  may  make  a  permanent  impress  on  its  pliant  brain.  Moreover,  the 
woman  will  bear  a  close  and  peculiar  relation  to  the  family  in  which  she  is 
introduced,  and  she  may  become  a  cause  of  no  little  unhappiness  if  she  is 
dissolute  or  of  bad  temper.  She  soon  learns  or  believes  that  her  services 
cannot  be  dispensed  with,  and  she  becomes  an  unbearable  tyrant.  If  of 
intemperate  habits,  she,  when  in  a  state  of  intoxication,  may  injure  the  infant 
by  accident  or  by  design,  and  at  that  time  will  furnish  milk  of  an  injurious 
character.  If  of  violent  temper,  she  will  furnish  during  her  exhibitions  of 
temper  milk  unfit  for  the  child ;  for  authenticated  cases  have  been  reported 
of  even  con\T.ilsions  occurring  because  of  milk  altered  by  such  mental  dis- 
turbance. A  woman  of  bad  temper,  or  one  Avithout  due  sense  of  her 
responsibility,  may  leave  suddenly,  possibly  when  tlie  child  cannot  bear  the 
consequent  abrupt  change  in  diet.  The  wet-nurse  should  be  cheerful,  active, 
good-natured,  temperate,  moral,  and  of  average  mental  capacity.  If  disso- 
lute, she  is  liable  to  contract  syphilis  or  gonorrhoea,  and  the  child  may 
330 


WET-NURSES.  331 

thus  become  infected.  When  the  woman  is  an  inmate  of  a  hospital,  it  is 
not  only  necessary  to  learn  of  her  conduct  while  in  the  hospital,  but  her 
habits  of  life  when  out  of  the  institution  should  be  ascertained  from  her 
acquaintances.  By  preference  she  should  be  married ;  but  in  this  country 
married  women  do  not  often  undertake  wet-nursing.  If  her  child  is  illegit- 
imate, it  is  best  that  it  should  be  her  first  child.  Repetition  of  illegitimate 
pregnancy  is  indicative  of  a  degree  of  moral  depravity  that  should  render 
her  fitness  more  than  doubtful.  To  say,  however,  that  only  mothers  of  legit- 
imate children  should  be  accepted  would  be  almost  equivalent  to  rendering 
the  attainment  of  a  wet-nurse  an  impossibility  in  the  United  States. 

In  Europe  it  is  not  unusual  to  employ  a  legitimate  mother  to  suckle  the 
child  several  times  during  the  twenty-four  hours,  she  coming  to  the  house 
for  that  purpose,  while  at  the  same  time  she  suckles  her  own  child  at  her 
own  home.  This  plan  has  its  drawbacks  ;  for  naturally  the  woman  gives 
the  preference  to  her  own  child,  and  her  diet  and  general  hygiene  cannot 
be  so  closely  overlooked  as  when  living  with  the  family  employing  her. 
There  is  some  danger,  too,  that  she  may  expose  herself  to  the  contagion  of 
such  diseases  as  measles,  scarlatina,  etc.,  and  convey  the  poison  to  the  child 
she  wet-nurses.  There  are  circumstances,  however,  under  which  such  em- 
ployment of  a  wet-nurse  would  seem  judicious,  provided,  of  course,  the 
woman  was  shown  to  be  suitable.  Generally,  in  America  the  woman 
is  entirely  separated  from  her  own  offspring,  and  the  latter,  if  living, 
either  is  placed  in  some  home  for  infants,  or  is  given  into  the  care  of 
some  woman  to  be  fed  artificially  and  usually  to  die.  A  proper  apprecia- 
tion of  the  moral  obligation  involved  would  induce  the  parents  of  the 
favored  child  to  make  due  efforts  to  secure  the  proper  care  of  the  infant 
deprived  of  its  natural  rights.  It  is  also  in  the  interest  of  their  child  to 
exercise  this  humane  act,  for  a  knowledge  on  the  part  of  the  wet-nurse  that 
her  child  is  receiving  kind  attention  will  go  far  towards  securing  that 
mental  equanimity  which  is  necessary  to  the  furnishing  of  a  proper  amount 
of  suitable  milk. 

General  Physical  Condition. — A  good  wet-nurse  should  be  robust  and 
strong,  but  not  veiy  fat.  Not  only  should  she  be  in  apparent  good  health 
at  the  time  of  employment,  but  she  should  also  be  free  from  evidences  of 
serious  past  dyscrasia. 

A  scrofulous  woman  cannot  furnish  good  milk.  The  applicant  must 
be  questioned  as  to  the  occurrence,  especially  during  her  childhood,  of  the 
symptoms  of  scrofulosis,  and  evidences  of  the  disease  must  be  looked  for, 
such  as  cicatrices  in  the  region  of  the  cervical  glands  or  enlargement  of 
those  glands.  The  presence  or  absence  of  scars  about  the  joints  must  be  as- 
certained. Existing  tuberculosis,  or  the  tuberculous  taint  as  indicated  by 
the  family  history,  should  exclude  her  as  a  wet-nurse.  The  possibility  of 
the  transference  of  tuberculosis  to  the  infant,  it  seems  to  me,  cannot  be  ques- 
tioned. Giving  suck  to  a  child  tends  to  develop  a  latent  tuberculosis  in 
the  woman,  and  thus  the  woman  giving  no  evidences  of  tuberculosis  when 


332  WET-NUESES. 

engaged  may  become  distinctly  tuberculous  during  lactation,  if  she  is  of  a 
diathesis  in  which  tuberculosis  readily  develops. 

A  woman  who  has  suffered  with  rachitis  in  her  childhood  should  be 
rejected.  The  evidences  of  rickets  are  to  be  looked  for  in  the  altered  con- 
dition of  such  bones  as  the  clavicles,  the  tibiae,  those  of  the  forearm,  the 
ribs,  and  the  vertebrae.  General  dwarfing  of  the  osseous  system  may  alone 
indicate  rachitis.  Neither  the  tuberculous  nor  the  rachitic  woman  will  fur- 
nish nutritious  milk,  nor  can  she  continue  to  suckle  the  child  for  the  usual 
period  of  twelve  or  fourteen  months.  It  is  well  to  remember  also  that 
rachitic  women  are  liable  to  lose  their  oifspring  during  labor  and  conse- 
quently seek  not  infrequently  the  position  of  wet-nurse. 

Marked  anaemia  may  indicate  some  serious  dyscrasia,  though  moderate 
anaemia  may  disappear  under  generous  diet  and  proper  medication. 

The  most  important  constitutional  disease  to  exclude  is  syphilis.  It 
must  be  remembered  that  the  woman  may  be  ignorant  of  ever  having  had 
a  chancre,  or  if  she  is  cognizant  of  the  fact  she  will  probably  deny  that  it 
ever  existed.  She  must  be  cross-questioned  as  to  the  multiform  manifesta- 
tions of  the  disease.  An  inspection  of  a  large  part  of  her  skin-surface  is 
necessary  to  determine  the  existence  or  absence  of  a  syphilide  or  of  charac- 
teristic or  suggestive  cicatrices.  The  mouth,  throat,  and  nasal  passages  also 
must  be  examined.  Should  the  symptoms  raise  a  doubt  in  the  examiner, 
and  he  be  unable  to  decide  the  point  to  his  full  satisfaction,  the  opinion  of 
an  expert  specialist  must  be  secured. 

A  syphilitic  woman  cannot  give  milk  duly  nutritious ;  and  there  is 
almost  a  certainty  that  the  child  will  become  infected  through  some  syphi- 
litic lesion,  it  may  be  of  the  nipple  or  the  breast,  or  of  some  other  part  of 
the  person,  as  of  the  lips,  the  tongue,  etc. 

As  it  would  be  criminal  to  furnish  a  syphilitic  wet-nurse  for  an  infant, 
I  agree  with  Parvin  that  it  would  be  also  criminal  to  secure  a  wet-nurse  for 
a  syphilitic  infant.     In  Prussia  the  latter  is  punishable  by  a  special  law. 

An  important  aid  in  determining  the  presence  of  syphilis  is  the  exami- 
nation of  the  infant. 

It  must  be  remembered,  however,  that  at  birtli  the  offspring  may  pre- 
sent no  evidences  of  syphilis,  but,  on  the  other  hand,  may  at  that  time  be 
robust  though  syphilitic.  Should,  however,  the  child  be  three  or  four 
months  old,  and  there  have  been  in  it  at  no  time  any  evidence  of  syphilis,  it 
may  be  decided  that  the  child  probably  is  not  infected  with  that  disease. 

Yet  a  healthy  infant  does  not  furnish  proof  of  a  non-syphilitic  mother ; 
for  she  may  have  acquired  syphilis  during  the  latter  part  of  her  pregnancy, 
in  which  case  the  child  may  escape  infection  ;  or  she  of  course  may  become 
syphilitic  after  her  delivery. 

A  syphilitic  offspring  should  certainly  lead  to  the  rejection  of  one  pre- 
senting herself  as  a  wet-nurse,  without  considering  the  unestablished  theory 
that  a  healthy  mother  may  give  birth  to  a  syphilitic  child  and  herself 
remain  healthy. 


WET-NUESES.  33*3 

A  healthy  offspring  merely  furnishes  no  evidence  against  the  mother  as 
to  her  infection  with  syphilis ;  and  we  must  still  scrutinize  the  woman  with 
the  greatest  care. 

Acute  or  chronic  non-syphilitic  exanthemata  are  contra-indications  as 
to  the  fitness  of  the  wet-nurse  in  proportion  to  their  severity  and  character. 
One  Avho  has  epilejjsy  or  who  has  been  epileptic  must  not  be  accepted. 
There  is  evident  danger  that  during  an  epileptic  seizure  the  child  may  be 
injured,  and  it  is  also  not  improbable  that  the  milk  furnished  by  such  a 
woman  is  not  only  insufficiently  nutritious  but  also  that  it  may  impart  a 
nervous  diathesis  to  the  child.  One  with  a  family  history  of  insanity  should 
not  be  employed,  nor  one  who  has  been  insane.  It  is  well  known  that  the 
insanity  of  lactation  is  especially  apt  to  develop  in  those  having  a  predis- 
position through  inheritance,  and  it  is  possible  that  the  liability  to  insanity 
may  be  transferred  through  the  milk  to  the  child  wet-nursed. 

The  hypochondriacal  woman  should  also  be  rejected.  She  cannot 
furnish  the  best  milk,  and  hypochondria  may  eventuate  in  insanity  under 
the  strain  of  lactation  and  of  separation  from  her  own  child,  or  in  case  of 
its  death. 

All  acute  diseases,  unless  trivial  in  character,  and  whether  contagious 
or  not,  render  the  woman  unsuitable. 

Pregnancy,  of  whatever  duration,  renders  the  woman  unfit,  because 
very  frequently  the  consequent  alteration  in  the  character  and  the  diminu- 
tion in  quantity  of  the  milk  render  it  decidedly  insufficient  and  deleterious. 

If  she  menstruates,  the  milk  is  usually  so  altered  at  the  period  as  to 
disagree ;  and  a  menstruating  ^voman  should  not  be  engaged  unless  it  is 
known  that  her  milk  remains  good  during  the  period  or  the  demand  for 
a  wet-nurse  is  exceedingly  urgent.  I  have  repeatedly  seen  a  nursing  child 
made  ill  by  the  milk  of  its  mother  taken  during  the  menstrual  flow.  In 
fact,  in  several  instances  it  has  occurred  under  my  observation  that  a  child, 
that  had  thriven  admirably  on  its  mother's  milk  prior  to  the  return  of 
menstruation,  became  fretful  and  subject  to  attacks  of  indigestion,  and  lost 
in  weight,  both  during  the  menstrual  and  the  intermenstrual  period,  indi- 
cating not  only  that  the  milk  of  the  menstrual  period  had  materially  altered, 
but  also  that  the  intermenstrual  milk  no  longer  agreed  with  the  child. 

Nature  has  not  intended  that  pregnancy  and  lactation  or  menstruation 
and  lactation  should  coexist. 

Abnormal  Conditions  of  the  Genitals. — The  applicant  for  the  position 
of  wet-nurse  may  deny  the  existence  of  any  symptom  of  genital  disease.  Yet 
a  skilful  questioning  may  secure  the  needed  information.  It  will  be  safer, 
however,  to  insist  upon  an  examination.  One  must  look  for  the  scar  of 
chancre,  although  this  not  infrequently  will  elude  observation.  Chancroids 
and  vegetations  are  positive  contra-indications. 

A  microscopic  examination  may  reveal  the  gonococcus,  if  gonorrhoea 
exists.  Gonorrhoeal  tubal  disease  is  a  decided  contra-indication,  even  thougli 
evidences  of  cxistino;  vajrinal  or  urethral  gonorrhoea  cannot  be  ascertained. 


334  WET-NURSES. 

There  is  in  such  a  patient  an  actual  risk  that  the  infant  may  become 
infected.  Even  a  latent  gonorrhoeal  septic  or  catarrhal  salpingitis  may 
become  at  any  time  an  active  inflammation  and  render  the  woman  bed- 
ridden. 

Of  course  the  discovery  of  hydro-,  hsemato-,  or  pyosalpinx,  or  of  an 
ovarian  cyst,  or  of  fibro-myomata,  or  of  sarcoma  or  carcinoma,  should  lead 
to  the  woman's  rejection.  Indurated  inguinal  glands  or  cicatrices  in  the 
groins  must  be  looked  for,  and  their  relation  to  chancre  and  chancroids 
borne  in  mind. 

A  protracted  lochial  flow  indicates  usually  subinvolution,  with  or  with- 
out some  other  lesion,  such  as  laceration,  ulceration,  or  polyp.  Such  con- 
ditions render  the  woman  unfit  in  proportion  to  their  effect  upon  the  general 
health. 

The  woman  who  refuses  to  submit  to  an  examination  of  the  genitals 
must  be  declined.  The  breasts  must  be  examined,  to  determine  their 
capacity  for  the  formation  of  milk  and  their  fitness  for  giving  suck. 

The  well-shaped  breast  of  the  primipara  is  conical,  and  does  not  drag. 
If  a  multipara,  the  breast  hangs  somewhat  downward  as  a  result  of  previous 
nursings.  A  large  breast  may  be  merely  a  mass  of  adipose  tissue,  with 
but  little  of  the  true  tissue  of  the  mammary  gland  in  it.  When  kneaded 
with  the  fingers,  the  large  mammary  gland  gives  a  sensation  of  greater 
resilience,  and  the  lobules  may  be  recognized.  The  breast  that  consists 
chiefly  of  adipose  tissue  diminishes  but  little  in  size  as  the  child  nurses, 
whereas  the  mammary  gland  furnishing  a  good  supply  of  milk  becomes 
decidedly  smaller  and  less  tense  after  the  child  has  emptied  it.  The  latter 
breast  also  enlarges  and  becomes  more  tense  at  the  expiration  of  two  or 
three  hours.  The  breast  must  be  examined  for  fibromata,  cysts,  carcinomata, 
and  tuberculosis.  The  contagiousness  of  carcinoma  and  of  tuberculosis 
of  the  breast  through  the  milk  is  at  least  so  probable  that  no  risks  should 
be  taken.  Lancereaux  describes  a  diffused  and  a  circumscribed  syphilitic 
mastitis.  The  diffused  form  is  usually  bilateral,  and  consists  of  an  indolent 
induration  without  discoloration  of  the  skin,  almost  painless,  but  attended 
with  enlargement  of  the  axillary  glands. 

The  circumscribed  or  gummatous  form  may  exist  either  in  the  super- 
ficial fascia  or  in  the  gland  itself.  It  is  of  slow  growth,  firm  and  somewhat 
lobulated,  produces  but  little  pain,  and  may  not  be  attended  with  enlarge- 
ment of  the  axillary  glands.  Softening  may  occur,  and,  after  ulceration, 
the  debris  escape.  With  any  syphilitic  lesion  of  the  breast  other  than  the 
primary,  a  careful  scrutiny  of  other  portions  of  the  body  will  probably 
furnish  corroborative  evidence.  Neuralgia  and  hypersesthesia  of  the  nipple 
or  breast  may  exist  as  a  late  residt  of  syphilis  :  a  hyperresthetic  or  neuralgic 
condition  of  a  non-syphilitic  character  may  be  present  and  of  itself  render 
the  woman  unfit  to  become  a  wet-nurse.  A  not  infrequent  site  of  syphilitic 
ulceration  is  the  under  surface  of  a  large  and  pendent  breast. 

The  nipple  may  present  syphilitic  fissures  or  ulcerations.     Even  if  the 


WET-NURSES.  335 

mother  should  have  escaped  infection  prior  to  and  during  pregnancy,  she 
may  contract  a  primary  sore  on  the  nipple  or  breast  from  a  syphilitic  lesion 
of  her  child,  such  as  a  mucous  patch  of  the  mouth,  or  a  fissure  of  the  lip. 
Any  syphilitic  lesion  of  the  breast,  whether  primary  or  secondary,  the  latter 
especially  if  moist,  is  liable  to  infect  the  child  wet-nursed. 

Tuberculosis  of  the  breast  not  infrequently  escapes  observation.  The 
most  usual  forms  are  the  cold  abscess  and  the  chronic  fistula.  A  dissemi- 
nated form  exists  in  which  the  nodules  are  of  various  sizes  and  are  hard 
to  the  examining  fingers.  They  are  liable  to  caseous  degeneration  and 
softening,  or  to  calcification.  In  this  variety  the  breast  is  but  slightly 
enlarged  from  the  deposits,  and  may  be  movable  over  the  ribs.  There  is 
a  confluent  form  of  mammary  tuberculosis  in  which  the  swelling  is  more 
marked.  Nodules  can  be  felt  as  irregular,  somewhat  lobulated,  and,  it 
may  be,  immovable  masses.  Fistulse  are  liable  to  occur.  A  true  miliary 
form  may  exist  as  an  early  manifestation. 

In  the  disseminated  variety  the  nipple  remains  quite  unaltered.  Palpa- 
tion reveals  the  nodules.  The  local  tuberculous  deposits  may  or  may  not 
be  associated  with  constitutional  evidences  of  tuberculosis.  Kolessnikow's 
investigation  shovv'S  that  there  is  actual  danger  of  infection  when  the  milk 
of  a  tuberculous  breast  of  a  cow  is  used ;  and  the  possibility  of  such  infec- 
tion occurring  from  the  putting  of  an  infant  to  a  tuberculous  breast  should 
be  most  carefully  avoided. 

Mastitis  and  cicatrices,  or  indurations  with  a  history  of  previous  inflam- 
mation, render  the  woman  unfit.  It  is  very  rare  that  a  breast  in  which 
parenchymatous  suppuration  has  once  occurred  is  ever  again  entirely  trust- 
worthy. The  nipple  should  be  neither  too  large  nor  too  retracted  :  if  too 
large,  a  feeble  child  cannot  draw  it ;  a  depressed  nipple  is  not  only  suckled 
with  difficulty,  but  is  liable  to  become  fissured  and  ulcerated,  with  the 
consequent  risk  of  mastitis  developing. 

The  quantity  of  milk  furnished  may  be  judged  of  by  the  extent  to  which 
the  breast  diminishes  in  size  when  the  child  suckles,  and  also  by  noticing 
the  degree  of  distention  at  the  expiration  of  two  or  three  hours  after  the 
suckling.  The  trickling  of  milk  from  the  child's  mouth,  the  act  of  swal- 
lowino;,  and  the  satisfied  manner  in  which  it  remains  at  the  breast  until  fall- 
ing  asleep  after  twenty  or  thirty  minutes,  aid  in  determining  the  quantity 
and  the  character  of  the  milk.  A  healthy,  well-developed,  and  vigorous 
child  of  a  few  weeks  or  older  indicates  that  the  milk  is  abundant  and  of 
good  quality.  Still,  it  must  be  remembered  that  a  syphilitic  child  may 
present  the  appearance  of  health  during  the  first  few  weeks.  The  quantity 
of  milk  taken  at  each  nursing  may  be  determined  more  accurately  by 
weigliing  tlie  child  Ix'fore  and  after  it  has  taken  the  breast. 

Good  human  milk  lias  an  alkaline  reaction,  is  of  a  dull-white  color,  and 
has  a  specific  gravity  of  1032.  The  microscope  shows  a  large  number  of 
medium-sized  fat-globules.  According  to  Bouchut,  if  a  drop  of  the  milk  is 
added  to  one  hundred  drops  of  a  one-pcr-ccnt.  solution  of  sodium  chloride, 


336  WET-NURSES. 

and  a  drop  of  this  be  placed  under  the  microscope,  each  square  millimetre 
should  contain  from  eight  hundred  thousand  to  one  million  milk-globules. 
Pressure  on  the  breast  even  after  the  child  has  nursed  should  cause  the  flow 
of  a  few  drops  of  milk.  It  is  not  necessary  that  the  child  of  the  wet-nurse 
should  be  of  the  same  age  as  the  one  to  be  nursed.  It  is  usually  better 
merely  that  the  wet-nurse's  child  shall  be  several  weeks  old.  Women  of 
twenty-five  to  thirty-five  years  are  to  be  preferred. 

The  diet  of  the  wet-nurse  should  be  generous,  and  any  article  known 
to  be  nutritious,  easily  digestible,  and  easily  assimilable  may  be  allowed. 
That  diet  which  tends  to  the  preservation  of  vigorous  health  in  the  woman 
will  lead  to  the  formation  of  the  largest  supply  of  nutritious  milk.  An 
excess  of  meats  must  be  guarded  against  if  the  accustomed  amount  of  exer- 
cise is  no  longer  partaken  of.  '  Such  things  as  occasion  flatulence  or  other 
evidence  of  indigestion  must  be  avoided.  Tea  must  not  be  drunk  in  excess. 
Milk  taken  during  the  meals  is  advantageous.  Beets  have  been  recom- 
mended as  peculiarly  serviceable  in  procuring  an  abundant  flow  of  milk. 

It  will  be  sometimes  advantageous  to  give  a  moderate  amount  of  porter 
or  other  malt  liquor ;  but  the  liability  of  wet-nurses  to  become  intoxicated 
must  be  remembered  always.  An  increase  in  the  amount  of  liquids  taken 
tends  to  increase  the  amount  of  milk  secreted,  but  the  liquids  should  be 
of  a  nutritious  character,  such  as  meat  broths,  gruels  made  with  milk,  and 
milk  itself.     It  will  rarely  be  advisable  to  resort  to  stimulants. 

The  nurse  should  be  required  to  take  a  considerable  amount  of  out-door 
exercise.  The  sleeping-apartment  should  be  well  ventilated,  and  not  too 
greatly  heated.  The  normal  action  of  the  bowels  must  be  secured,  and 
abundant  ablutions  exacted.  The  child  should  sleep  in  a  crib,  not  with  the 
Avet-nurse,  and  the  mother  should  be  always  on  the  alert  that  the  wet-nurse 
does  not  give  an  anodyne  in  some  form  to  the  infant. 

In  Prussia  there  are  special  laws  bearing  on  the  relations  existing  be- 
tween the  employer  and  the  wet-nurse  ;  but  I  know  of  no  such  special  laws 
in  this  countrv. 


DIET  AFTER  WEANING. 

By  SAMUEL   S.  ADAMS,  A.M.,  M.D. 


Weaning  may  be  defined  to  be  the  period  of  infancy  when  the  child  is 
deprived  of  breast-milk,  and  such  changes  are  made  in  its  alimentation  as 
are  rendered  necessary  by  its  independent  existence.  The  time  of  weaning 
cannot  be  arbitrarily  fixed  at  the  same  age  for  all  infants.  There  is  no 
uniform  opinion  as  to  the  exact  time  for  weaning,  although  most  authorities 
assert  that  it  should  take  place  between  the  twelfth  and  eighteenth  months. 
Under  normal  conditions  the  infant  should  not  be  weaned  before  the  twelfth 
month,  nor  should  lactation  be  continued  after  the  eighteenth  month.  In 
ninety-one  observations  made  by  the  writer  but  four  were  found  nursing 
after  the  first  year.  There  is  such  a  general  conformity  between  dental 
evolution  and  age  that  weaning  usually  takes  place  at  the  evolution  of  the 
eight  incisor  teeth,  which  is  completed  about  the  twelfth  month. 

For  convenience  it  is  necessary  to  assume  that  the  child  has  been  de- 
prived of  the  breast-milk  at  the  twelfth  month,  and  to  formulate  a  dietary 
accordingly.  The  eruption  of  the  lower  central  incisors,  during  the  seventh 
or  eighth  month,  seems  to  be  the  indication  to  mothers  to  begin  supple- 
mental feeding.  Very  few  infants  pass  far  beyond  this  physiological  epoch 
without  it. 

During  the  period  of  dentition  developmental  changes  gradually  take 
place  in  the  digestive  apparatus  which  fit  the  child  for  an  independent  ex- 
istence. The  glandular  structures  become  more  active,  and  the  muscular 
tonicity  increases,  so  that  at  the  period  of  eruption  of  the  anterior  molars 
the  alimentary  tract  is  prepared  for  semi-solid  food. 

The  object  of  this  paper  being  to  prescribe  a  suitable  dietary  for  the 
child,  in  health  and  disease,  from  weaning  to  puberty,  it  will  be  best  attained 
by  making  divisions  to  conform  to  the  recognized  anatomical  and  physio- 
logical changes  in  the  organism.  The  following  divisions  seem,  therefore, 
to  meet  all  the  requirements  :  1,  twelftli  to  eighteenth  month  ;  2,  eighteenth 
to  thirty-sixth  month ;  3,  third  to  fifth  year ;  4,  fifth  to  eighth  year ;  5, 
eighth  year  to  puberty. 

While  most  mothers  will  appreciate  the  value  of  milk  as  the  chief  food 
for  infants  during  the  first  year,  very  few  Avill  be  convinced  of  its  value  as 
such  after  weaning.  Several  months  before  the  child  is  weaned,  in  many 
Vol.  I.— 22  337 


338 


DIET   AFTEE   WEANIXG. 


iustances,  it  has  had  some  of  the  farinacese,  and  also,  jirobably,  meat  broths. 
If  weaning  takes  place  before  the  eruption  of  the  molars,  the  diet  should 
be  milk.  If  it  is  weaned  during  the  summer  months,  milk  should  be  its 
only  food,  although  the  molars  and,  perhaps,  the  canines  have  appeared. 
If,  however,  the  child  does  not  seem  to  derive  sufficient  nourishment  from 
the  milk,  it  may  be  given  some  additional  food,  provided  the  weather  be 
cool,  but  always  remembering  that  its  chief  constituent  must  be  milk.  If 
it  seems  to  thrive  on  milk  alone,  it  will  be  advisable  to  limit  it  to  it  until 
the  eighteenth  month.  It  is  the  exception,  however,  when  a  child  will  be 
satisfied  with  milk  until  this  late  period.  It  is  generally  necessary  to  sup- 
plement its  food  by  adding  some  farinaceous  aliment.  If  there  is  a  tendency 
to  loose  bowels,  barley-water  is  preferable.  It  is  made  by  grinding  a  table- 
spoonful  of  the  grain  barley  and  adding  to  it  six  ounces  of  water :  this 
should  be  boiled  for  fifteen  or  twenty  minutes,  salt  added  to  suit  the  taste, 
and  the  mixture  strained.  This  decoction  should  be  made  fresh  twice  a  day 
and  kept  cool.  It  should  be  added  to  the  milk  in  the  proj)ortion  of  one  to 
three  or  one  to  two.  The  prepared  barley  may  be  used  in  the  same  manner, 
but  it  is  not  so  reliable.  If  constipation  is  the  rule,  oatmeal  may  be  used  by 
prej)aring  a  decoction  similar  to  that  of  the  barley.  Arrow-root  should  not 
be  used,  on  account  of  the  large  proportion  of  starch  it  contains. 

Bread  jelly  has  been  highly  recommended  by  Churchill  and  others  as. 
an  excellent  food  for  children  just  after  weaning.  It  is  made  by  taking  a 
quantity  of  the  soft  part  of  stale  bread,  breaking  it  into  small  pieces,  cover- 
ing it  with  boiling  water,  and  allowing  it  to  soak  for  some  time.  The 
water  is  then  strained  off,  and  fresh  water  added.  This  should  now  be 
boiled  until  it  becomes  soft ;  the  water  is  then  pressed  out,  and  the  bread 
on  cooling  will  form  a  jelly.  A  portion  of  this  should  be  mixed  with 
sweetened  milk. 

In  some  cases  beef  tea  will  be  well  borne.  That  made  in  a  bottle  swim- 
ming; in  a  water-bath  does  not  contain  soluble  albuminoids.  It  contains 
large  quantities  of  salts,  and  should  not  be  given  when  there  is  a  tendency 
to  diarrhoea.  Excellent  beef  tea  is  made  by  mincing  one  pound  of  lean 
beef  and  adding  a  pint  of  cold  water  and  ten  drops  of  dilute  hydrochloric 
acid.  This  should  stand  for  two  or  three  hours,  with  occasional  stirring. 
It  should  then  be  left  to  simmer  for  fifteen  or  twenty  minutes,  when  it  will 
be  ready  for  use. 

Beef  broth  is  not  very  nutritious,  and  is  not  recommended.  Mutton, 
veal,  and  chicken  broths  are  nutritious,  and  are  applicable  in  many  cases. 
It  must  be  borne  in  mind,  however,  that  mutton  causes  constipation,  and 
veal  diarrhoea. 

Cow's  milk  is  that  most  generally  used  in  feeding  infants.  We  should 
not  delude  our  patients  Avith  the  idea  that  they  can  secure  one  coic^s  milk, 
because  that  will  not  be  done  if  the  dairyman  has  more  than  one.  He  may 
promise  to  keep  it  apart,  and  will  accept  an  additional  price  for  doing  so, 
but  he  will  more  than  likely  deliver  a  part  of  the  "  general  milking"  in  the 


DIET    AFTER    WEANING.  339 

can  that  has  been  provided  for  the  one  cow's  milk.  If  the  dairyman  has 
but  one  cow,  a  thorough  examination  into  its  keeping  may  disclose  that  it  is 
not  the  best.  The  cow  may  be  kept  in  a  small,  badly- ventilated,  and  foul 
stable ;  it  may  scarcely  ever  run  at  large  or  browse,  and  probably  its  food 
will  be  mainly  swill ;  though,  even  without  exercise  or  browsing,  if  it  is  fed 
on  long  food  and  brans,  with  an  occasional  feed  of  fresh  green  grass,  it  may 
furnish  a  good  quality  of  milk.  Again,  the  particular  cow  may  be  a  sickly 
one,  but  the  milkman  will  not  let  it  be  known  so  long  as  he  is  receiving  an 
extra  price  for  its  milk.  If  we  are  sure  of  getting  good,  sweet  milk,  twice 
daily,  from  properly-fed  cows,  let  us  be  satisfied.  Probably  a  great  many 
more  children  would  be  saved  if  more  attention  were  paid  to  the  prepara- 
tion and  dispensing  of  milk.  Unmethodical  and  irregular  feeding  is  quite 
as  bad  as  feeding  with  improper  aliments.  The  child  should  be  fed  regu- 
larly with  enough  milk  to  satisfy  its  appetite ;  but  giving  milk  to  appease 
its  anger  should  be  positively  prohibited.  The  quantity  must  necessarily 
be  increased  as  the  child  advances,  but  due  regard  should  always  be  paid  to 
its  digestive  and  assimilative  powers.  Overloading  its  stomach  impairs  its 
digestion. 

The  most  satisfactory  general  rule  is  to  secure  good  sweet  milk  from  a 
country  dairy,  delivered  twice  a  day  if  possible.  As  soon  as  it  is  delivered, 
pour  on  the  requisite  amount  of  boiling  water  to  scald  it ;  put  this  in  the 
refrigerator,  to  be  used  when  required.  Until  the  fifteenth  month  at  least, 
the  milk  should  be  given  from  a  bottle,  to  insure  steady  feeding ;  after  this 
it  may  be  given  from  a  cup  or  glass.  Do  not  permit  the  bottle  to  be  used 
as  a  soothing  apparatus  ;  when  thus  employed  it  does  harm.  Never  let  the 
child  sleep  with  the  nipple  hanging  to  its  lips.  It  should  be  fed  not  oftener 
than  once  in  four  hours.  With  every  feeding  add  a  tablespoonful  of  lime- 
Avater  or  from  one-half  to  one  grain  of  the  bicarbonate  of  sodium.  When  it 
is  through  feeding,  throw  away  the  remaining  portion,  never  allowing  it  to 
stand  in  the  bottle.  Scald  the  nipples,  tubes,  and  bottle,  and  keep  them  in  a 
solution  of  soda  until  the  next  meal.  The  simplest  and  most  conveniently 
cleansed  feeding-bottle  is  always  the  best. 

Of  the  various  substitutes  for  breast-milk,  condensed  milk  is  probably 
the  most  extensively  used.  Owing  to  its  apparent  cheapness,  and  its  ease 
of  preservation  and  preparation,  it  is  a  popular  food  with  the  lower  classes. 
Very  many  cannot  afford  to  purchase  cow's  milk,  and  cannot  spend  tlie  time 
necessary  for  its  preservation  and  preparation,  and,  consequently,  feed  their 
children  on  this  unstable  article.  The  weight  of  authority  is  against  i\\o 
use  of  condensed  milk,  owing  to  the  lack  of  nutrient  ingredients.  Children 
fed  Avith  it  will  grow,  but  are  deficient  in  muscular  vigor.  Under  some  cir- 
cumstances we  may  be  compelled  to  use  it.  During  very  warm  weather, 
when  poor  people  cannot  buy  ice  to  keep  cow's  milk,  or  when  infants  are 
travelling,  and  it  is  impossible  to  obtain  sweet  cow's  mil]-:,  it  may  be  ad- 
visable to  use  it ;  but  its  use  sliould  never  be  sanctioned  when  good  cow's 
milk  can  be  secured. 


340  DIET  AFTER   WEAXING. 

The  writer's  experience  with  peptonized  and  pancreatized  milk  has  not 
been  favorable.  It  cannot  be  recommended  as  generally  as  ^yas  at  first  sup- 
posed. These  methods  have  given  way  to  the  sterilizing  process,  which  is 
by  no  means  new. 

The  writer  desires  to  enter  a  protest  against  the  use  of  the  various 
"  infant  foods"  as  substitutes  for  or  aids  to  cow's  milk.  The  agents  em- 
ployed in  introducing  them  to  the  medical  profession  are  skilful  in  pointing 
out  the  advantages  each  possesses  over  the  others.  The  manufacturers  resort 
to  many  artful  devices  to  increase  their  sales.  The  physician  is  constantly 
annoyed  by  confidential  letters  asking  him  to  try  this  food  which  has  been 
so  successfully  used  by  the  professional  gentlemen  whose  names  they  exhibit 
on  the  fancy  cards,  calendars,  and  books.  Mothers  are  attracted  to  them 
by  the  warnings  posted  in  the  street-cars,  and  the  pictures  of  plump,  rosy 
babies  distributed  by  the  druggists.  Analyses  by  competent  and  honest 
chemists — not  paid  by  the  manufacturers— have  shown  them  to  be  rich  in 
the  ingredients  they  are  guaranteed  not  to  contain  and  to  be  deficient  in 
those  which  are  lauded  as  being  present  in  larger  proportion  than  in  any 
other  food.  Rotch,  in  a  valuable  paper,^  discusses  the  merits  of  the  dif- 
ferent "infant  foods,"  and  demonstrates  their  unreliability  as  substitutes 
for  milk. 

With  the  sixteen  teeth  the  child  should  be  allowed  a  more  liberal  diet. 
Its  digestive  apparatus  is  now  capable  of  digesting  food  which  has  been 
masticated.  It  may  be  allowable  to  give  it  stale,  w^ell-cooked  bread,  and 
butter,  or  crackers.  It  may  also  be  given  a  little  mashed  white  potato,  with 
grsivj.  A  sandwich  of  scraped  lean  beef  and  bread,  seasoned  with  salt  or 
sugar,  will  be  relished,  and  is  very  nutritious.  It  may  have  a  piece  of  rare 
beef  or  a  chicken-bone  to  suck,  care  being  taken  that  it  does  not  swallow 
the  pulp  or  bone. 

Peptonized  beef  preparations  have  been  recommended  by  the  recognized 
authorities. 

In  regulating  the  regimen  of  a  healthy  infant  during  this  period,  very 
little  change  is  required  in  its  food.  It  should  be  fed  five  or  six  times,  at 
the  same  hours,  every  day,  but  should  not  be  awakened  for  the  purpose. 
If  it  desire  its  food  before  its  accustomed  time,  it  should  have  it. 

First  meal,  6  a.m. — A  cup  of  milk,  with  cream  biscuit  or  a  slice  of 
buttered  bread. 

Second  meal,  8  a.m. — Stale  bread,  broken  and  soaked  in  a  tumblerful 
of  rich  milk. 

Third  meal,  12  M. — A  slice  of  buttered  bread,  with  about  half  a  pint 
of  weak  beef  tea  or  mutton  or  chicken  broth. 

Fourth  meal,  4  p.m. — A  tumblerful  of  milk,  with  crackers  or  a  slic«  of 
buttered  bread. 

Fifth  meal,  8  p.m. — A  tumblerful  of  milk,  with  bread  or  crackers. 


^  Archives  of  Pediatrics,  vol.  iv.  No.  44,  p.  4-58. 


DIET   AFTER   WEANING.  341 

Towards  the  latter  part  of  this  period,  when  the  child  has  sixteen  teeth, 
it  may  be  desirable  to  snbstitute  the  following : 

First  meal,  6  a.m. — Bread  or  crackers,  with  a  half-pint  of  milk. 

Second  meal,  8  a.m. — A  tablespoonful  of  oatmeal,  cracked  wheat,  or 
corn-meal  mush,  with  milk,  and  a  couple  of  slices  of  buttered  bread. 

Third  meal,  12  M. — Bread-and-butter,  milk,  and  a  soft-boiled  egg. 

Fourth  meal,  4  p.m. — A  piece  of  rare  roast  beef  to  suck  ;  mashed  boiled 
potatoes,  moistened  with  dish-gravy ;  bread  and  milk ;  and  a  small  portion 
of  rice,  bread  jelly,  or  farina. 

Fifth  meal,  8  p.m. — Milk  and  bread  or  crackers.^ 

This  is  a  modification  of  the  diet  laid  down  by  Louis  Starr ;  but  the 
writer  usually  insists  that  the  infant  should  be  confined  to  milk,  milk  and 
barley-water,  or  milk  and  oatmeal-water,  during  this  entire  period.  When 
his  advice  has  been  followed,  the  perils  of  the  "  second  summer"  have  been 
avoided. 

Fruits  and  berries  of  all  kinds  should  be  interdicted. 

Every  case  of  infant-feeding  must  be  regulated  by  its  own  indicated 
requirements.  There  is  no  uniform  rule  applicable  to  all.  Each  must  be 
studied  carefully,  and  that  mode  of  feeding  must  be  adopted  which  proves 
best  suited  to  it. 

The  child  should  not  be  permitted  to  sit  at  the  family  table.  It  may 
have  a  separate  table,  where  it  can  have  its  frugal  meal  without  being 
tempted  by  unwholesome  dishes. 

The  diet  in  sickness  during  the  first  period  must  be  regulated  by  the 
nature  of  the  case.  It  is  impossible  to  prescribe  a  regimen  suitable  to  all 
sick  children. 

Vomiting  is  unquestionably  the  most  frequent  symptom  to  be  controlled. 
It  may  be  due  to  overfeeding,  or  to  some  fault  in  the  quality  of  the  food. 
When  it  is  caused  by  overfeeding,  a  diminution  in  the  quantity  of  food,  as 
well  as  a  longer  interval  between  meals,  will  usually  correct  it.  If  it  should 
be  caused  by  a  defect  in  the  quality,  this  should  be  discovered  and  remedied. 
If  the  ejected  matter  is  sour-smelling,  the  alkali  must  be  increased.  Fre- 
quently, forced  abstinence  will  correct  it ;  and  in  many  cases  small  <|uan- 
tities  of  food  given  every  fifteen,  twenty,  or  thirty  minutes  Avill  have  a 
salutary  effect. 

Diarrhoea  is  often  the  result  of  improper  feeding.  The  food  may  be 
too  concentrated,  or  its  quality  may  be  poor.  When  it  is  due  to  too  much 
solid  food,  the  indicated  treatment  is  to  confine  the  patient  to  a  liquid  diet. 
If  the  quality  of  the  food  is  not  good,  it  should  be  improved.  In  many 
cases  the  addition  of  barley-water  to  the  milk  will  ])rove  effectual  in 
checking  the  diarrhoea. 


^  Often  it  would  ]w  prefenible  to  t^ivc  tlir  fourtli  inc;il  at  three  p.m.,  iiiul  tlie  fifth  7iieal 
at  six  P.M.,  ejjpeciull}'  in  winter,  S(j  that  the  child  can  he  put  to  bed  by  seven  o'clock. — 
Ed. 


342  DIET   AFTER   WEAXING. 

Constipation  may  often  be  corrected  by  adding  oatmeal  to  the  second 
meal,  or  oatmeal-water  to  the  milk. 

It  should  be  the  invariable  rule  to  confine  children  to  a  liquid  diet  as 
soon  as  any  impairment  of  digestion  or  assimilation  is  noticeable  or  they  be- 
come ill.  Milk  should  always  have  the  preference.  It  may  be  given  pure, 
diluted,  boiled,  or,  perhaps,  predigested.  In  rare  instances  milk  will  not  be 
retained  by  the  stomach,  or  will  be  passed  from  the  bowels  only  partially 
digested.  In  such  cases  a  mixture  of  equal  parts  of  milk  and  lime-water, 
given  in  teaspoonful  doses  every  ten  or  fifteen  minutes,  will  not  infrequently 
be  retained  and  digested.  In  some  cases  where  milk  cannot  be  retained, 
barley-  or  rice-water  may  be  temporarily  substituted.  In  other  cases  beef 
tea,  beef  essence,  or  beef  juice  may  be  administered  in  small  quantities,  fre- 
quently repeated,  with  marked  benefit.    Tea  and  coffee  should  not  be  allowed. 

In  weakly  children  the  following  may  be  given  : 

Chicken  jelly. — Clean  a  fowl  that  is  about  a  year  old,  and  remove  the 
skin  and  fat.  Chop  it,  bones  and  flesh,  and  put  it  in  a  pan  with  two  quarts 
of  water.  Heat  slowly,  and  skim  often  and  carefully.  Let  it  simmer  for 
five  or  six  hours ;  then  add  salt  and  mace  or  parsley  to  taste,  and  strain. 
Set  away  to  cool.  When  cold,  skim  off  the  fat.  The  jelly  is  usually 
relished  cold,  but  may  be  heated.     Give  this  in  small  quantities,  very  often. 

Wine  whey. — Boil  three  wineglasses  of  milk,  and  add  a  wineglass  of 
sherry  or  port  wine.  Strain,  and  add  a  wineglass  of  warm  water.  A  wine- 
glassful  of  this  may  be  given  once  or  twice  a  day. 

White  wine  whey. — To  half  a  pint  of  boiling  milk  add  a  wineglassful 
of  sherry ;  strain  through  a  fine  muslin  cloth,  and  sweeten.  A  tablespoonful 
of  this  may  be  given  every  two  or  three  hours. 

It  is  quite  as  important  to  regulate  the  diet  of  the  second  period  as  that 
of  the  first,  but  much  more  difficult.  At  this  period  the  child  is  walking, 
and  often  helps  itself  to  indigestible  substances.  It  now  has  all  its  milk- 
teeth,  and  is  capable  of  mastication.  Its  mind  is  generally  sufficiently  active 
to  be  taught  what  edible  articles  it  should  have.  Its  power  of  masticating, 
its  flow  of  saliva,  its  good  digestion  and  assimilation,  and  its  increasing 
bodily  growth  demand  a  greater  variety  of  food.  If  it  reach  its  second 
jjeriod  during  the  summer,  and  have  the  appearance  of  health,  and  seem 
satisfied  with  its  milk  and  simple  food,  it  will  be  prudent  to  wait  until  cool 
weather  to  change  its  diet  to  a  more  substantial  kind. 

It  is  now  admissible  to  allow  it  to  eat  at  the  family  table,  because  the 
opportunity  to  begin  its  training  early  should  not  be  overlooked.  It  can 
be  taught  to  eat  slowly,  that  certain  articles  are  not  suitable  for  it,  and 
that  it  can  have  enough  of  the  projaer  kind  of  food.  When  a  child  frets 
for  different  articles  of  food  on  the  table  it  is  generally  because  some  im- 
prudent person  has  allowed  it  to  taste  them.  If  it  is  not  tempted  by  tasting 
other,  it  will  be  contented  with  its  simple  food.  It  should  be  fed  at  least 
four  times  daily,  and  occasionally  will  require  a  few  crackers  or  a  slice  of 
bread-and-butter  between  meals. 


DIET   AFTER    WEANIXG.  343 

First  meal,  8  a.m. — A  portion  of  well-cooked  oatmeal,  wheateu  grits, 
or  corn-meal  mush,  with  a  liberal  supply  of  milk ;  cold  bread-and-butter ; 
and  a  piece  of  finely-cut,  tender  beefsteak,  or  a  soft-boiled  egg. 

Second  meal,  12  m. — A  bowl  of  chicken  or  oyster  soup,  or  weak  beef 
tea ;  milk,  with  bread  or  crackers,  and  butter. 

Third  meal,  4  p.m. — Roast  beef,  mutton,  chicken,  or  turkey  ;  fresh  white 
fish ;  mashed  white  potato,  moistened  with  gravy ;  bread-and-butter ;  and 
rice  and  milk. 

Fourth  meal,  8  p.m. — Milk,  with  bread  or  crackers. 

It  may  be  necessary  to  give  a  glass  of  milk  and  a  piece  of  bread-and- 
butter  between  the  first  and  second  meals ;  and  if  the  child  is  particularly 
hearty  the  same  may  be  occasionally  required  in  the  early  morning. 
Towards  the  latter  part  of  this  period  fresh  ripe  fruits  are  admissible, 
provided  due  care  is  taken  to  prevent  the  ingestion  of  seeds  and  rinds.  A 
popular  fruit  is  the  banana ;  but  the  writer's  experience  has  been  such  that 
he  considers  it  more  productive  of  eclampsia  than  any  other  fruit,  and 
consequently  he  cannot  recommend  it. 

The  meal-hours  vary  in  diiFerent  communities,  so  that  those  for  children 
will  be  governed  by  the  local  customs.  It  may  be  necessary  to  give  the 
principal  meal  earlier  than  four  p.m.  It  must  be  remembered,  however, 
that  most  children  sleep  the  greater  part  of  the  afternoon,  so  that  if  they 
eat  dinner  at  two  o'clock  they  will  be  asleep  during  the  digestion  of  the 
bulk  of  the  day's  solid  food ;  on  the  other  hand,  if  the  meal  be  at  four 
o'clock  there  will  be  active  exercise  after  it  to  aid  digestion  and  assimilation. 

It  will  need  constant  watching  to  prevent  it  from  obtaining  unsuitable 
food. 

Frequently  the  neuroses,  as  eclampsia,  "  night-terrors,"  petit  mal,  and 
the  numerous  symptoms  attributable  to  "  worms,"  may  be  directly  traceable 
to  the  presence  of  indigestible  food  in  the  alimentary  tract.  A  brisk  purga- 
tive seldom  finds  the  "  worms,"  but  generally  allays  the  excessive  exaltation 
of  the  nervous  system  by  removing  the  offending  material. 

When  the  child  is  suffering  from  an  acute  disease,  its  diet  should  be 
limited  to  milk  and  beef  tea.  In  chronic  ailments,  or  in  protracted  conva- 
lescence from  acute  disease,  each  case  must  be  treated  by  its  individual 
requirements,  while  good  judgment  will  render  valuable  assistance  in  the 
selection  of  those  foods  which  are  easily  digested  and  which  possess  the 
maximum  quantity  of  nutritious  matter  to  the  quantity  ingested.  In  sick- 
ness, tea  and  toast  are  favorite  articles,  but  only  load  the  alimentary  tract 
with  innutritions  matter. 

During  the  third  period — from  the  third  to  the  fifth  year — the  difficulty 
of  regulating  the  cJiild's  diet  will  he  great.  It  has  now  reached  the  age 
when  its  friends  will  humor  it  with  knick-knacks  and  table-food  of  difficult 
digestion.  It  has  twenty  teeth,  and  its  friends  cannot  understand  why  it 
should  not  have  such  food  as  a  healthy  adult  can  digest.  A  devoted  mother, 
or  usually  grandmother,  will  argue  that  all  her  children,  at  this  age,  were 


344  DIET   AFTER    WEAXIXG. 

fed  from  the  table  and  were  not  injured.  Such  children  lived  in  spite  of 
mismanagement.  Granting  that  its  diet  must  be  more  liberal  at  this  age,  it 
must  still  be  restricted,  for  even  now  the  presence  of  indigestible  or  undi- 
gested food  in  the  alimentary  tract  may  be  productive  of  reflex  nervous 
disturbances. 

Its  activity  and  waste  and  repair  demand  an  increase  in  the  quantity 
of  nutritious  food.  Three  substantial  meals  a  day  will  usually  suffice,  but 
occasionally  a  snack  between  meals  will  be  required.  While  it  is  well  to 
apply  the  rule  of  regularity,  it  is  not  always  prudent  to  enforce  it,  especially 
if  the  child  is  hungry.  The  practice  of  children  running  to  the  pantry  and 
helping  themselves  should  be  discouraged.  In  such  cases  children  do  not 
eat  enough  at  the  regular  meals. 

It  is  impossible  to  lay  down  "  a  bill  of  fare"  for  this  period,  but  a  frugal 
meal  can  be  selected  from  the  following : 

BEEAKFAST. 

Corn-meal  mush ;  oatmeal ;  wheaten  grits ;  hominy ;  ^^'ith  plenty  of 
cream. 

Potatoes,  baked  and  stewed. 

Eggs,  poached,  soft-boiled,  and  omelet. 

Fish,  fresh,  broiled. 

Meats. — Beef  hash ;  broiled  steak ;  stewed  liver  and  kidney ;  lamb- 
chojjs ;  chicken  fricassee. 

Tomatoes,  sliced  (occasionally). 

Bread. — Cold,  light ;  Graham ;  entire  wheat ;  corn  ;  muffins,  plain  and 
Graham  (occasionally)  ;  corn  and  rice  cakes. 

Fresh  ripe  fruit  may  be  given  in  moderate  quantity. 

Highly-seasoned  food  must  be  avoided. 

LUNCHEON. 

Soups. — Oyster ;  bean  ;  chicken  ;  consomm6. 

Vegetables. — Potatoes,  baked  and  stewed  ;  sliced  tomatoes. 

Meats. — Beefsteak  ;  lamb-chops  ;  cold  lamb  or  mutton. 

Bread. — Cold  rolls  and  soda-crackers. 

Fruits  in  season. 

Pice  and  milk. 

DINNEE. 

Soups. — Consomme ;  noodle ;  oyster ;  cream  of  barley ;  potato ;  chicken ; 
and  chicken  stew. 

Fish. — Fresh,  baked,  broiled,  and  boiled. 

Meats. — Beef,  chicken,  lamb,  and  mutton. 

Vegetables. — Potatoes,  rice,  cauliflower,  macaroni,  peas,  tomatoes,  beans. 

Bread. — Well-cooked  wheaten. 

Desserts. — Rice  and  milk  ;  light  puddings  ;  ice-cream  occasionally. 

Fruits  and  berries  in  season  (fresh  and  sound). 


DIET   AFTER   WEAXIXG.  345 

The  regimen  of  the  sick  during  this  period  docs  not  differ  very  materially 
from  that  of  the  preceding,  except  that,  generally,  a  more  generous  diet  may 
be  allowed.  If  the  illness  be  of  a  nature  demanding  liquid  food,  the 
principles  already  set  forth  will  be  applicable.  In  all  cases  of  illness  the 
food  should  be  reduced  in  quantity  and  changed  in  character,  although  the 
patient  may  not  be  confined  to  liquids.  As  soon  as  the  appetite  becomes 
imj)aired,  the  child  should  be  put  upon  a  simple  diet.  Frequently,  in 
children  of  this  age,  too  much  or  deteriorated  fruit  will  cause  digestive 
disturbances.  Withholding  the  fruit  for  a  few  days  will  usually  effect  a 
cure.  The  child  should  always  have  its  fruit  selected  for  it.  When  sick, 
knick-knacks,  jellies,  and  fancy  dishes  should  be  forbidden.  If  the  illness 
be  protracted,  and  the  food  be  digested  and  assimilated,  it  should  have  the 
most  nutritious  aliment.  This  rule  is  especially  applicable  to  scrofulous, 
syphilitic,  rachitic,  and  tuberculous  children.  We  need  not  wait  for  the 
manifestation  of  these  diatheses.  If  there  is  good  reason  for  suspecting 
their  presence,  the  sooner  the  select  diet  is  begun  the  better ;  and,  even  if 
they  are  not  latent  in  these  children,  the  care  in  feeding  will  prove  beneficial. 

New  troubles  seem  to  arise  during  the  fourth  period  ^^•hich  require  close 
vigilance  over  the  child's  dietary.  At  this  time  the  milk-teeth  begin  to 
decay,  and  the  first  of  the  permanent  teeth  make  their  appearance.  The 
child  has  frequent  attacks  of  toothache,  the  dread  of  which  prevents  him 
from  properly  masticating  his  food.  Consequently,  indigestion  and  diar- 
rhoea, from  bolting  food,  are  of  frequent  occurrence. 

Again,  the  child  is  old  enough  to  be  indulged  by  its  parents  with  every- 
thing they  eat :  hence  the  impossibility  of  restricting  the  diet  as  long  as  it 
is  healthy. 

It  is  advisable  to  select  its  food  from  the  articles  recommended  for  the 
third  period,  with  the  addition,  perhaps,  of  game,  corn,  string-beans,  sweet 
potatoes,  lima  beans,  hot  bread  and  cakes,  and  light  custards  and  puddings. 

In  sickness  the  general  rule  of  restricting  the  diet  according  to  the 
nature  of  each  individual  case  is  also  applicable. 

The  physiological  changes  which  take  place  during  the  fifth  period  would 
seem  to  warrant  the  statement  that  extraordinary  care  should  be  exercised 
in  regulating  the  child's  regimen  between  the  eighth  year  and  puberty. 

The  ingestion  of  highly-seasoned  or  very  rich  food  may  unduly  excite 
the  passions  and  pervert  the  physiological  phenomena  of  boyhood  and  girl- 
hood.    It  is  also  apt  to  cause  lascivious  dreams  and  sexual  excitement. 

The  rules  governing  the  dietary  during  sickness  are  similar  to  those  for 
adults. 

The  use  of  wines  and  beers  should  be  prohibited,  and  that  of  tea  and 
coffee  discountenanced. 

In  discussing  the  diet  for  children  in  the  preceding  pages  the  writer  has 
not  lost  sight  of  the  fact  that  some  regard  should  be  paid  to  the  important 
factor  of  the  circumstances  of  life.  It  is  well  in  jircscribing  a  regimen 
which  has  stood  the  tests  of  the  laboratory  to  remember  that  such  advice  is 


346  DIET   AFTER    WEANING. 

given  to  a  large  number  who  are  not  able  to  incur  the  necessary  expense  of 
typical  feeding.  To  prescribe  such  food  as  that  hereinbefore  recommended 
for  the  child  of  the  laborer,  whose  wages  are  scarcely  adequate  to  support 
his  large  family,  would  entail  hardships  on  those  whose  affections  are 
strongest  for  the  weak  and  afflicted.  The  expense  necessary  to  obtain  cream, 
milk,  and  milk-sugar  will  not  be  considered  by  people  of  even  moderate 
circumstances,  but  will  be  difficult  for  the  mechanic  and  impossible  for  the 
laborer.  Therefore  it  is  important  in  selecting  a  food  for  children,  either 
well  or  ill,  in  the  lower  walks  of  life,  to  recommend  that  which  will  be 
liealthful  and  of  reasonable  cost. 

If  the  following  good  advice  is  impressed  upon  the  nurse,  the  success  of 
treatment  may  be  greater  : 

"  Never  give  re-cooked  meats,  fish,  or  vegetables  to  an  invalid,  and  cook 
only  small  quantities  for  him.  Simplicity,  variety,  and  healthfulness  are 
the  things  to  be  considered  in  preparing  food  for  the  sick.  What  is  good 
for  one  person  is  frequently  injurious  to  another.  One  must  not  become 
impatient  or  discouraged  because  the  invalid  is  changeable  in  his  tastes. 

"  The  eye  as  well  as  the  palate  of  the  patient  is  to  be  considered.  The 
tray  always  should  be  covered  with  a  fresh  napkin ;  the  china,  glass,  and 
silver  should  be  the  daintiest  the  house  affords. 

"  Only  a  few  things  should  be  served  at  a  time :  it  is  better  that  the 
patient  should  think  that  he  has  not  had  enough  to  eat,  than  that  he  should 
lose  his  appetite  on  the  appearance  of  a  large  quantity  of  food." 


NURSING  OF  SICK  CHILDREN. 


By  Miss  CATHEEINE    WOOD. 


There  can  be  no  doubt  that  in  this  department  great  strides  have  been 
made  during  the  last  twenty  years  or  so,  and  perhaps  this  improvement  may 
be  entirely  set  to  the  account  of  the.  children's  hospitals  which  have  now 
sprung  up  everywhere.  The  children  are  important  little  people,  and  set 
so  much  store  by  themselves  that  they  demand  study  and  thought  on  the 
part  of  those  who  would  understand  their  treatment ;  and  all  who  have 
had  experience  in  the  care  of  sick  children  will  admit  that  a  special 
education  and  training  are  required  for  those  who  aim  at  nursing  them 
successfully.  To  a  casual  observer  passing  through  a  ward  of  sick 
children  they  may  seem  all  much  alike, — alike  in  their  restlessness,  in 
their  weariness,  in  their  perpetual  demand  on  the  patience  and  care  of 
their  attendants, — and  yet  to  the  practised  eye  there  is  every  shade  of 
difference  in  that  row  of  cots ;  the  diversities  of  character  are  as  strongly 
marked  as  among  adults ;  even  the  little  babes  differ  one  from  the  other. 
In  the  study  of  these  idiosyncrasies,  and  in  the  adaptation  of  means  to  an 
end,  the  real  child's  nurse  will  at  once  declare  her  aptitude  for  her  task ; 
she  will  see  at  once  that  though  her  duties  should  be  performed  methodic- 
ally and  with  regularity,  each  child  must  be  the  subject  of  special  study,  and 
rules  and  red  tape  made  sufficiently  elastic  to  cover  all. 

It  is  curious  to  review  how  by  degrees  the  little  sick  ones  have  been 
forcing  themselves  to  the  front.  At  first  thev  were  ffrudoino-lv  admitted 
into  the  wards  of  a  general  hospital,  and  then  the  nurses  and  patients  only 
tolerated  them  ;  but  now,  as  in  a  well-ordered  house,  the  children  have 
their  own  department  and  their  own  attendants,  their  special  nurses,  and 
harmonious  arrangements,  or  they  may  be  promoted  to  the  dignity  of  their 
own  hospitals :  whatever  may  be  the  plan  pursued,  the  cliildren  have 
trained  their  nurses  and  instructed  their  doctors,  to  the  manifest  advantage 
of  all  parties.  There  can  be  no  question  that  many  a  sick  child  in  its  own 
hospital,  or  ward,  is  infinitely  better  circumstanced  for  its  recovery  than  in 
its  cot  at  home.  A  child  is  very  sympathetic  and  receptive,  and  when 
one  among  a  number  of  otlier  sick  children,  receiving  oidy  a  portion  of 
a  nurse's  time  and  attention  and  being  acted  upon  by  the  various  har- 

347 


348  NURSING   OF    SrCK    CPrrLDP.EX. 

monious  influences  around,  its  physical  and  vital  energies  are  aroused 
and  directed  to  a  healthy  action,  it  is  taken  out  of  itself,  and  its  mind  is 
diverted  from  its  ailments,  a  result  most  satisfactoiy  for  either  adult  or 
infantile  sick ;  moreover,  it  is  saved  from  the  inevitable  spoiling  that  is  the 
natural  end  of  home  nursing,  or  it  is  rescued  from  the  mischievous  and 
sometimes  fatal  indulgence  of  its  Avliims  iind  fancies ;  it  is  tided  over  the 
fretful  stage  of  convalescence  almost  unnoticed,  and  returns  to  its  home  a 
little  hero,  fit  to  take  its  usual  place  in  the  family.  Tiic  sad  exjicrience  of 
every  doctor  who  has  had  to  treat  a  spoiled  child  at  home  ^v\\\  confirm 
this :  the  child  refuses  to  take  its  medicine  or  food,  and  the  united  efforts 
of  the  parents  and  household  are  useless ;  it  remains  master  of  the  situa- 
tion, a  hardened  little  sinner.  Or  some  particular  posture  must  be  main- 
tained to  allow  an  inflamed  joint  to  recover  itself;  it  screams  and  kicks  at 
all  efforts  to  place  it  aright,  it  frets  if  fastened  do^vn,  and  refuses  its  food, 
until  at  last  it  is  allowed  to  lie  as  it  lik'cs,  and  valuable  time  is  wasted. 
Place  that  same  little  one  iii  a  cliildren's  hospital  in  the  hands  of  doctors 
and  nurses  accustomed  to  children,  and  it  at  once  becomes  tractable ;  all 
friction  and  contests  are  avoided ;  it  follows  the  example  of  the  next  cot, 
and  swallows  medicine  and  food  quietly  ;  it  submits  to  he  laid  down,  for  it 
seems  the  fashion  of  this  nursery  and  so  must  be  right.  Then  the  atmos- 
phere of  play  and  merriment  carries  it  over  the  tedious  hours  of  a  clironic 
illness  almost  unnoticed.  Dr.  West,  who  Avas  certainly  the  pioneer  in  ini- 
tiating a  specialty  in  the  treatment  of  sick  children,  says  in  his  opening 
lecture  to  students,  "  Children  will  form  at  least  one-third  of  all  your 
patients ;  so  serious  are  their  diseases  that  one  child  in  five  dies  within  a 
year  after  birth,  and  one  in  three  before  the  completion  of  the  fifth  year. 
These  facts,  indeed,  afford  conclusive  arguments  for  enforcing  on  you  the 
importance  of  closely  watching  every  attack  of  illness  that  may  invade  the 
body  while  it  is  so  frail."  If  the  medical  attendant  is  being  educated  by 
his  patient,  the  nurse  also  is  its  pupil ;  for  the  cliild  will  not  be  nursed  by 
any  one,  it  is  as  elective  in  its  tastes  as  the  most  experienced  valetudinarian, 
and  those  who  aim  at  nursing  sick  children  must  have  the  art  of  winning 
the  child's  love  and  confidence  at  the  onset.  Then  on  this  the  special  train- 
ing may  l)e  based,  the  power  to  observe,  to  interpret  aright  these  ol^serva- 
tions,  to  understand  and  anticipate  the  wants  of  the  patient,  to  comprehend 
the  em])hatic  but  unspoken  language  of  the  aspect,  manner,  ciy,  posture, 
etc.,  of  sickness ;  it  must  be  the  first  object  of  the  nurse  to  learn  these,  or 
she  will  fail  in  her  task;  and  she  must  also  bring  to  her  aid  invincible 
patience,  gentleness,  cheerfulness,  good  temper,  and  self-restraint.  She  will 
not  only  have  to  learn  how  to  feed  a  refractory  child,  but  she  must  grasp 
the  method  and  science  of  giving  fi)od  so  as  to  sustain  the  strength  and  yet 
not  overtax  the  powers ;  she  will  have  to  adjust  her  foods  to  the  most 
irritable  stomach  as  well  as  the  rebellions  one;  and  above  all  she  will  have 
to  steel  her  lieart  to  the  pathetic  petition  for  indulgences  or  treats.  She 
must  also  learn  how  to  combine  firmness  with  gentleness,  how  to  insist 


NURSING    OF   SICK    CHILDREN.  349 

M'ithout  coercion,  liow  to  win  obedience  without  friction,  how  to  take  her 
patient  along-  with  her;  and  all  this  can  be  accomplished  only  by  love  and 
truthfulness.  Once  win  the  child's  trust,  and  then  it  will  yield  itself  a 
williuiy  slave.  The  most  fearless  truthfulness  should  be  insisted  on  from 
all  those  who  have  to  tend  the  sick  child,  even  when  it  wrings  the  loving 
heart  to  speak  the  truth.  The  pain  the  child  will  feel  will  be  far  less  than 
upon  finding  itself  deceived,  especially  when  among  strangers. 

It  is  very  touching  when  among  sick  children  to  see  the  quiet  and  con- 
tented way  in  which  they  lie  in  their  cots,  thankful  to  be  only  let  alone  ;  and 
it  is  this  letting-alone  which  is  so  important  in  nursing  a  sick  child.  The 
less  the  child  is  handled  the  better.  The  poor  mothers  in  their  own  homes 
make  quite  a  toil  of  their  children ;  they  will  hardly  put  them  out  of  their 
arms,  and  they  certainly  will  not  believe  that  the  child  can  be  thriving 
unless  they  are  dandling  it  on  their  knees ;  both  are  quite  wearied,  mother 
and  child.  But  this  is  all  mistaken  kindness.  A  sick  child  will  thrive 
best  if  laid  quietly  in  its  own  cot,  so  that  the  fresh  air  may  play  around  it, 
and  that  it  may  rest.  Its  little  face  will  soon  lose  the  worried  look  that 
is  so  often  marked  on  the  faces  of  the  children  of  the  poor,  and  a  look 
of  happiness  and  content  will  take  its  place.  It  is  not  difficult  to  accus- 
tom the  children  to  lie  quiet ;  at  first  they  will  be  restless  and  fret  at  not 
being  taken  u}),  but  when  they  see  that  their  frettings  are  of  no  avail,  with 
the  ready  adaptability  of  childhood  they  make  the  best  of  it,  and  soon 
find  how  much  the  best  it  is. 

It  is  most  essential  in  the  care  of  sick  children  that  they  should  b^ 
supplied  with  plenty  of  light  and  fresh  air,  in  neither  case  pouring  in 
directly  on  them,  but  flooding  them  all  round  in  generous  profusion. 
They  by  no  means  appreciate  the  darkened  room  and  hushed  voice :  like 
the  plants  in  the  garden,  they  expand  under  the  rays  of  light ;  and  there 
can  be  no  doubt  that  the  light  has  a  physiological  influence  on  their  growth 
and  development,  especially  so  in  the  case  of  illness.  Therefore  in  arranging 
the  sick-room,  let  it  have  as  much  of  the  light  as  possible,  a  southern  or 
western  aspect,  and  a  free  circulation  of  air  tlirough  it,  by  maintaining 
an  interchange  witli  the  outer  air  witliout  makino;  a  draught :  and  this 
should  be  kept  up  by  night  as  well  as  by  day,  especially  in  crowded  cities. 
Of  course  in  certain  fever  cases,  in  acute  diseases  of  the  brain  or  diseases 
of  the  eye,  a  darkened  room  may  be  required. 

I.     THE   SICK   CHILD. 

The  sympathetic  nature  of  the  child  is  at  once  affected  by  any  deviation 
from  the  standard  of  licalth  ;  its  organism  is  like  a  delicate  machine,  dis- 
turbed by  the  presence  of  a  minute  grain  of  sand ;  it  at  once  gives  token 
that  there  is  some  morbific  influence  at  work.  The  severe  onset  of  an 
illness,  its  rapid  course,  and  its  speedy  termination  either  in  recovery  or 
death,  are  always  matters  of  surprise  to  those  unaccustomed  to  sick  children  ; 
and  so  it  requires  that  the  attendants  should  be  fully  on  the  alert  to  catch 


350  NURSING    OF   SICK    CHILDREN. 

each  new  symptom,  give  it  its  value,  and  be  prepared  with  appropriate 
treatment.  It  is  hardly  a  safe  course  for  the  mother  to  wait  until  her 
child's  illness  has  declared  itself  before  she  takes  action ;  and  even  then,  as 
a  mild  domestic  ailment  and  an  acute  disease  may  alike  assume  the  same 
symptoms,  she  would  act  more  wisely  to  seek  some  skilled  assistance,  for, 
however  experienced  a  mother  may  be,  she  can  hardly  read  symptoms 
aright.  Or  it  may  be  that  one  of  the  infantile  infectious  complaints  is 
declaring  itself;  and  then  for  the  sake  of  the  other  children  some  system 
of  isolation  is  necessary. 

Illness  at  first  shows  itself  in  a  child  by  listlessness  and  loss  of  appetite ; 
the  eyes  look  heavy ;  the  child  may  be  fretful,  especially  if  disturbed,  or  it 
may  be  drowsy ;  it  will  feel  hot,  and  if  the  temperature  be  taken  the  ther- 
mometer will  generally  show  an  elevation  above  the  normal ;  but  this  in 
itself  must  not  be  regarded  with  disquiet,  as  a  very  little  suffices  to  disturb 
the  normal  heat  of  the  body ;  in  nearly  all  cases  there  will  be  vomiting 
and  some  bowel-disturbance,  and  then  special  symptoms  will  declare  them- 
selves. In  the  older  child,  one  able  to  give  some  account  of  itself,  the 
symptoms  generally  set  in  in  the  same  sequence,  and  they  must  be  taken  as 
a  warning  that  something  is  amiss.  The  best  treatment  is  to  wait  and  see 
what  is  coming,  at  the  same  time  placing  the  child  in  favorable  circum- 
stances,— that  is,  keeping  it  quiet  and  away  from  its  fellows,  giving  it  light 
food,  of  easy  digestion,  seeing  that  the  bowels  are  not  overloaded,  and  then 
waiting  for  the  diagnosis  of  the  medical  attendant. 

Age  has  much  influence  upon  the  diseases  of  children,  and  if  it  is  borne  in 
mind  that  before  the  age  of  seven  years  the  body  is  being  built  up  rapidly, 
and  this  means  a  great  expenditure  of  vital  force,  it  is  more  easily  under- 
stood that  a  small  disturbing  cause  will  seriously  upset  the  equilibrium  of 
its  powers.  It  is  of  more  importance  to  keej)  a  child  in  health  than  to 
restore  it  from  illness  to  its  normal  condition ;  and  very  much  may  be  done 
by  regularity  in  all  its  habits.  Appropriate  food  at  regular  intervals  will 
drill  the  digestive  apparatus  into  strong,  healthy  ways ;  regular  hours  of 
rest  and  exercise  will  soothe  and  strengthen  the  nerve-centres  ;  the  muscular 
powers  will  be  developed  by  use,  and  the  mental  faculties  develop  them- 
selves in  harmony  wdth  the  animal  vigor.  There  are  certain  crises  in  the 
child's  life  that  must  always  be  reckoned  with  as  causes  of  disturbance, — 
notably,  the  period  of  teething.  This  is  a  sea  of  troubled  waves,  over 
which  the  little  bark  must  be  sensibly  steered  and  it  will  voyage  in  safety ; 
but  then  it  is  a  natural  process,  for  which  provision  has  been  made  in  the 
child's  constitution,  and  if  its  surroundings  and  habits  are  healthful  it  will 
pass  over  the  storm  with  but  little  danger.  Of  more  serious  moment  are 
the  hereditary  defects  that  are  ever-present  dangers  to  the  child  life  and 
will  break  out  into  flame  with  the  least  spark  and  will  modify  acute  disease 
by  their  influence.  If  the  mother  has  a  good  knowledge  of  her  child's 
constitution,  she  may  do  much  to  defend  the  weak  point  by  engendering 
a  wholesome  habit  of  living.     This  much  is  quite  certain,  that  no  two 


NURSING   OF   SICK   CHILDREN.  351 

children  are  alike,  and  that  they  will  thrive  the  best  who  receive  the 
most  individual  thought. 

Of  secondary  importance,  but  by  no  means  to  be  forgotten,  is  the  child's 
nursery  :  here  three-fourths  of  its  day  will  be  spent,  and  its  aspect  and  tra- 
ditions wall  never  die  out  of  the  child's  life.  It  is  of  paramount  importance 
that  it  should  be  bright,  cheerful,  clean,  and  Avholesome,  that  its  presiding 
genius  should  be  a  lovable,  common-sense  woman,  and  that  order  and 
method  should  rule  its  habits.  The  little  ones  will  then  look  back  upon 
their  nursery  days  as  some  of  the  brightest  in  their  life. 

It  may  become  the  sad  necessity  to  turn  this  bright  room  into  a  sick- 
ward.  In  such  case,  turn  all  the  unnecessary  articles  of  furniture  out  of 
the  room,  take  up  the  carpet,  remove  the  hangings  if  there  are  any,  and 
have  at  hand  everything  that  is  likely  to  be  wanted,  extra  basins,  jugs, 
cups,  and  feeders,  small  pans  for  the  linen,  a  plentiful  supply  of  water  and 
liberal  means  of  making  it  hot,  baths,  and  a  ready  supply  of  linen.  Keep 
all  these  appliances  handy,  but  outside  the  room,  and  also  outside  have 
vessels  for  receiving  the  slops,  so  that  nothing  offensive  may  be  about  the 
patient.  Provide  a  good  supply  of  some  disinfectant  in  a  concentrated 
form,  to  be  readily  w-eakened,  and  let  this  be  freely  used  on  the  floor,  in 
the  vessels,  and  for  soaking  the  linen  from  the  patient.  Last,  but  of  no 
less  importance,  is  the  choice  of  the  sick  child's  nurse.  It  docs  not  follow 
that  either  the  mother  or  the  nurse  is  the  most  fitting ;  the  one  may  be  too 
nervous  and  excitable,  the  other  too  indulgent  or  ignorant :  what  is  wanted 
is  a  steady,  reliable  woman,  who  can  manage  the  patient  with  kindness  and 
firmness,  who  can  be  trusted  to  carry  out  orders  and  yet  have  a  discretion 
of  her  own,  cheerful  and  even-tempered,  physically  strong  in  the  face  of 
an  extra  demand  on  her  jiow^ers,  cool  and  self-possessed  in  an  emergencv, 
and,  above  all,  with  a  love  for  her  work  and  her  patient.  If  added  to 
these  qualifications  there  is  hospital  training,  then  the  right  attendant  is 
found.  It  is  very  essential  that  as  far  as  possible  the  management  of  the 
sick-room  should  be  kept  in  the  hands  of  one  person,  so  that  there  mav  be 
a  unity  of  treatment  and  that  methodical  harmony  whicli  is  of  more  im- 
portance in  sickness  than  in  health  ;  and  then,  if  the  assistants  are  obedient, 
good  work  may  be  done.  There  are  few  things  more  harmful  tlian  the 
fidgety  nursing  that  one  so  often  sees  in  the  family.  The  nurse,  if  she 
shows  herself  to  be  a  woman  of  tact  and  sympathy,  will  soon  infuse  her 
spirit  into  the  members  of  the  fiimily,  and  they  will  readily  work  under 
her  guidance. 

Tliere  are  many  little  niceties  of  method  and  order  that  form  ])art  of  the 
training  of  a  nurse  in  the  hospital  wards,  that  w'ill  add  to  the  comfort  of  the 
patient.  A  child  with  any  form  of  joint-disease  or  fever  is  easily  washed 
in  the  recumbent '  position  on  a  blanket,  being  rolled  gently  from  side  to 
side,  and  in  the  case  of  an  injured  limb  it  must  be  steadied  with  one  hand 
or  by  a  second  person,  and  tlien  there  is  very  little  pain  or  displacement.  It 
is  a  great  husbanding  of  the  strength  in  fever,  especially  typhoid,  to  keep 


352  KUESING    OF   SICK    CHILDEEN. 

the  patient  always  lying  down,  and  the  whole  of  the  person  can  be  properly 
washed  in  this  way.  This  is  the  sovereign  preventive  of  bed-sore,  especially 
in  cases  of  paralysis,  where  the  evacuations  are  not  retained,  and  enables 
the  nurse  to  see  at  once  any  weakness  of  the  skin.  Complete  drying  of 
the  skin  must  be  insisted  on,  and  the  liberal  use  of  dusting-powder,  and 
then  a  child  may  lie  for  months  on  its  back  without  any  ill  effects.  An 
important  part  of  the  nurse's  work  is  to  prepare  her  patient  for  a  physical 
examination,  and  to  do  this  quickly  and  readily  without  undue  exposure  is  a 
sign  of  good  training.  It  is  very  irritating  to  a  doctor  to  watch  a  nurse 
fumbling  at  buttons  and  strings,  and  it  wearies  the  child.  Before  the  time  of 
the  doctor's  visit  she  should  have  all  the  clothing  loosened,  and  a  blanket 
warming  at  the  stove  to  wrap  the  child  in  if  it  is  to  be  taken  out  of  bed. 
If  the  child  is  to  be  examined  in  bed,  the  night-gown  and  vest  are  drawn 
over  the  head  and  placed  on  the  stove  to  keep  warm  :  this  is  a  little  detail, 
but  it  is  important  for  a  delicate  child  to  be  saved  the  chill  of  cold  garments 
when  exhausted  by  the  examination.  A  loose  wrap  will  serve  to  cover  the 
parts  not  under  observation ;  and  if  the  doctor  uses  the  towel  whilst  exam- 
ining the  chest,  be  sure  that  it  is  one  well  aired.  If  the  patient  is  removed 
from  the  bed,  the  nurse  will  take  the  child  in  the  warmed  blanket  on  her  lap 
and  be  ready  to  adjust  it  to  the  doctor's  needs.  Some  little  gentleness  and 
coaxing  are  required  to  prevent  the  child  from  being  frightened,  and  a  few 
moments  of  time  must  be  spent  in  winning  the  patient's  confidence  and 
allaying  its  fears  ;  and  if  this  is  successfully  accomplished,  the  patient  will 
probably  look  upon  the  whole  as  a  game  for  its  amusement.  Should  some 
operation  be  necessary  without  an  anaesthetic,  it  is  far  better  to  tell  the 
child  that  it  will  be  hurt  a  little  bit,  and  if  the  instrument  be  kept  out  of 
sight  the  fright  will  be  very  momentary.  It  is  marvellous  how  patiently 
children  submit  to  painful  remedies  if  only  they  are  treated  with  candor. 
In  putting  on  hot  applications  it  must  be  borne  in  mind  that  the  child's 
skin  is  more  sensitive  and  tender  than  an  adult's,  and  that  the  test  of  the 
nurse's  hand  is  not  sufficient ;  the  child's  sensations  must  be  the  guide.  It 
is  a  cruel  thing  to  put  on  a  fomentation  or  poultice  too  hot,  and  it  does 
no  good  if  it  excites  the  child.  If  a  blister  is  ordered,  it  can  be  put  on 
more  efficiently  with  blistering  fluid,  care  being  taken  that  it  does  not 
run,  and  if  put  on  at  night  the  child  will  generally  sleep  through  it; 
the  after-treatment  will  be  according  to  the  instructions  of  the  medical 
attendant.  Children  are  very  tolerant  of  blisters,  and  in  Avise  hands  they 
are  useful  remedies.  The  application  of  leeches  is  more  complicated :  the 
sight  of  them  must  frighten  the  child,  so  they  should  be  dealt  with  quickly 
and  decidedly.  The  easiest  way  is  to  turn  the  box  on  to  the  part,  which 
should  be  first  well  washed,  and  then  wait  until  they  have  all  taken ;  or 
take  them  up  in  cotton-wool  in  the  mass  and  hold  them  on ;  in  either  way 
the  child  does  not  see  them  moving  about,  and  if  the  cotton-wool  is  left 
on  they  will  not  be  very  evident.  They  must  be  left  until  they  drop  off, 
and  then  the  part  washed,  pads  of  lint  or  absorbent  wool  put  on,  and  the 


NUESIXG    OF   SICK    CHILDEEX,  353 

whole  bandaged  up.     The  nurse  must  be  on  the  watch  for  after-bleediuo- 
and  report  to  the  doctor. 

Leeches  should  not  be  placed  on  the  prominence  over  a  bone,  nor  on  a 
vein,  nor  on  any  part  that  receives  pressure.  The  pain  is  not  severe,  and 
the  fright  is  caused  more  by  the  sight  of  them  than  by  their  bite.  If 
possible,  the  child  should  be  kept  quiet  after  the  application,  or  the  bleed- 
ing may  become  troublesome. 

A  very  frequent  remedy  ordered  is  an  enema,  either  as  a  medicine  in 
diarrhoea  or  constipation,  or  as  a  means  of  giving  food.  Its  nature  and 
quantity  will  be  prescribed  by  the  doctor,  but  its  administration  will  be  in 
the  hands  of  the  nurse.  Supposing  it  is  to  check  diarrhoea,  it  will  probably 
consist  of  starch  and  opium,  and  should  be  made  as  small  in  bulk  as  possi- 
ble,— not  more  than  two  or  four  teaspoonfuls  of  mucilage  with  the  quan- 
tity of  opium  prescribed ;  if  to  deal  with  constipation,  it  will  be  large  in 
quantity,  such  as  a  pint  of  soapy  water  warm,  or  gruel  and  castor  oil,  or 
soap  and  castor  oil ;  and  after  the  injection  has  been  given  leave  the  patient 
quiet  until  there  is  a  desire  to  return  it.  The  tube  should  be  well  oiled 
and  passed  up  the  rectum  gently  as  far  as  it  will  go.  In  giving  nutrient 
enemata,  the  food  must  be  made  as  concentrated  as  possible,  and  be  a  little 
thickened  with  starch  powder  or  arrowroot.  Four  ounces  is  as  much  as 
the  bowel  will  retain  with  advantage. 

A  nurse  who  knows  her  work  will  know  that  she  has  to  put  out  the 
urine  for  testing  by  the  doctor :  it  should  be  a  small  quantity  taken  from 
the  first  passed  in  the  morning,  and  let  it  be  put  aside  in  a  clean  vessel 
and  covered  over. 

It  may  be  that  she  is  instructed  to  measure  and  record  the  amount  of 
urine  passed  in  the  twenty-four  hours :  in  such  case  she  must  have  a  suit- 
able vessel,  such  as  a  marked  jug  or  glass,  provided  for  her,  and  then  should 
begin  her  observations  thus.  Let  her  fix  on  an  hour,  say  nine  a.m.,  at 
which  to  take  the  observation  :  on  the  first  morning  let  the  child  pass  water 
at  that  hour,  and  then  throw  it  away :  all  the  water  passed  subsequently  is 
to  be  saved,  and  at  nine  a.m.  the  next  morning  the  child  is  to  be  invited  to 
pass  water,  and  then  the  whole  quantity  is  measured,  recorded,  and  thrown 
away.  If  the  specific  gravity  is  to  be  taken,  the  nurse  must  be  shown  how 
to  use  the  little  instrument  that  weighs  it,  and  how  to  record  it. 

It  is  also  part  of  the  nurse's  duty  to  examine  the  evacuations  and 
report  on  them,  and  in  any  case  of  doubt  to  save  them  for  inspection.  On 
this  point  there  is  a  great  deal  of  ignorance  and  diversity  of  opinion  :  one 
nurse  will  call  that  diarrhoea  which  another  nurse  will  name  only  "  a  little 
looseness,"  and  so  on.  The  presence  of  slime  and  blood  in  the  evacua- 
tions should  be  at  once  reported,  and  the  stool  saved  for  inspection ;  also 
the  presence  of  undigested  food.  The  frequency  of  the  action  and  the 
quantity  must  likewise  be  observed,  and  intelligent  answers  given  to  the 
doctor's  questions. 

Vol.  I.— 23 


354  NURSING   OF   SICK   CHILDREN. 


II.     MANAGEMENT  IN   SICKNESS. 

The  diseases  of  young  children  are  so  frequently  induced  by  bad 
management  that  the  medical  attendant  will  rely  very  much  for  the  success 
of  his  remedies  upon  the  intelligence  and  good  management  of  the  nurse. 
He  may  lay  down  theoretical  rules  for  feeding  and  rest  which  may  be 
entirely  upset  by  the  wilfulness  of  his  patient.  What  is  to  be  done  with  a 
child  who  will  not  take  milk,  where  that  is  the  special  diet  indicated  by  its 
complaint  ?  What  is  to  be  done  with  a  child  who  will  sleep  by  day  and  feed 
by  night  ?  Or  with  one  who  refuses  all  food  ?  In  diarrhoea  and  vomiting, 
the  administration  of  food  has  much  to  do  with  the  recovery  :  first  of  all  it 
must.be  suitable,  then  it  must  be  given  in  such  quantities  as  will  suit  the 
digestion,  then  it  must  be  given  regularly  and  with  patience,  and  it  must  be 
freshly  prepared.  All  the  vessels  used  for  it  should  be  scrupulously  clean, 
for  the  least  trace  of  decomposition  will  upset  the  stomach. 

The  popular  feeding-bottle  with  the  india-rubber  tube  is  a  great  offender  : 
it  is  almost  impossible  to  prevent  particles  of  food  from  clinging  to  its  inner 
surface,  and  as  these  decompose  they  will  taint  the  most  carefully  pre- 
pared food.  The  bottle  and  nipple  need  careful  scalding  and  rinsing,  and 
should  be  kept  in  cold  water  betweentimes.  If  an  infant  hand-fed  is 
troubled  with  diarrhoea  and  vomiting,  look  to  the  bottle  first.  As  a  sub- 
sidiary measure,  and  one  of  some  importance,  see  that  the  loins  and  the 
abdomen  are  quite  warmly  clothed.  In  feeding  a  child  who  has  a  delicate 
or  irritable  stomach  it  is  of  great  importance  to  give  the  food  in  small 
quantities  and  as  frequently  as  the  digestion  will  bear. 

In  all  diseases  of  the  respiratory  organs  the  child  requires  a  warm,  even 
temperature,  not  made  stuffy  or  poisonous  by  want  of  efficient  ventilation, 
but  a  constant  temperature  kept  up  with  a  free  interchange  of  fresh  air. 
This  requires  a  little  management,  but  it  can  be  done.  What  is  essential  is 
that  the  external  air,  which  is  the  freshest,  should  be  admitted  steadily,  and 
the  temperature  kept  from  falling  below  60°  F.  The  means  by  which  this 
is  to  be  brought  about  must  be  left  to  the  nurse's  ingenuity,  but  she  must 
remember  that  letting  in  the  used-up  air  off  the  staircase  and  passages  is 
not  ventilating  with  fresh  air. 

At  times  it  is  a  great  relief  to  the  patient  to  moisten  the  air  with  steam  ; 
this  is  best  done  by  surrounding  the  bed  with  some  light  curtains  or  screen 
and  then  letting  the  steam  come  into  the  bed  from  some  suitable  apparatus, 
care  being  taken  that  there  is  an  escape  from  the  top  of  the  bed,  or  the 
curtains  will  become  damp.  This  is  an  essential  in  the  treatment  of  laryn- 
gitis and  diphtheria  after  the  operation  of  tracheotomy,  it  being  advisable 
to  moisten  and  Avarm  the  air  before  it  enters  immediately  into  the  lungs 
through  the  tube. 

It  will  not  be  necessary  in  an  article  of  this  nature  to  give  instructions 
for  dealing  with  diphtheria  or  laryngitis,  as  these  cases  require  incessant 
care  on  the  part  of  both  medical  attendant  and  nurse.     Still,  a  few  hints 


NURSING   OF   SrCK   CHILDREN.  355 

of  arrangement  may  be  of  use.  There  are  few  cases  that  demand  more 
skilled  nursing  than  diphtheria,  and  the  attendance  on  such  cases  should  be 
always  put  into  the  hands  of  old,  experienced  nurses,  especially  after  the 
operation  of  tracheotomy,  as  careful  feeding  and  watching  by  an  experienced 
nurse  are  essential  to  recovery.  One  small  precaution  may  prevent  the 
nurse  from  taking  a  disease  which  is  propagated  by  the  breath,  and  that  is 
to  keep  her  mouth  closed  whilst  standing  over  the  patient,  and  to  use  a  dis- 
infectant for  washing  the  hands  before  taking  her  meals.  A  basin  of  weak 
carbolic  solution  should  be  put  near  the  cot  for  washing  the  sponges,  etc., 
used  about  the  patient,  and  all  feeding-cups,  spoons,  and  glasses  must  be 
kept  apart.  Linen  over  a  piece  of  waterproof  to  make  a  bib  and  pinned 
over  the  neck  of  the  child's  night-dress  is  a  clean  way  of  keeping  the  neck 
dry  and  wholesome ;  for  it  must  be  remembered  that  the  diphtheritic  dis- 
charges are  most  irritating  to  the  skin.  To  sum  up,  a  nurse  in  dealing  with 
these  cases  must  be  prepared  for  a  work  that  will  tax  all  her  skill,  patience, 
and  vigilance :  her  patient  will  require  incessant  watching,  and  will  make 
endless  demands  on  her  ingenuity.  Instead  of  pocket-handkerchiefs,  some 
rao:s  that  can  be  burnt  at  once  are  advisable. 

When  infectious  diseases  are  in  the  house,  very  much  may  be  done  by 
way  of  precaution  in  the  use  of  disinfectants  for  the  linen  and  the  dis- 
charges before  they  are  taken  out  of  the  room,  as  it  is  in  these  that  the 
germs  of  disease  are  conveyed.  A  sheet  kept  moistened  with  some  disin- 
fectant, and  hung  over  the  outside  of  the  door  of  the  sick-room,  is  very 
eifective.  Then,  of  course,  there  should  be  no  intercourse  between  the  in- 
habitants of  the  sick-room  and  the  rest  of  the  household,  and  the  nurse  and 
friends  should  change  their  garments  before  going  out.  The  floor  of  the 
sick-room  should  be  swept  with  saw-dust  moistened  in  the  disinfectant,  and 
all  dust  and  refuse  should,  if  possible,  be  burnt.  In  scarlet  fever  in  the 
desquamating  stage,  it  is  the  practice  of  some  doctors  to  have  the  patient 
rubbed  over  with  an  ointment  ;•  some,  on  the  other  hand,  say  that  the  oil 
retards  the  process  of  desquamation  and  closes  the  pores  of  the  skin ;  but, 
whatever  treatment  is  adopted,  it  is  essential  that  the  skin  be  kept  clean 
by  frequent  sponging  with  warm  water,  and  by  baths,  and  that  the  patient 
be  kept  warm  in  bed  until  the  process  is  over.  Every  precaution  should 
be  taken  to  hinder  the  dust  from  the  bed  or  room  from  being  scattered 
about. 

Measles  is  a  much  more  unruly  disease  to  deal  with ;  it  starts  infection 
in  the  early  stage,  before  the  eruption  has  declared  itself,  and  so  spreads 
among  a  household  almost  unchecked.  The  same  rules  of  disinfection  will 
apply  to  this;  it  is  of  importance  to  keep  the  patient  in  a  warm  room,  in 
bed, until  the  eruption  has  quite  disappeared,  and  longer  still  if  there  is  any 
tendency  to  lung-disease,  as  shown  by  a  continued  high  temperature  and  the 
state  of  the  breathing. 

In  this  and  in  all  other  eruptive  diseases  the  diet  should  be  light 
and  nourishing  and  with  but  little  animal  broth  or  tea  in  it,  as  this  is  apt 


356  NURSING   OF   SICK    CHILDEEN. 

to  be  over-stimulating,  except  when  contra-indicated  by  great  prostration. 
Careful  observation  of  the  temperature  is  of  great  assistance  to  the  nurse. 
It  begins  to  fall  about  the  third  day  ;  but  if  it  persists  high  or  rises  above 
103°,  then  the  nurse  must  be  on  the  alert  for  some  complications  and  look 
out  for  all  symptoms  that  may  aid  the  doctor  in  detecting  the  mischief,  and 
for  her  part  she  must  keep  her  patient  warm,  lying  down,  pay  attention  to 
the  evacuations,  and  support  the  strength  with  careful  systematic  feeding. 

Whatever  may  be  the  nature  of  the  illness,  one  great  essential  in  its 
nursing  is  scrupulous  cleanliness  in  the  person  of  the  patient  and  in  all  its 
surroundings.  A  sick  child  should  be  washed  all  over  every  day,  and  some- 
times twice  a  day ;  every  part  of  its  body  should  be  examined,  that  the  first 
sign  of  a  sore  may  be  detected,  or  any  change  in  its  condition,  such  as  a 
swelling,  discoloration,  or  enlargement  about  a  joint,  and  such  information 
should  be  handed  over  to  the  doctor  at  the  earliest  opportunity.  In  the 
case  of  young  babies,  their  skin  requires  washing  and  drying  each  time  the 
napkin  is  changed ;  a  nurse  who  knows  her  work  well  will  be  able  to  keep 
her  charges  clean  and  their  wants  anticipated  without  giving  in  to  these  lazy 
ways.  If  the  patient  is  to  be  clean,  so  must  also  the  bed,  and  all  soiled 
linen  at  once  be  taken  away,  not  pushed  under  the  bed  out  of  sight,  nor 
one  wet  end  of  the  sheet  tucked  under  the  mattress,  but  absolutely  put  in 
its  proper  receptacle,  where  it  will  do  no  harm.  The  hospital  draw-sheet 
is  very  useful  on  the  sick-bed  ;  it  can  be  quickly  drawn  away  without  much 
disturbance  to  the  patient,  and  another  substituted.  A  draw-sheet  is  a  nar- 
row, long  sheet,  about  one  and  one-half  yards  long  by  three-fourths  of  a 
yard  wide,  of  a  coarser  material  than  the  linen,  and  is  placed  under  the 
body  of  the  patient,  sometimes  with  a  square  of  mackintosh  under  it ;  it 
tucks  in  well  and  keeps  things  straight. 

III.    FEEDING. 

It  is  hardly  possible  to  exaggerate  thfe  importance  of  the  subject  with 
which  this  section  deals.  Nine-tenths  of  the  ailments  of  children  are 
caused  by  erroneous  feeding ;  and  it  is  not  too  much  to  say  that  many  lives 
are  lost  in  sickness  that  might  have  been  saved  if  only  the  nurse  had  under- 
stood something  of  this  art.  And  it  is  an  art ;  for  when  we  consider  that 
the  free  will  of  man  is  very  rampant  in  infancy,  and  that  it  is  quite  possible 
for  the  wilfulness  of  the  babe  to  puzzle  the  skill  of  its  elders,  it  will  be 
understood  that  the  feeding  of  a  wilful  sick  child  is  a  problem  of  no  ordi- 
nary complexity.  In  the  first  place,  there  are  varying  ideas  as  to  the 
quantity  that  a  child  should  consume,  and  as  to  the  frequency  with  which 
food  should  be  given,  and  also  as  to  its  component  parts.  Nature  has  given 
a  standard  as  to  what  is  the  proper  food  and  proper  quantity  for  the  infant, 
and  from  this  she  intends  us  to  work  out  the  problem. 

In  the  case  of  a  child  constitutionally  weak,  that  has  to  be  brought  up 
by  hand,  the  problem  of  feeding  is  very  difficult ;  the  child's  diet  must  be 
carefully  studied,  and  then  that  food  which  seems  to  suit  it  best  must  be 


NUESIXG   OF   SICK    CHILDREN.  357 

adhered  to.  In  dealing  with  these  difficnlt  cases,  all  theories  must  be  laid 
aside,  and  that  food  used  which  agrees  the  best.  The  addition  of  five  drops 
of  brandv  to  each  feed  for  twenty-four  hours  or  so  will  often  give  the  tone 
and  vitality  to  the  stomach  that  it  has  lost  through  weakening  diarrhoea 
and  vomiting.  A  little  gentle  friction  over  the  abdomen  with  carefully- 
sustained  warmth  may  bring  about  an  improvement. 

Another  essential  in  rational  feeding  is  that  it  should  be  systematic. 
Supposing  that  a  child  has  to  take  one  and  a  half  or  two  pints  of  food  in 
the  twenty-four  hours,  then  let  this  be  divided  into  equal  quantities,  to  be 
given  at  equal  intervals  of  time.  Suppose  that  the  diet  consists  of  milk 
one  pint,  beef  tea  one  pint,  with  some  stimulant,  then  it  will  be  found  that 
an  alternate  feed  of  two  ounces  every  hour  will  use  up  the  quantity  in  the 
time.  This  mode  of  feeding  naturally  applies  in  its  frequency  to  serious 
illness,  where  the  strength  requires  such  sustenance ;  but  where  the  child's 
condition  permits,  it  is  of  importance  to  allow  the  stomach  its  night's  rest 
with  the  rest  of  the  body.  It  is  a  mistake  into  which  hospital  nurses  fall 
to  consider  that  night-feeding  is  as  essential  as  day,  unless  otherwise  ordered  : 
better  than  all  food  is  a  good  sound  sleep,  and  a  little  nourishment  given 
early  in  the  morning,  when  vitality  is  low,  is  then  of  great  value. 

In  typhoid  fever  systematic  and  rational  feeding  is  nine-tenths  of  the 
treatment :  as  long  as  the  temperature  keeps  high, — and  that  will  be  gener- 
ally for  three  weeks  at  the  shortest  computation, — the  patient  must  be  kept 
strictly  to  a  fluid  mild  diet,  such  as  milk  and  beef  tea,  Avith  no  admixture 
of  bread  or  starch  foods.  The  well-meant  but  mistaken  efforts  of  relatives 
to  interfere  with  the  diet  of  a  typhoid  patient  must  be  sternly  set  aside. 

A  useful  mode  of  feeding  when  a  child  is  refractory,  or  when  from  any 
other  cause  it  cannot  take  its  food,  is  through  the  nose.  In  skilled  hands 
this  is  a  useful  accessory,  but  in  over-ambitious  hands  its  use  may  be  fatal. 

IV.     BATHING. 

Some  children  dread  the  water :  the  origin  of  this  fear  is  very  often 
caused  by  roughness  in  washing  them,  or  by  hustling  them  too  suddenly 
into  a  bath.  Rickety  children  are  essentially  tender  to  the  touch,  and  they 
require  gentle  handling  when  in  the  bath. 

As  the  bath  is  essential  for  both  the  healthy  and  the  sick  child,  the 
nurse  must  use  her  ingenuity  to  overcome  the  fear.  An  ordinary  warm 
bath  sliould  be  of  the  temperature  of  98°  F.,  and  this  should  be  decided 
by  the  use  of  a  thermometer  and  not  by  the  nurse's  hand.  Let  the  child 
be  quite  ready  for  the  bath  when  the  bath  is  ready  for  the  child,  or  it 
will  be  cooling.  When  the  bath  is  over,  have  at  hand  a  warmed  blanket 
on  which  to  place  the  child  whilst  being  dried  ;  let  the  drying  be  done  quickly 
and  the  child  be  put  into  its  warmed  garments  for  bed.  If  a  douche-bath 
is  ordered  and  the  regular  appliances  are,  not  handy,  place  the  child  in 
an  ordinary  warm  bath,  standing  if  possible,  and  then  pour  a  jug  of  cool 
water  down  the  spine  from  a  height,  or  on  to  that  particular  part  for  which 


358  NUESIXG    OF   SICK    CHILDEEX. 

the  douche  is  ordered.  Eub  the  part  well  with  a  rough  towel,  so  as  to  get 
up  good  circulatiou,  and  knead  it  with  the  hand.  If  a  bath  is  ordered 
to  reduce  the  temperature,  its  temperature  should  be  65°  F.  The  bath 
being  brought  to  the  bedside,  the  patient  is  lowered  in  on  a  blanket  and 
kept  in  it  five  or  ten  minutes,  according  to  the  doctor's  orders ;  then  the 
patient  is  dried  quickly  and  put  back  to  bed. 

In  cases  of  skin-disease  an  oatmeal  bath  is  very  useful,  of  course  using 
no  soap.  A  sulphur  bath,  used  in  cases  of  scabies,  is  made  by  dissolving 
half  a  pound  of  sulphur  in  a  bath  of  ordinary  size  and  warmth.  The 
patient  remains  in  it  from  twenty  to  thirty  minutes.  The  sulphur  turns  all 
metal  black,  and  the  offensive  smell  from  the  bath  suggests  that  it  be  given 
in  some  out-of-the-way  place. 

In  very  young  children  and  in  babes  a  w^arm  bath  should  be  a  part  of 
the  daily  programme,  morning  and  night,  for  it  is  most  essential  that  the 
pores  of  the  tender  skin  should  be  kept  freely  open  and  healthy.  Use  a 
soft  Turkey  sponge,  and  then  dry  the  body  tenderly  but  carefully;  and 
let  the  soap  that  is  used  be  the  purest.  As  the  child  groAvs  older,  the 
bath  may  be  made  tepid,  until  at  last  it  may  be  strong  enough  to  take  a 
cold  bath.  In  administering  the  cold  bath,  keep  the  feet  from  the  cold 
water,  then  give  a  good  dash  of  cold  water  all  over  the  body  with  a  large 
sponge,  and  quickly  dry  the  body.  If  the  reaction  is  imperfect  and  the 
surface  is  blue,  then  the  tepid  must  be  substituted  for  the  cold  bath,  as  the 
shock  is  too  great  for  the  system.  No  child  under  seven  years  of  age  should 
take  a  cold  bath ;  and  it  is  an  essential  in  all  bathing  that  the  skin  and  the 
hair  be  dried  thoroughly.  A  cork  or  a  toy  in  the  bath  will  often  reconcile 
the  nervous  child  to  the  inevitable. 

V.     CLOTHING  AND   THE    BED. 

It  is  an  essential  in  the  clothing  of  a  sick  child  that  it  should  be  loose, 
light,  easily  changed,  and  sufficient.  A  sick  child  does  not  make  the  same 
use  of  its  bedclothes  that  the  sick  adult  does,  and  so  some  warm  jacket  must 
be  put  on  to  keep  its  chest  and  shoulders  protected.  The  bedclothes  also 
must  be  light  and  warm,  and  not  douJDled  in  a  heavy  fold  over  the  chest, 
perhaps  already  ovenveighted  with  some  difficulty  in  breathing. 

When  the  patient  first  gets  up  it  is  necessary  that  the  surface  of  the 
body  be  thoroughly  well  covered  with  light  warm  clothing,  put  on  quite 
loosely.  Woollen  clothing  is  more  warmth-giving  than  cotton,  and  is  lighter. 
JSTeither  in  sickness  nor  in  health  should  the  child's  body  be  confined  in  stiff 
clothing ;  binders  and  stays  of  all  kinds  are  a  mistake ;  they  interfere  with 
the  free  use  of  the  muscles,  and  do  not  improve  the  shape.  In  construction 
also  the  clothing  should  be  simple  and  easily  put  on  and  off.  It  would 
not  be  advisable  in  this  chapter  to  advise  any  patterns  or  styles  for  the 
children's  dress ;  but,  laying  down  these  rules  as  above,  feminine  ingenuity 
may  easily  devise  a  shapely  garment  that  will  harmonize  with  them  and 
with  the  child's  requirements.     In  sickness,  the  flannel  vest  and  bed-gown 


NURSING    OF    SICK    CHILDREN.  359 

require  frequent  changing ;  and  it  is  a  great  soother  of  the  night's  rest  to 
change  the  garments  entirely  at  the  child's  usual  bedtime.  In  dealing  with 
surgical  cases  which  must  be  kept  in  one  position,  it  facilitates  the  process 
to  have  a  night-gown  open  down  its  whole  length ;  the  same  applies  to 
patients  with  typhoid  fever. 

In  arranging  the  bedclothes  for  a  child  that  has  been  cut  for  stone,  a  cir- 
cular bedpan  placed  under  a  circular  air-cushion  and  the  sheets  arranged 
accordingly  will  serve  to  keep  the  little  patient  quite  dry.  The  same  can 
be  done  when  the  patient  has  paralysis  with  no  control  over  the  sphincters. 

In  preparing  a  bed  for  an  operation,  or  where  the  patient  must  remain 
on  it  for  a  long  time,  a  firm  hair  mattress  should  be  selected,  and  a  con- 
tinuous board  placed  under  it,  two  sheets  folded  straight  down  the  centre, 
so  that  they  can  be  easily  withdrawn  and  kept  in  their  places  with  a  draw- 
sheet,  and  then  the  rest  of  the  clothing  arranged  so  as  to  give  the  most 
warmth.  All  creases  must  be  carefully  avoided,  as  they  will  cause  a  sore ; 
and  if  pillows  are  required  to  support  a  limb,  they  should  be  firm,  like  sand 
pillows,  and  as  small  as  possible.  A  good  feather  pillow  is  often  of  use  for 
slinging  a  limb ;  but  every  appliance  must  be  adjusted  to  the  restlessness  of 
childhood  and  to  the  tender  nature  of  its  skin.  It  is  wonderftil  how  tolerant 
children  are  of  one  posture  and  of  long  confinement  in  bed,  if  only  they  are 
placed  in  a  comfortable  position  and  well  amused ;  and  they  will  maintain 
an  ordinary  standard  of  health  under  such  circumstances,  if  fed  sensibly. 

It  may  strike  the  reader  that  many  of  these  details  are  needlessly  minute ; 
but  it  is  by  attention  to  such  minutiae  that  the  work  of  nursing  a  sick  child 
back  to  health  may  be  accomplished.  Nothing  is  too  small  that  contributes 
to  such  an  object,  and  those  who  have  had  much  experience  in  the  care  of 
sick  children  know  that  all  their  success  will  depend  upon  careful  thought 
for  these  details. 

There  can  be  no  doubt  that  it  is  very  hard  work  to  nurse  a  sick  child ; 
but  there  also  can  be  no  doubt  that  the  hard  work  amply  repays  itself  in 
its  results. 


NURSERY  HYGIENE. 

By  L.  M.  YALE,  M.B. 


NuRSEEY  Hygiene  in  its  full  sense  includes  the  same  topics  and  covers 
the  same  ground  as  does  general  hygiene,  with  such  variations  as  to  details 
as  are  required  by  the  ages  of  the  occupants  of  the  nursery.  But  in  the 
present  work  these  subjects  have  been  assigned  to  various  hands,  and  this 
article  will  not  consider  the  care  of  the  new-born,  the  feeding  of  infants 
and  young  children,  nor  dentition,  but  will  be  restricted  to  suggestions 
concerning  the  nursery  itself,  its  situation  and  surroundings,  its  warming 
and  ventilation ;  nursery  nuisances  and  their  avoidance ;  the  dress,  bath, 
and  toilet  of  children,  and  the  care  of  their  food. 

While  it  is  true  that  as  regards  many  of  these  topics  medical  advice  is 
rarely  asked,  it  is  also  true  that  to  the  mass  of  persons  the  family  physician 
is  the  only  sanitary  authority,  and  that  by  opportune  suggestions  he  may 
do  much,  in  the  aggregate,  in  the  way  of  the  prevention  of  disease.  How- 
ever much  such  guidance  may  be  necessary  in  general,  it  is  still  more 
imperatively  demanded  in  nursery  matters,  owing  to  the  exaggerated 
susceptibility  of  young  children  to  the  depressing  influence  of  unwholesome 
surroundings,  and  the  far-reaching  effects  of  such  influence  upon  their 
development.  It  seems  proper,  therefore,  to  call  attention,  even  at  the  risk 
of  insisting  upon  truisms,  to  details  which  are  often  relegated  to  the  discre- 
tion of  nurses. 

The  Nursery  Itself. — Of  course  na  nurser}'-  can  be  thoroughly  health- 
ful unless  the  house  itself  is  such, — is  well  placed  upon  good  soil,  and  so 
constructed  in  detail  that  the  rules  of  sanitation  have  been  consciously  or 
unconsciously  considered.  The  space  at  our  command  does  not  permit  any 
discussion  of  these  rules.  It  will  be  assumed  that  the  house  is  as  well 
situated,  as  well  drained,  as  well  built,  and  as  well  lighted  as  the  means  of 
the  owner  or  occupant  will  permit.  The  details  which  follow  are  such  as 
assist  in  making  the  nursery  the  most  healthful  part  of  a  good  house,  and 
as  wholesome  as  practicable  in  a  defective  one. 

In  selecting  a  room  for  a  nursery,  that  should  be  chosen  which  is  the 

sunniest,  best  aired,  and  driest;    and  in  deciding  between  two  or  more 

houses  in  other  respects  equally  eligible,  distinct  preference  should  be  given 

to  that  one  admitting  of  the  best  arrangements  for  nursery  pui-poses.     In 

360 


NURSERY    HYGIEXE.  361 

houses  where  no  room  is  to  be  specifically  set  apart  as  a  nursery,  and  chil- 
dren are  to  occupy  the  general  living-room  by  day  and  the  parents'  bedroom 
by  night,  the  same  rules  should  govern  the  selection  of  these  rooms,  the 
sanitary  benefit  in  such  case  accruing  to  adults  and  children  alike.  When 
the  nursery  is  separate  it  is  preferably  to  be  placed  above  the  ground-floor, 
unless  the  latter  be  unusually  well  raised  from  the  ground,  but  it  should 
not  be  immediately  under  a  roof,  on  account  of  the  difficulty  of  regulating 
the  temperature  in  such  a  situation. 

The  beneficial  influence  of  sunlight  needs  no  insisting  upon  ;  neverthe- 
less it  is  constantly  overlooked.  The  nursery  should,  if  possible,  look  to 
the  south,  or  as  nearly  so  as  the  situation  of  the  house  permits,  with  a 
morning  exposure  in  preference  to  an  afternoon  sun,  if  but  one  can  be  had. 
The  windows  should  be  ample  in  size,  and  more  than  one  if  possible,  as 
they  not  only  serve  for  the  admission  of  light,  but  in  the  ordinary  dwelling 
are  the  only  avenues  of  ventilation.  The  sensibility  to  the  loss  of  sunlight 
seems  to  vary  somewhat  with  adult  individuals,  but  we  believe  that  all 
children  suffer  from  its  absence ;  and  the  physician  should  insist  upon  the 
daily  complete  sunning  of  the  apartment.  In  summer,  even,  it  is  usually 
better  to  have  the  sun  and  to  mitigate  its  power  at  proper  times  by  means 
of  awnings  and  blinds  than  to  have  a  room  upon  which  it  does  not  shine. 
There  may  be  circumstances  of  climate  or  of  prevailing  winds  which 
will  modify  this  rule,  but  it  holds  in  general.  The  room  should  be  of 
ample  size,  particularly  if  it  serve,  as  is  the  rule  in  ordinary  houses,  the 
double  purpose  of  night  and  day  nursery.  The  precise  amount  of  space 
required  for  each  child  will  vary  with  the  arrangements  for  ventilation,  but 
not  less  than  fifteen  hundred  cubic  feet  of  air  per  hour  should  be  allowed, 
and  preferably  double  that  amount. 

As  only  in  the  houses  of  the  wealthy  can  a  room  be  specially  set  apart 
as  a  sick-bay  or  hospital,  the  nursery  must  ordinarily  serve  that  purpose 
whenever  illness  occurs.  For  this  reason,  as  well  as  for  others,  the  furnish- 
ing of  a  nursery  should  be  as  simple  and  as  easy  of  cleansing  as  is  consistent 
with  comfort.  The  floor  should  be  of  smooth,  closely-joined  boards,  pref- 
erably of  hard,  close-grained  wood.  The  ssams,  if  they  open  by  shrinkage, 
should  be  closed  either  by  relaying  or  by  calking  well  done.  Poor  calking 
is  worse  than  useless,  and  any  calking  is  inconvenient  in  rooms  the  floors 
of  which  must  be  raised  to  reach  gas-  or  water-pipes,  as  is  unfortunately 
often  the  case.  Carpets  are  necessary  to  comfort,  ])ut  moval)lc  carpets  or 
rugs  are  fixr  preferable,  as  permitting  more  frequent  cleansing  both  of  the 
carpet  and  floor.  At  the  present  time  even  cheap  grades  of  carpet  are  made 
in  rug  form,  or  the  desired  pattern  can  be  made  up  witli  tasty  borders  with- 
out much  expense.  In  case  of  actual  illness  of  a  contagious  nature  the 
rugs  may  be  taken  away  at  once,  and  their  contamination  be  prevented, 
wliich  in  view  of  the  difficulty  of  subsequent  disinfection  is  very  desirable. 
The  same  precaution  against  dangerous  dirt  leads  to  the  preferring  of  painted 
and  varnished  to  papered  walls  for  the  nursery,  even  at  the  loss  of  some 


362  NUESEPvY    HYGIENE. 

beauty  in  the  apartment.  If  paper  is  strongly  insisted  on,  it  should  be  of 
a  kind  that  can  be  thoroughly  varnished  and  will  admit  of  being  washed, 
and  all  old  paper  must  be  first  removed  before  new  is  laid.  The  furniture 
of  the  room  should  be  as  light  as  consistent  with  serviceability,  in  order  that 
the  pieces  may  be  easily  moved  from  place  to  place  to  admit  of  frequent 
cleansing ;  and  for  the  same  reason,  every  bulky  or  heavy  article  should 
have  large  and  strong  casters.  It  is  further  desirable  that  all  furniture 
should  be  as  plain  and  simple  as  possible,  carved  wood  and  thick  upholstery 
stuffs  being  objectionable  as  receptacles  for  dust.  Taste  may  be  gratified 
without  violating  this  requirement.  Further,  all  cupboards,  closets,  and 
similar  places  of  deposit  should  be  as  open  to  inspection  as  possible,  in  order 
that  offensive  or  untidy  things  may  easily  be  detected  and  removed.  On 
account  of  this  facility  of  examination  and  cleansing,  the  writer  usually 
prefers  shelves  with  a  removable  curtain  in  front  to  closed  cupboards  and 
deep  drawers.  The  latter  are  suitable  enough  for  clean  linen,  but  are 
temptations  to  careless  attendants  to  indulge  in  "  tuck-away  neatness." 

Warming  and  Ventilation  can  only  be  touched  upon  in  this  article.  If 
the  nurseiy  is  in  a  house  with  a  good  system  of  heating  and  ventilating, 
nothing  in  particular  will  be  needed  except  a  grate  or  a  stove  for  use  in 
emergencies.  Ordinarily,  however,  even  houses  which  have  a  fairly  good 
furnace  or  other  heating-apparatus  have  no  specific  arrangements  for  ven- 
tilation beyond  what  are  afforded  by  the  windows,  chimneys,  and  imper- 
fections of  structure.  The  ordinary  methods  of  warming  in  use  in  this 
country  are  open  fires,  stoves,  and  hot-air  furnaces.  The  hot-air  furnace, 
if  properly  constructed,  is  quite  satisfactory.  Its  commonest  faults  are  the 
'delivery  of  too  small  a  quantity  of  air  at  too  high  a  temperature  (a  larger 
quantity  at  a  lower  temperature  being  preferable),  and  such  an  arrangement 
of  its  cold-air  flue  that  the  supply  is  from  an  impure  source.  The  former 
difficulty  is  overcome  by  having  the  furnace  considerably  larger  than  neces- 
sary and  by  keeping  the  fire  moderate ;  the  latter,  by  using  a  tight  metal  flue 
the  outer  end  of  which  is  free  from  unwholesome  surrounding  and  preferably 
raised  some  feet  from  the  ground,  by  which  means  some  of  the  foul  air  of 
dark  city  back-yards  or  of  the  gutters  is'  avoided.  The  same  precaution 
is  of  use  in  many  country  houses.  The  outer  end  must  be  protected  by  a 
wire  screen,  to  prevent  mischief  being  done  by  children  or  small  animals. 
If  the  screen  be  fine-textured  it  will  diminish  the  amount  of  dust  drawn 
into  the  house.  For  a  nursery  it  is  of  advantage  to  have  the  registers  for 
warm  air  rather  high,  as  this  arrangement  makes  a  better  general  circulation 
of  air,  diminishes  the  intensity  of  floor-draughts,  and  renders  meddling 
with  the  register  by  small  children  more  difficult. 

The  open  fireplace  has  for  advantages  cheerfulness  of  aspect  and  a  fair 
amount  of  ventilating-power,  for  disadvantages  great  wastefulness  of  fuel 
in  proportion  to  its  heating-power,  so  that  ordinarily,  when  this  is  the  only 
source  of  heat,  great  differences  of  temperature  exist  in  different  parts  of  the 
room ;  if  the  neighborhood  of  the  fire  is  comfortable,  the  remoter  parts  are 


NUESEEY   HYGIENE. 


363 


cold.  Further,  it  ventilates  by  the  production  of  draughts,  particularly  of 
floor-draughts,  which  are  especially  dangerous  in  the  nursery,  where  little 
children  spend  so  much  of  their  time  upon  the  floor.  The  wood  fire  is  very 
beautiful  and  useful  when  a  short,  quick  heat  is  needed,  but,  aside  from  its 
costliness,  it  is  not  so  good  for  steady  heating  as  a  coal  fire.  In  the  nursery 
any  open  fire  must  be  carefully  guarded  by  a  strong  wire  screen,  to  prevent 
accidents  from  sparks  or  from  the  clothing  of  children  taking  fire.  Stoves  of 
the  ordinary  close  varieties,  the  "  air-tights,"  are  very  economical  of  fuel,  but 
nearly  useless  as  ventilators,  and  if  used  make  especial  watchfulness  as  to 
ventilation  necessary.  The  ventilating  stoves  which  are  the  ofPs2:)ring  of  the 
old  "  Franklin"  make  a  compromise  by  which  all  the  ventilating  value  of 
the  open  grate  is  preserved  with  far  less  waste  of  fuel,  about  three  times 
as  much  of  the  heat-value  of  a  given  amount  of  fuel  being  utilized  by  these 
stoves  as  by  the  open  fire.  The  principle  of  construction  in  its  simplicity  is 
to  surround  the  stove  and  its  smoke-flue  for  some  distance  with  an  air- 
chamber  ;  to  this  chamber  air  is  admitted,  preferably  from 
out  of  doors,  and  as  it  is  warmed  it  is  poured  into  the 
room  at  a  higher  point, — for  instance,  near  the  mantel. 
As  regards  all  stoves,  it  is  perhaps  safer  to  have  no 
damper  in  the  smoke-flue,  or  else  to  fasten  it  so  that  it 
cannot  be  closed  without  difliculty,  since  by  so  doing  the 
danger  of  the  gases  of  combustion  being  forced  into  the 
room  is  removed. 

Ventilation,  in  a  house  which  has  been  constructed 
with  no  reference  to  it,  usually  must  be  accomplished  by 
simple  devices  or  not  at  all ;  any  radical  improvements 
would  be  practical  reconstruction.  The  most  natural  thing 
to  do  to  let  in  fresh  air  and  let  out  foul  is  to  open  a  win- 
dow ;  but  this  of  course  in  cold  weather  involves  danger- 
ous draughts;  We  cannot,  with  our  fickle  and  often  severe 
climate,  even  do  as  some  English  writers  suggest  should 
be  done, — fasten  the  upper  sash  so  that  it  cannot  be  quite 
closed.  Window-ventilation,  therefore,  must  in  winter  be 
carried  on  by  means  of  some  contrivance  which  will  break 
the  force  of  the  current  of  air  and  direct  it  upward  so 
that  it  may  be  diffused  about  the  room.  The  "elbow- 
tube"  ventilator  placed  under  the  lower  sash  is  well  known  ; 
so  are  various  wire  screens,  either  vertical  or  rotating  like 
a  transom.  A  very  useful  one,  and  the  simplest  and 
cheapest,  is  the  common  window-board,  which,  fitting 
against  the  inside  of  the  lower  sash,  allows  the  latter  to  be  raised  and  the 
current  of  air  inward  is  sent  directly  upward  at  the  overlapping  of  the  two 
sashes.  The  board  should  be  at  least  eight  inches  higli.  The  plan  of  a 
stout  cloth  nailed  across  the  lower  part  of  the  window  allows,  when  the 
sash  is  raised,  two  currents,  one  above  and  one  below.     The  writer  thinks 


sU.\- 


364  NURSERY   HYGIENE. 

he  gets  the  same  advantages  by  modifying  the  window-board  as  in  the 
figure.  The  strip  B  runs  the  whole  length  of  the  board.  If  it  is  desired 
to  shut  off  the  lower  current,  the  sash  is  left  in  contact  with  the  strip ;  if 
the  lower  current  is  desired,  it  is  left  below  the  strip,  as  at  A. 

The  stove  with  jacket  used  in  barracks  seems  to  be  well  adapted  for 
nursery  use.  The  stove  is  surrounded  by  a  jacket  of  sheet  zinc  or  iron, 
with  necessary  doors,  leaving  space  between  the  stove  and  the  jacket.  This 
should  come  to  the  floor,  and  the  cold  air  be  brought  from  out  of  doors  to 
within  the  jacket  by  means  of  a  small  pipe ;  the  air  escapes  warmed  at  the 
top  of  the  jacket.  For  the  nursery  the  jacket  has  the  advantage  of  being 
a  safeguard  against  burns,  at  least  against  severe  ones. 

The  getting  of  foul  air  out  is  a  rather  more  difficult  problem,  especially 
with  stove  heat.  An  open  window  with  the  double  current  described  will 
do  fairly  well  under  favorable  circumstances,  but  is  rarely  sufficient  when 
an  air-tight  stove  is  used.  If  in  the  construction  of  chimneys  a  ventiiating- 
flue  is  included,  or  if  the  smoke-flue  is  enclosed  in  a  space  which  may  serve 
as  a  ventilation-flue  (as,  for  instance,  a  stove-pipe  running  up  within  a 
chimney  which  has  a  fireplace  at  the  bottom),  it  is  easy  to  ventilate  a  room. 
If  the  chimneys  are  already  closed  in,  the  cheapest  and  at  the  same  time  an 
efficient  method  is  to  have  an  air-flue  leading  from  near  the  floor  into  the 
chimney  higher  up.  The  upward  current  of  air  in  the  latter  draws  the 
air  through  the  ventilatlng-shaft.  It  is  more  efficient  if  placed  near  the 
stove,  so  that  the  air  within  it  is  heated  and  its  upward  movement  hastened. 
Its  mouth  is  placed  low,  to  save  unnecessary  waste  of  warm  air. 

It  should  be  remembered  that  the  artificial  light  of  lamps  or  gas  in  a 
room  rapidly  spoils  air  for  breathing.  Lighting-capacity  is  usually  meas- 
ured in  candles,  and  an  average  adult  produces  rather  less  than  twice  as 
much  carbonic  acid  as  one  candle :  as  a  consequence,  a  large  kerosene  lamp 
or  gas-burner  often  equals  the  production  of  five  or  six  adults.  It  is  very 
desirable,  therefore,  if  a  night-light  is  necessary  in  the  nursery,  that  its 
carbonic  acid  be  got  rid  of;  and  by  the  device,  often  used  for  ventilating 
purposes,  of  putting  the  burner  or  lamp  within  or  beneath  a  tube  or  flue 
going  to  the  roof  or  chimney,  the  results  of  combustion  are  carried  away 
and  an  outward  current  of  small  power  is  also  established.  By  having  at 
the  bottom  of  the  flue  a  box,  with  a  door,  to  contain  the  light,  the  latter 
inay  be  shut  off  partly  or  wholly  except  when  needed. 

As  to  the  temperature  of  the  nursery  authorities  are  not  quite  agreed ; 
but  it  is  certain  that  in  American  cities  it  is  usually  too  high,  in  common 
with  that  of  the  rest  of  the  house.  Children  and  adults  are  often  forced  to 
endure  in  winter  apparel  a  temperature  (70°  F.  and  upward)  which  in  sum- 
mer is  considered  to  demand  much  lighter  dress.  There  are  good  reasons 
why  the  standard  of  house-temperature  is  usually  set  high  in  America,  but 
it  is  carried  too  far.  The  discrepancy  between  in-door  and  out-door  tem- 
perature is  made  too  great,  the  skin  and  mucous  membranes  are  made  sensi- 
tive, and  the  multitudinous  forms  of  "  colds"  favored.     We  believe  that  if 


NURSERY    HYGIENE.  365 

a  room  can  be  uniformly  heated,  65°  F.  will  be  found,  on  the  whole,  more 
comfortable  and  healthful  than  the  usual  70°  F.,  which  latter  should  not  be 
exceeded.  Where  intelligent  supervision  of  the  temperature  can  be  relied 
upon,  we  believe  that  a  still  lower  degree  than  65°  F.  will  be  healthful  to 
children  old  enough  to  play  about.  At  night  the  temperature  should  not  be 
allowed  to  fall  too  far  below  the  day  standard  ;  and  especial  pains  should  be 
taken  to  guard  against  the  uncovering  of  children  in  bed. 

A  word  should  be  added  concerning  windows.  As  is  well  known,  the 
loss  of  heat  from  the  cold  glass  is  very  great :  Mr.  Hood  puts  it  that  by 
each  square  foot  of  glass  more  than  one  and  one-quarter  cubic  feet  of  air 
(1.279  cu.  ft.)  will  be  lowered  each  minute  as  many  degrees  as  the  diiference 
between  the  internal  and  external  temperatures.  If,  for  instance,  the  ther- 
mometer outside  showed  no  colder  than  freezing  temperature,  32°  F.,  and 
within  no  higher  than  67°  F.,  the  discrepancy  would  be  still  35°  F.  A 
window  three  feet  by  six  feet  would  expose  eighteen  feet  of  glass  surface, 
and  according  to  this  rule  it  would  cool  each  minute  (18  X  35  X  1.279=) 
805+  cubic  feet  one  degree,  or  about  two  hundred  cubic  feet  four  degrees. 
This  makes  a  constant  current  of  descending  cold  air  near  a  window,  very 
sensibly  felt  by  any  one  obliged  to  work  in  such  a  place  in  cold  weather. 
It  is  important,  then,  that  children  should  not  play  immediately  near  a 
window  in  cold  weather,  and  a  low  article  of  furniture  may  be  often  so 
placed  as  to  keep  them  away  without  the  trouble  of  constant  oversight. 
The  ingenuity  of  the  attendant  will  similarly  devise  means  of  keeping 
them  from  sitting  on  the  floor  if  it  be  draughty. 

Besides  the  admission  of  pure  air  and  the  discharge  of  foul  air,  jDurity 
of  atmosphere  demands  that  no  nursery  nuisances  be  allowed  to  exist.  It 
is  better  that  no  plumbing  of  any  sort  should  be  in  the  room  itself.  Bath 
and  closet  conveniences  are  very  necessar}^,  but  should  be  a  little  removed 
and  well  ventilated.  In  houses  that  are  not  plumbed,  a  place  to  which 
all  offensive  or  soiled  articles  can  be  directly  removed  should  be  provided, 
which  place  should  have  free  ventilation.  In  especial  all  soiled  napkins  and 
vessels  containing  evacuations  or  urine  should  be  promptly  removed,  and 
in  case  of  sickness  a  vessel  should  be  provided  in  which  the  napkins  or 
stools  can  be  disinfected. 

Under  ordinary  circumstances,  however,  disinfectants,  in  the  usual 
sense  of  the  word,  have  no  place  in  the  nursery  nor  in  hygiene  generally. 
A  place  that  cannot  be  made  wholesome  by  sunlight,  air,  and  cleanliness 
should  not  be  occupied.  Whenever  emergencies  demand  their  use,  they 
should  be  of  the  safest  kinds  consistent  with  efficiency,  and  after  a  conta- 
gious illness  only  the  more  costly  contents  of  the  nui'sery  should  be  disin- 
fected ;  the  cheaper  ones  can  be  burnt  with  greater  ultimate  economy.  For 
this  reason  we  always  urge  that  toys  be  of  the  cheapest  description,  particu- 
larly if  of  such  a  kind  as  readily  to  conceal  supposed  sources  of  contagion. 
The  painting  of  walls  and  ceilings  and  the  closely-laid  floor  already  urged 
are  of  great  assistance  in  promoting  efficiency  of  disinfection. 


366  NURSERY   HYGIENE. 

Toilet. — Baths  have  many  uses  in  the  nursery  as  remedial  agents,  both 
as  lessening  temperature  and  as  quieting  nervous  irritation  of  various  sorts. 
They  are  here  considered  only  in  their  hygienic  uses  as  a  part  of  the  toilet : 
thus  employed,  their  object  is  simply  cleanliness  and  the  aiding  of  the 
proper  functions  of  the  skin,  with  practically  little  intent  to  produce  the 
stimulant  effect  incident  to  the  cool  morning  bath.  Such  a  bath  needs  to  be 
of  a  moderately  high  temperature ;  that  is  to  say,  not  very  much  below  the 
usual  skin-temperature,  so  that  no  great  eifect  shall  be  had  upon  the  general 
system.  By  using  warm  water,  moreover,  a  smaller  amount  of  soap  and  of 
friction  is  necessary  for  cleansing ;  both  of  which  in  excess  tend  to  irritate 
the  delicate  skin  of  infancy.  Only  the  best,  purest,  and  blandest  soaps 
should  be  used.  While  undue  coddling  is  to  be  avoided,  all  "  hardening" 
or  "  toughening"  regimen  is  distinctly  pernicious  in  infancy,  and  is  to  be 
used  with  judgment  according  to  individual  constitution  throughout  the 
developmental  years.  The  power  of  a  bath  at  a  given  temperature  (ac- 
cording as  the  effects  of  a  hot  or  a  cold  bath  are  sought)  is  much  greater 
when  the  body  is  immersed  than  when  it  is  sponged  for  the  same  length 
of  time.  For  this  reason,  in  children  at  all  feeble  the  immersion  should  be 
brief  or  omitted  altogether.  The  bath  should  never  be  allowed  to  become 
a  domestic  fetich,  but  its  objects  be  kept  in  mind  and  its  results  noted.  For 
young  infants  in  ordinary  health  the  method  of  administration  followed  by 
intelligent  nurses  is  entirely  satisfactory.  The  bath-tub  contains  water  of 
about  95°  F.,  which  may  cool  a  few  degrees  during  the  operation.  The 
child,  lying  upon  the  bath-blanket  spread  upon  the  nurse's  lap,  is  sponged 
with  soap  and  warm  water,  particular  attention  being  paid  to  those  parts 
most  likely  to  have  sebaceous  accumulations  or  to  be  otherwise  soiled,  such 
as  the  scalp,  armpits,  groins,  and  seat.  This  done,  the  child  is  dipped  into 
the  bath  for  simple  rinsing,  laid  in  its  blanket,  and  dried  with  it  without 
rubbing.  As  it  grows  older  its  back  is  supported  by  the  hand  of  the  nurse 
and  it  is  allowed  to  frolic  in  the  water  for  a  few  minutes,  the  exercise  of 
kicking  and  its  pleasure  insuring  a  healthy  reaction  after  the  bath.  If  a 
child  is  alarmed  at  its  bath,  the  immersion  should  be  omitted  or  very  brief, 
as  fright  will  counteract  any  benefit  from'  the  immersion,  and  may  often  be 
accepted  as  evidence  that  from  some  cause  the  procedure  is  unsuitable.  If 
it  enjoys  the  bath,  its  immersion  may  be  gradually  prolonged  and  the  tem- 
perature somewhat  diminished,  say  to  85°  F. 

Toilet-powders  are  not  necessary.  Their  purpose  is  only  to  dry  the 
skin.  This  is  better  done  by  careful  pressure  with  soft  cloths  with  little 
friction.  If  irritation  exists  around  the  seat  or  in  the  groins  or  in  other 
places  where  moisture  is  usually  excessive,  powder  may  be  useful.  "We 
prefer  mineral  to  vegetable  powders,  on  account  of  their  freedom  from  fer- 
meutive  changes.     Powdered  talc  we  think  the  best. 

If  a  cold  bath  is  to  be  used  for  its  stimulating  effect  upon  a  young  child, 
before  the  full  bath  the  bath  by  affusion  should  be  tried,  the  child  standing 
in  a  tub  while  the  water  is  applied  by  squeezing  it  from  a  full-sized  sponge. 


NUESERY   HYGIENE.  367 

The  shower  and  douche  baths  have  no  place  in  the  nursery  except  as  thera- 
peutic resources. 

For  very  young  children,  sea-bathing,  unless  ordered  as  a  remedy,  is 
rarely  desirable.  When,  however,  a  child  is  old  enough  to  take  pleasure  in 
it,  at  the  age  of  about  three  years  on  the  average,  it  may  be  begun,  warm 
weather  and  a  place  where  the  surf  is  very  gentle  being  chosen.  It  is  of 
the  utmost  importance  that  the  child  should  not  be  alarmed  :  fright  under 
such  circumstances  is  deleterious  physically  and  morally.  The  bath  for  a 
child  of  this  age  should  consist  of  but  a  few — at  first  but  one  or  two — dips, 
a  warm  wrap  being  at  hand  and  the  child  taken  directly  away  for  drying. 
If  the  "  reaction"  from  the  bath  is  satisfactory, — i.e.,  if  the  skin  promptly 
becomes  warm  and  the  child  not  depressed, — the  number  of  immersions  may 
be  gradually  increased,  and  the  child  be  alloAved  to  play  a  few  minutes  in 
the  water,  always  beside  an  adult  and  in  shallow  water.  But  it  must  not  be 
allowed  to  wade  in  the  water  with  the  upper  part  of  the  body  dry  :  it  should 
be  first  immersed.  As  soon  as  the  child  is  old  enough  to  comprehend  the 
method,  it  should  be  taught  to  swim. 

Neither  the  in-door  nor  the  out-door  bath  should  be  given  soon  after  a 
meal,  nor  when  the  child  is  really  hungry.  In  the  one  case  indigestion  is 
likely  to  follow,  in  the  other  the  shock  of  the  bath  is  not  well  reacted  from. 

The  care  of  the  hair  consists  in  infancy  chiefly  in  the  care  of  the  scalp, 
which  must  be  kept  strictly  clean.  If  the  vernix  caseosa  is  as  completely 
removed  from  the  scalp  at  birth  as  from  other  parts  of  the  person,  there  is 
usually  little  difficulty  in  preventing  future  accumulations.  A  soft  brush 
should  be  frequently  used  upon  the  hair,  a  comb  only  as  a  separator  for 
parting  the  locks  and  in  emergency  for  disentangling. 

The  teeth  require  the  same  care  as  in  adult  life,  but  brushing  should  be 
of  the  gentlest  sort,  for  fear  of  irritation  of  the  gums,  which  may  cause 
their  subsequent  retraction.  In  infancy  after  each  feeding  or  nursing  the 
gums  should  be  washed,  to  prevent  the  formation  of  aphthous  growths,  and 
the  teeth  treated  likewise  as  they  appear.  When  the  child  is  old  enough 
to  be  quiet  while  the  cleansing  is  done,  a  soft  badger-hair  tooth-brush  should 
be  used. 

Dress. — The  hygienic  essentials  of  dress  are — sufficient  warmth  witli- 
out  burdcnsomencss,  uniformity  of  protection  as  far  as  consistent  ^vith 
activity,  freedom,  and,  for  children  at  least,  softness.  The  problem  of 
warmth  without  undue  weiglit  is  best  solved  by  the  use  of  woollen  garments. 
By  reason  of  the  poor  conducting  power  of  wool,  such  garments  retain  the 
bodily  heat  longer  than  those  made  of  other  materials.  This  slowness  of 
conduction  is  greater  in  loose-textured  fabrics.  That  is  to  say,  a  given 
Aveight  of  wool  is  Avarmer  if  loosely  than  if  tightly  woven.  Hence  the 
warmth  of  knitted  garments.  The  diffi^reuce  is  due  to  tlie  retention  in  the 
interstices  of  a  certain  amount  of  air,  which  is  a  poor  conductor.  For  the 
same  reason,  two  garments,  two  shirts  for  instance,  are  warmer  than  one 
shirt  of  weight  equal  to  the  two,  and  loose-fitting  garments  are  warmer  than 


368  NURSERY    HYGIENE. 

tight  ones.  In  hot  weather,  however,  tight  garments  are  distressing  for 
other  reasons.  Linen  stands  at  the  other  extreme  of  ordinary  dress-materials, 
being  the  best  conductor  of  heat.  It  follows  that  woollen  garments  give  the 
best  protection  against  change  of  temperature  and  chilling,  and  in  proper 
weight  they  make  the  safest  dress  in  all  places  where  temperature  may  vary 
or  for  all  children  who  may  become  heated  in  play.  Fashion  or  taste 
usually  calls  for  outer  garments  of  linen,  but  the  protective  garments  should 
be  beneath.  The  absorption  of  heat  from  the  sun  varies  very  much  accord- 
ing to  the  color  of  the  garment,  the  material  and  texture  being  unchanged, 
white  taking  the  least  heat,  or  being  the  coolest,  while  black  will  absorb 
about  twice  as  much.  Singularly  enough,  the  "  cool-looking"  light  blue  is 
found  by  some  experiments  to  be  very  nearly  as  hot  as  black.  For  very 
young  children  who  are  little  exposed  to  the  sun's  heat  this  question  of 
color  is  of  minor  importance. 

Softness  of  material  is  essential  for  children  on  account  of  the  sensitive- 
ness of  their  skins.  To  most  infants  fine  soft  woollen  shirts,  either  knitted 
or  of  "  baby  flannel,"  are  seemingly  entirely  comfortable.  Some,  however, 
manifest  unusual  irritability  of  skin,  and  for  such  a  shirt  of  fine  linen  should 
be  placed  within  the  flannel.  This  precaution  is  more  often  necessary  in 
hot  weather,  when  the  flow  of  perspiration  is  increased. 

The  ordinary  dress  of  very  young  children  is  objectionable  in  several 
ways.  It  is  ordinarily  unnecessarily  confining  about  the  body  and  limbs, 
although  it  has  never  in  this  country  reached  the  degree  in  this  respect  that 
seems  to  be  usual  in  some  Continental  countries.  There  is  also  an  unneces- 
sary number  of  layers  of  fabric  involved,  as  they  are  not  required  for  the 
child's  Warmth  under  ordinary  circumstances.  The  process  of  dressing  or 
undressing  is  really  an  ordeal  to  the  infant,  as  it  is  alternately  rolled  upon  its 
back  and  belly  in  the  nurse's  lap,  in  order  that  one  band  after  another  shall 
be  fastened  by  pins  or  stitches.  Very  much  of  this  dressing  is  unnecessary, 
if  not  harmful.  First  of  all  is  the  "  band,"  a  girdle  enveloping  the  trunk 
from  about  the  nipples  to  the  iliac  crest.  Such  an  appliance  may  possibly 
be  useful  during  the  healing  of  the  navel ;  afterwards  it  is  not  of  use  if 
tight.  The  abdomen  needs  no  support  in  health,  the  compression  of  the 
ribs  is  not  advantageous,  and  so  far  as  such  a  girdle  affects  the  question  of 
hernia  (which  it  is  popularly  supposed  to  prevent)  at  all,  it  rather  favors 
the  production  of  the  inguinal  or  femoral  variety.  A  loose  girdle  worn  to 
prevent  chilling  is,  however,  often  advisable  in  hot  weather ;  and  in  cold 
weather  a  flannel  girdle,  or  binder,  "  cut  bias"  to  secure  elasticity,  makes  a 
useful  envelope  for  the  entire  trunk  of  very  young  children  as  a  preventive 
of  bronchitis. 

As  a  means  of  getting  rid  of  the  objectionable  features  of  the  ordinary 
dress,  the  writer  has  for  some  years  recommended  the  following  plan'  or 

1  This  plan  was  originally  devised  by  Dr.  Grosveuor,  of  Chicago,  for  use  in  his  own 
family,  and  subsequently  published  by  him. 


NUESEEY   HYGIENE.  369 

some  modification  of  it.  There  are  three  garments  (besides  the  napkins)^  all 
covering  the  neck  and  shonlders  and  reaching  ten  or  twelve  inches  below  the 
teet.  The  outer  garment,  as  well  as  the  middle  one,  is  a  little  larger  in  every 
dimension  than  that  beneath  it,  so  that  no  binding  shall  take  place.  They 
are  all  cut  in  the  girdle-less  pattern  called  "  Princess."  The  inner  one  has 
sleeves,  and  may  be  made  of  cotton  flannel  or  very  soft  wool  flannel :  if 
wool  is  used,  care  must  be  taken  against  shrinkage  in  washing.  The  next 
garment  has  no  sleeves,  and  no  seams  at  the  arm-holes,  to  insure  against 
pressure  there ;  the  material  is  wool  flannel.  The  outer  one  is  the  usual 
dress,  with  high  neck  and  sleeves,  the  details  of  which  may  be  modified  to 
suit  taste.  Thus,  except  the  sleeves,  the  thickness  is  the  same  throughout. 
At  night  a  garment  like  the  inner  one  above  described  and  a  napkin  only 
are  worn.  These  three  garments  are  placed  one  within  the  other  before  the 
dressing  commences,  pains  being  taken  to  avoid  wrinkles  and  folds,  and 
they  are  put  upon  the  child  as  one  garment  with  very  little  trouble.  They 
are  removed  with  equal  ease. 

The  napkins  may  be  of  any  suitable  kind ;  i.e.,  soft  and  absorbent 
material,  easily  washed.  Linen  has  no  real  advantage  ordinarily  over 
cotton,  except  sesthetically.  Old  linen  is  soft,  but  likely  to  be  thin.  It  is 
desirable  to  diminish  tlie  bulk  of  the  napkins  as  far  as  possible,  to  prevent 
uncomfortable  pressure :  this  is  accomplished  by  having  a  small  napkin 
simply  to  cover  the  seat  and  genitals  thick  enough  to  retain  the  urine  or 
fseces,  covered  by  another  one  not  thick,  but  large  enough  to  envelop  the 
hips.  The  age  at  which  napkins  may  be  discontinued  depends  upon 
circumstances.  Among  English  families  of  the  better  classes,  apparently, 
children  are  tauo;ht  to  make  their  needs  known  earlier  than  is  usual  with 
us.  Much  can  be  done  by  an  attentive  and  intelligent  nurse  who  holds 
the  child  over  a  vessel  with  suitable  frequency.  But  children  vary  greatly 
in  this  particular,  and  under  no  circumstances  is  any  severity  justified,  or 
even  scolding,  as  nervousness  or  anxiety  on  the  part  of  the  child  simply 
aggravates  the  trouble.  As  soon  as  the  child  can  regularly  give  notice  of 
its  wants  in  this  respect  it  is  better  to  discontinue  the  diajjer,  as  its  absence 
gives  greater  freedom  to  the  limbs.  Of  course  at  all  times  napkins  should 
be  clianged  as  soon  as  discovered  to  be  damp  or  soiled.  Rubber  or  other 
impervious  covers  for  diapers  should  not  be  used.  Even  the  exigencies 
of  a  railway-journey,  with  the  conveniences  usual  in  this  country,  do  not 
require  their  employment.  They'  simply  convert  a  wet  napkin  into  an 
unclean  fomentation. 

When  a  child  begins  to  use  its  limbs  freely,  the  clothing  should  be 
shortened.  In  fact,  there  is  no  real  need  of  long  clothes  at  any  time,  except 
to  save  labor  in  kec]>ing  the  infant's  feet  covered.  When  it  begins  to  creep, 
its  manoeuvres  arc  fiicilitated  by  sli]:)ping  over  its  skirts  a  loose  baggy  pair 
of  breeches  of  woollen  which  is  tied  around  its  waist  and  buttoned  about  its 
knees.  This  Iccops  tlie  skirts  from  impeding  its  progress,  and  protects  it 
against  floor-draughts  in  a  measure. 
Vol.  I.— 24 


370  NTJRSEEY   HYGIENE. 

The  dress  of  older  children  should  conform  to  the  same  hygienic  re- 
quirements as  given  above.  The  two  most  frequently  disregarded  are  free- 
dom from  constriction  and  uniformity  of  protection.  The  former  is  violated 
by  the  use  of  tight  girdles,  or  even  by  corsets,  tight  sleev^es,  garters,  and 
misshapen  stockings  and  shoes.  Their  harmfulness  is  well  understood  :  the 
neglect  is  usually  a  wilful  preference  of  fashion  to  healthfulness.  The  same 
might  perhaps  be  said  of  the  fashion  of  unevenly  distributing  the  clothing 
over  the  person  ;  but  the  injurious  effects  of  this  are  less  understood.  Chill- 
ing is  resisted  far  better  if  the  whole  person  is  exposed  to  the  same  temper- 
ature than  if  one  part  is  exposed  to  a  lower  temperature  than  another.  It 
is  a  matter  of  universal  experience  that  many  persons  who  rejoice  in  out- 
door life  even  in  severe  weather  are  directly  injured  by  a  draught  and  by 
sitting  near  a  window.  Yet  formerly  more  than  now  low-necked  dresses 
were  used  for  children,  the  entire  shoulders  being  exposed,  while  the  re- 
mainder of  the  trunk  was  burdened  with  dress.  At  the  present  time 
fashion  exposes  the  legs  more.  Shoes  and  stockings  are  often  too  thin,  but 
in  particular  children  are  too  often  dressed  with  the  lower  limbs  bare  from 
above  the  knee  to  a  little  way  above  the  ankle,  the  foot  being  covered  by  a 
slipper,  Tlie  difference  is  often  aggravated  by  too  much  clothing  on  the 
body  and  a  sash  over  all.  The  lower  limbs  should  be  thoroughly  clad, — 
not  cumbrously,  but  warmly.  The  stocking  of  a  child  old  enough  to  run 
about  should  be  long  enough  to  meet  or  be  overlapped  by  the  next  article, 
napkin  or  drawers,  as  the  case  may  be.  Stockings  of  wool,  for  the  reasons 
already  given,  are  to  be  preferred.  They  should  be  soft.  They  should  not 
be  pointed  at  the  toes,  but  be  wide  enough  to  admit  of  ample  play  in  every 
direction  of  the  anterior  part  of  the  foot.  Color  is  not  indifferent,  as  some 
dyes  have  been  found  to  produce  eruptions  on  the  skin.  Public  attention 
has,  however,  been  so  thoroughly  drawn  to  this  subject  as  to  have  led  in 
some  instances  to  legislative  enactments,  and  such  dyes  are  probably  less 
frequently  used  than  formerly.  Aniline  reds  have  been  thought  to  be 
especially  irritating. 

Shoes  of  proper  shape  are  not  easy  to  get  for  children ;  not  nearly  so 
easy  as  for  adults.  This  comes  probably' partly  from  the  supposed  necessity 
of  making  them  for  a  low  price  and  partly  from  a  belief,  often  openly  ex- 
pressed, that  "  a  baby's  foot  has  no  shape."  The  real  shape  of  the  human 
foot  is  followed  in  the  true  "  waukenphast"  shoe,  but  this  we  have  never 
seen  of  proper  sizes  for  infants  or  young  children.  It  is  not  enough  that 
a  shoe  should  be  as  wide  or  wider  than  the  foot,  but  it  should  have  its 
width  rightly  disposed  :  space  where  the  foot  does  not  demand  it  in  no  wise 
compensates  for  pressure  elsewhere.  The  result  must  inevitably  be  a  dis- 
tortion. In  choosing  shoes  for  infants  it  is  better  that  they  should  be  un- 
duly long,  if  that  be  necessary  to  obtain  the  requisite  width  in  front,  than 
that  they  should  be  narrow. 

The  Care  of  Pood. — The  feeding  of  cliildren  will  be  treated  of  else- 
where in  this  volume,  but  it  remains  to  say  a  few  words  concerning  the  care 


NURSERY   HYGIENE.  371 

of  their  food  and  of  drinking-water.  Food  for  children  who  are  on  a 
general  diet  is  to  be  cared  for  in  the  same  way  as  that  for  adults,  but  with 
additional  scrutiny,  owing  to  the  greater  susceptibility  of  children  to  the 
injurious  effects  of  unwholesome  articles.  These  effects  are  in  many  in- 
stances now  attributed  to  the  development  of  ptomaines  in  the  food.  Most 
of  the  ptomaines  already  recognized  are  developed  in  articles  of  food,  such 
as  sausages,  ham,  and  canned  goods,  that  do  not  form  a  proper  part  of  the 
food  of  young  children.  One  only  is  of  importance  in  this  connection, 
namely,  tyrotoxicon,  which  may  be  developed  in  milk  or  any  food  of  which 
it  is  a  component  part.  To  prevent  its  development,  scrupulous  cleanliness 
must  be  observed  as  to  every  vessel  that  may  contain  milk,  the  room  in 
Avhich  it  is  kept,  and  every  utensil  which  may  be  used  in  the  preparation  or 
administration  of  food ;  for  all  these  things  have  been  distinctly  shown 
to  be  the  conveyers  of  the  poison.  Food  should  not  be  allowed  to  stand 
about  the  nursery  except  as  immediately  needed,  and  especially  it  should 
never  (and  this  is  emphatically  true  of  milk)  remain  in  the  room  with 
soiled  napkins  or  alvine  discharges. 

The  sterilization  of  milk  often  becomes  necessary,  although  it  cannot  be 
said  that  it  is  ordinarily  so.  Whenever  there  is  any  special  reason  for  sus- 
pecting the  purity  of  milk,  when  the  Aveather  or  other  conditions  are  par- 
ticularly favorable  to  changes  in  it,  when  the  occupants  of  the  nursery  are 
already  affected  with  diarrhoeal  diseases,  or  when  such  ailments  are  prevalent 
in  the  neighborhood,  sterilization  is  advisable.  The  elaborate  apparatus  for 
the  purpose  devised  by  Dr.  Soxhlet  is  now  manufactured  in  this  country  -^ 
but  the  process  may  be  simply  and  effectually  carried  out  by  placing  the 
milk  in  suitable  bottles,  such  as  ordinary  nursing-bottles  or  the  stout  bottles 
used  for  soda-water  or  ginger  ale,  and  putting  these  into  an  ordinary  kitchen 
steamer  and  keeping  them  at  the  temperature  of  steam  for  at  least  fifteen 
minutes.  If  no  steamer  is  at  hand,  the  bottles  may  be  partly  immersed  in 
water  kept  boiling  for  the  same  length  of  time.  The  bottles  are  then  seized 
by  a  well-protected  hand  and  tightly  stopped  with  corks  which  have  been 
boiled, — rubber  corks  are  preferable, — and  put  away  till  needed.  If  the 
milk  is  to  be  kept  for  any  length  of  time,  boiling  or  steaming  on  successive 
days  gives  greater  surety  of  permanent  sterilization. 

An  additional  word  may  be  said  about  the  care  of  nursing-bottles.  The 
long-tubed  l)ottle  has  been  pretty  generally  condemned,  owing  to  the  diffi- 
culty, amounting  in  practice  to  impossibility,  of  keeping  the  calibre  of  the 
tube  clean.  The  rubber  nipples  are  quite  readily  kept  clean,  and  so  are  the 
bottles  with  care.  The  writer  has  used  with  satisfaction  the  bottle  devised 
by  Dr.  Haven,  of  Boston,  which  is  really  a  feeding  cup  rather  than  l)ottle. 
It  is  made  of  stout  glass ;  its  sliape  is  much  the  same  as  that  of  the  beaked 
cup  used  to  feed  the  sick.     The  bottom  is  flat,  the  upper  side  open,  at  one 

1  In  New  York  by  C.  Riessner,  403  Pearl  Street,  and  R.  Van  der  Enide,  Second  Street 
and  Bowery. 


372  NURSERY    HYGIENE. 

end  is  a  handle,  at  the  opposite  end  the  tubular  nose  terminates  in  a  thick- 
ened end  which  keeps  the  rubber  nipple  in  place.  Its  advantages  are  that 
it  is  as  easily  cleansed  as  a  cup,  and  that  the  child  cannot  be  left  to  play 
with  its  bottle,  to  eat  when  it  pleases,  stop,  and  resume  again,  drinking  some- 
times warm  and  sometimes  cold  food.  It  must  be  held  by  the  nurse  during 
the  entire  time  of  feeding.  As  the  flow  of  milk  is  very  free,  the  holes  in  the 
rubber  nipple  should  be  very  small. 

To  the  care  of  drinking-water  the  same  general  rules  of  cleanliness 
apply  as  to  the  care  of  food.  But  if  the  supply  of  water  is  not  good,  the 
consumer  is  usually  less  able  to  remedy  the  difficulty  than  he  is  in  the 
matter  of  food. 

If  water  is  too  hard,  it  can  usually  be  improved  somewhat  by  boiling, 
which  causes  the  deposit  of  a  part  of  the  lime.  If  the  water  is  impure  from 
organic  matter,  the  impurities  may  or  may  not  be  deleterious  to  health. 
Water  from  ponds  is  often  high-colored  and  even  at  times  disagreeable  in 
odor  from  vegetable  matter  without  any  mischief  following  its  use.  We 
have  observed  an  instance  where  an  active  outbreak  of  typhoid  fever  seemed 
to  be  directly  due  to  a  mistaken  dread  of  discolored  and  unpleasant  water 
from  an  aqueduct,  leading  many  persons  to  resume  the  use  of  neglected  wells 
which  were  contaminated  from  privies,  although  the  well-water  seemed  to 
the  eye  and  nose  to  be  pure.  Perfectly  efficient  filters  which  yield  any  con- 
siderable amount  of  filtered  water  (porcelain  filters,  etc.)  are  too  costly  for 
general  use.  But  water  can  ordinarily  be  made  safe  by  thorough  boiling  for 
fifteen  or  twenty  minutes — better  still  by  boiling  on  two  successive  days— 
and  subsequent  coarse  filtration  through  filter-paper,  or  a  wad  of  absorbent 
cotton  packed  neatly  into  the  bottom  of  the  funnel.  The  entire  outfit  of  a 
large  funnel  and  a  water-vessel  costs  but  very  little.  It  may  be  of  tin  if 
constantly  watched  and  cleansed. 

The  use  of  iced  water  is  undesirable  for  various  reasons :  the  ice  may  be 
impure,  and  freshly-made  iced  water  is  not  proper  for  children's  consump- 
tion. Both  difficulties  may  be  overcome  by  putting  the  household  drinking- 
water  into  large  corked  bottles  or  into  closed  jars  and  placing  these  near  the 
ice  or  in  the  refrigerator.  In  this  way  water  may  be  had  that  is  cooler  than 
ordinary  spring-water  and  safe  to  drink.  If  the  taste  of  water  that  has 
been  boiled  seems  insipid,  as  it  is  apt  to  do  at  first,  the  addition  of  a  minute 
quantity  of  salt  generally  renders  it  palatable. 

Out-door  Exercise. — Except  in  inclement  weather,  most  children  are 
better  for  being  abroad  daily  to  receive  the  influence  of  the  sun  and  the  pure 
air.  Exceptions,  of  course,  exist,  particularly  in  winter.  Young  children 
— under  six  months  of  age^ — should  be  carried  in  arms  in  cool  weather,  that 
they  may  have  the  warmth  and  support  of  the  nurse's  arms  and  person.  In 
very  cold  weather  or  in  inclement  weather  we  believe  it  is  preferable  to 
open  for  a  while  the  windows  of  a  room  that  faces  the  sun,  until  the  air  is 
as  pure  as  that  out  of  doors,  then  to  close  the  windows  and  to  allow  the 
children  to  play  there  or  be  carried  about  there  attired  as  if  for  out  of  doors. 


DENTITION. 

By  JOHN   DORNING,   M.D. 


Definition. — The  term  dentition,  as  generally  used,  refers  only  to  that 
stage  of  development  when  the  tooth  is  penetrating  the  superficial  tissues 
of  the  gum.  The  period  between  the  seventh  mouth,  when  the  first  teeth 
appear,  and  the  end  of  the  second  year,  at  which  time  the  second  temporary 
molars  erupt,  is  spoken  of  as  the  dentition  epoch. 

By  the  second  dentition  is  meant  the  eruption  of  the  permanent 
teeth. 

Development  of  the  Teeth. — The  space  allotted  to  this  article  forbids 
more  than  the  briefest  general  description  of  the  development  of  the  teeth. 
For  a  full  account  of  the  evolution  of  the  teeth  the  reader  is  referred  to  the 
different  modern  treatises  on  dental  histology. 

In  the  human  subject  two  sets  of  teeth  appear  in  the  course  of  life. 
The  first  set,  consisting  of  twenty  teeth,  appear  during  the  first  two  years 
after  birth,  and  are  known  as  the  temporary,  milk,  or  deciduous  teeth. 
The  second  set,  thirty-two  in  number,  appear  after  the  fifth  year,  and  are 
called  the  permanent  teeth. 

The  first  trace  of  the  future  tooth  is  perceptible  about  the  sixth  week 
of  intra-uterine  life.  There  is  an  active  proliferation  of  the  epithelial  cells 
covering  the  rudimentary  gum,  which  becomes  centred  along  a  line  marking 
tlie  location  of  the  future  arch  of  teeth.  This  rapid  cell-multiplication 
causes  a  depression  or  groove  in  the  jaw,  which  deepens  as  the  cell-growth 
advances.  In  other  words,  we  have  a  groove  (the  dental  groove  of  Goodsir) 
in  the  jaw,  filled  with  epithelial  elements.  The  collection  of  epithelial  cells 
filling  the  groove  is  called  the  epithelial  cord,  and  from  it  is  developed  the 
enamel  organ,  which  furnishes  the  enamel  for  tlie  future  tooth.  As  the 
epithelial  cord  extends  into  the  gum,  its  distal  end  expands  into  a  club-shaped 
enlargement,  and,  meeting  the  dentinal  papilla  whicli  springs  from  the  deep 
connective  tissue  of  the  jaw,  becomes  invaginatcd  by  tlie  latter,  so  as  to 
form  a  complete  cap  for  the  papilla.  The  dentinal  papilla  is  the  future 
pulp,  and  from  it  is  developed  the  dentine  of  the  prospective  tooth. 

From  the  side  of  the  c})ithelial  cord  is  given  off  a  secondary  process, 
the  epithelial  cord  of  the  future  permanent  tooth.     Extending  from  the 

373 


374  DEXTITIOX. 

base  of  the  papilla  up-svard  along  the  outer  side  of  the  enamel  organ  is  seen 
a  thin  layer  of  fibrous  connective  tissue,  which  becomes  condensed  into  what 
is  known  as  the  tooth  follicle,  or  sac.  The  cementum  of  the  tooth  is  also 
probably  developed  from  this  connective  tissue.  As  this  follicle-wall  grows 
up  over  the  expanded  end  of  the  epithelial  cord,  or  enamel  organ,  and  en- 
croaches upon  the  neck  of  the  cord,  the  latter  atrophies  and  the  connection 
between  the  mucous  membrane  of  the  mouth  and  the  enamel  organ  is  con- 
sequently  severed.  The  tooth-germ  is  now,  about  the  sixteenth  week,  en- 
closed in  its  follicle.  Very  soon,  about  the  seventeenth  week,  calcification 
of  the  dentine  and  enamel  begins,  and  is  followed  in  a  few  weeks  by  com- 
mencing ossification  of  the  crypt  which  encloses  the  tooth-germ. 

"  The  germs  of  the  milk-teeth  make  their  appearance  in  the  following 
order :  at  the  seventh  week,  the  germ  of  the  first  molar  of  the  upper  jaw 
appears;  at  the  eighth  week,  that  for  the  canine  tooth  is  developed;  the 
two  incisor  papillae  appear  about  the  ninth  week  (the  central  preceding  the 
lateral) ;  lastly,  the  second  molar  papilla  is  seen  at  the  tenth  week,  behind 
the  anterior  molar.  The  teeth  of  the  lower  jaw  appear  rather  later,  the 
first  molar  papilla  being  only  just  visible  at  the  seventh  week,  and  the  tenth 
papilla  not  being  developed  before  the  eleventh  week."  ^ 

According  to  Dr.  Pierce,^  calcification  of  the  dentine  and  enamel  of  the 
central  and  lateral  incisors  begins  at  the  seventeenth  week  of  embryonic 
life,  and  calcification  of  the  cuspids  and  molars  commences  at  the  eighteenth 
week.  At  the  fortieth  week,  or  at  birth,  calcification  of  the  crowns  of  the 
incisors  is  quite  complete  and  the  roots  are  beginning  to  calcify.  Three 
months  after  birth,  the  cuspid  and  molar  crowns  are  complete  and  calcifica- 
tion commences  in  their  roots. 

With  the  completion  of  the  .crown  and  beginning  calcification  of  the 
fang,  the  process  of  eruption  commences.  The  gro^^■th  of  the  root  propels 
the  crown  towards  the  surface  of  the  gum,  the  superimposed  tissues,  first 
the  margin  of  the  bony  cr^i^t,  and  then  the  soft  structures  of  the  gum,  dis- 
appearing by  absorption.  Synchronously  with  the  development  of  the  root, 
the  jaw  increases  in  depth  by  the  addition  of  new  osseous  material.  The 
bony  crypt  is  rebuilt  around  the  neck  of  the  tooth,  and  forms  the  alveolus 
or  socket  of  the  milk-tooth. 

By  many  there  is  thought  to  be  some  force  in  addition  to,  or  indepen- 
dent of,  the  elongation  of  the  fang,  in  impelling  the  tooth-crown  forward. 
Among  the  facts  offered  in  substantiation  of  this  view  are :  first,  in  teeth 
prematurely  erupted  the  roots  are  sometimes  undevelof>ed ;  second,  a  tooth 
may  be  completely  formed,  and  still  remain  buried  in  the  jaw,  and  erupt 
later  in  life ;  and,  third,  when  a  normal  tooth  erupts,  its  crown  travels  a 
greater  distance  than  is  represented  by  the  increase  in  the  length  of  its 
fano;  during:  the  same  time. 


^  Gray's  Anatomy,  8th  ed.,  p.  753. 

2  American  System  of  Dentistry,  vol.  iii.  p.  636. 


DEXTITIOX.  375 

Eruption  of  the  Teeth. — Between  the  sixth  and  eighth  mouths  after 
birth,  the  two  lower  centi-al  incisors  erupt,  usually  simultaneously. 

Between  the  eighth  and  tenth  months,  the  two  upper  central  incisors 
appear,  followed  shortly  by  the  two  lateral  incisors. 

Between  the  twelfth  and  fourteenth  months,  the  two  upper  anterior 
molars,  the  two  inferior  lateral  incisors,  and  the  two  lower  anterior  molars 
appear,  in  the  order  mentioned. 

Between  the  sixteenth  and  twenty-second  months,  the  four  canine  teeth 
erupt. 

Between  the  twentieth  month  and  the  end  of  the  third  year,  the  four 
posterior  molars  erupt. 

The  eruption  of  the  twenty  milk-teeth  is  now  complete,  and  no  more 
teeth  appear  until  the  fifth  or  sixth  year,  when  the  eruption  of  the  perma- 
nent teeth  commences. 

Shedding-  of  the  Deciduous  Teeth. — The  temporary  teeth  drop  out 
in  about  the  same  order  as  they  appear. 

Scarcely  a  year  elapses  after  calcification  of  the  milk-teeth  is  complete 
before  absorption  begins.  There  is  still  some  obscurity  about  this  most 
interesting  physiological  phenomenon.  The  process  of  absorption  would 
seem  to  be  quite  independent  of  the  presence  and  pressure  of  the  permanent 
tooth,  as  is  evinced  in  the  fact  that,  not  infrequently,  absorption  of  a  milk- 
tooth  is  carried  on  in  the  absence  of  its  successor  ;  and,  again,  decalcification 
is  known  to  commence  on  that  side  of  the  fang  opposite  to  the  successional 
tooth,  and  also  in  several  places  at  once. 

Normally,  absorption  begins  at  the  apex  of  the  root  and  advances  to- 
wards the  crown.  Shortly  after  the  root  has  disappeared  the  crown  is 
removed  either  by  the  advancing  permanent  tooth  or  by  an  accidental 
rupture  of  the  attachment  between  the  neck  of  the  tooth  and  the  mucous 
membrane  of  the  gum. 

Development  and  Eruption  of  the  Permanent  Teeth. — The  germs 
of  the  first  permanent  molars  appear  during  the  fourth  month  of  embryonic 
life ;  at  about  the  same  time  may  be  noticed  the  first  steps  in  the  formation 
of  the  twenty  anterior  teeth  of  the  second  set.  The  germs  of  the  second 
permanent  molars  do  not  show  themselves  until  the  third  month  after 
birth ;  and  those  of  the  third  molars  (wisdom-teeth)  not  before  the  third 
year. 

The  epithelial  cords  of  the  twenty  anterior  teeth  spring  from  the  epi- 
tliclial  cords  of  the  corresponding  temporary  teeth.  The  cords  for  the 
twelve  permanent  molars  arise  either  from  the  epithelium  of  the  mouth  or 
from  successive  extensions  backward  of  the  epithelial  cords  of  the  posterior 
milk  molars. 

The  development  of  the  permanent  teeth  is  similar  to  that  of  the  de- 
ciduous teeth. 

Calcification  of  the  permanent  teeth  begins  in  the  first  molars  about  the 
sixth  month  of  fcetal  life. 


376  DENTITION. 

"  First  year  after  birth,  central  and  lateral  incisors  begin  calcification. 
Four  years  of  age,  cuspids,  bicuspids,  and  second  molars  begin  calcification. 
Eight  years  of  age,  third  molars  begin  calcification."  ^ 

To  accommodate  the  developing  molars,  the  jaw  increases  in  length  by 
the  addition  of  bony  material  at  the  posterior  border.  As  the  permanent 
teeth  erupt,  the  sockets  and  roots  of  the  temporary  teeth  disappear  by 
absorption,  and  new  alveoli  are  built  for  the  second  set. 

Ordinarily,  the  permanent  teeth  erupt  at  the  following  periods,  the  teeth 
of  the  lower  jaw  preceding  those  of  the  upper  : 

Sixth  year,  first  molars. 

Seventh  year,  central  incisors. 

Eighth  year,  lateral  incisors. 

Tenth  year,  first  bicuspids. 

Eleventh  year,  second  bicuspids. 

Twelfth  to  thirteenth  year,  canines. 

Twelfth  to  fifteenth  year,  second  molars. 

Seventeenth  to  twenty-first  year,  wisdom-teeth. 

ANOMALIES    OF   THE   TEETH. 

Precocious  Dentition. — It  is  not  uncommon  for  dentition  to  begin  prior 
to  the  sixth  or  seventh  month.  Some  children  are  even  born  with  teeth. 
Many  interesting  examples  of  this  singular  anomaly  have  been  placed  on 
record.  The  younger  Pliny  states  that  the  Roman  consul  Manius  Curius 
had  a  full  set  of  teeth  at  birth,  on  account  of  which  he  was  named  Dentatus. 
Louis  XIV.,  Richard  III.,  and  Mirabeau  are  said  to  have  had  congenital 
teeth.  I  have  seen  two  infants  both  of  whom  were  born  with  a  lower 
central  incisor  through  the  gum. 

In  some  cases  congenital  teeth  are  less  dense  than  normal  teeth,  have  no 
roots,  become  loose  and  drop  out  during  the  first  few  months  of  life,  and 
are  replaced  by  the  deciduous  teeth  proper.  In  other  cases  these  teeth  have 
been  known  to  remain  until  displaced  by  the  permanent  teeth,  and  were, 
therefore,  undoubtedly  genuine  inilk-teeth. 

Precocious  dentition  is  usually  associated  with  premature  ossification  of 
the  bones,  particularly  those  of  the  head.  As  a  consequence,  there  is  early 
closure  of  the  fontanels  and  sutures,  which  may  interfere  with  the  normal 
development  of  the  brain. 

After  the  premature  eruption  of  one  or  more  teeth,  dentition  may  cease 
for  from  four  to  twelve  months,  or  even  longer,  as  a  result  of  malassimilatiou 
from  some  cause. 

Premature  dentition  is  believed  by  some  observers  to  be  evidence  of  a 
tubercular,  scrofulous,  or  syphilitic  diathesis.  It  is,  however,  sometimes 
observed  in  children  in  whom  no  inherited  taint  can  be  discovered. 

Retarded  Dentition. — It  is  very  common  for  the  beginning  of  dentition 


^  Dr.  Pierce,  American  System  of  Dentistry,  vol.  iii. 


DENTITION.  377 

to  be  deferred  for  several  months  after  the  normal  period.  In  some  rare 
cases  teething  does  not  commence  until  the  second  }-ear  or  later.  I  have  had 
under  my  care  three  children  who  did  not  cut  their  first  teeth  until  the 
twenty-fifth,  twenty-seventh,  and  twenty-eighth  months  respectively.  Jacobi 
mentions  the  case  of  a  boy  \vhom  he  had  under  observation  until  the  age  of 
two  years  and  ten  months,  "  at  which  time  he  had  not  a  tooth,  nor  a  symp- 
tom of  approaching  dentition."  Churchill  reports  a  case  in  which  the  first 
tooth  appeared  at  seven  years  of  age.  Smellie  records  the  case  of  a  patient 
whose  first  tooth  erupted  at  twenty-two  years  of  age. 

Delayed  dentition  is  an  indication  of  a  late  general  development, — in 
the  vast  majority  of  cases  the  result  of  rachitis.  As  a  rule,  in  cases  of 
protracted  teething  the  anterior  fontanel  closes  later  than  the  seventeenth 
month,  the  normal  period,  and  ossification  of  the  bones  is  also  delayed. 
Teeth  that  are  cut  late  are  frequently  marked  by  imperfections  of  the 
enamel,  lack  density,  and  decay  very  early. 

Absence  of  Teeth. — Deficiency  in  the  number  of  teeth  is  of  more 
frequent  occurrence  in  the  permanent  than  in  the  temporary  set.  A  milk- 
tooth  may  fail  to  appear  because  of  the  destruction  of  its  germ  by  trauma- 
tism or  disease.  In  some  rare  instances  there  is  an  absence  of  a  number  of 
teeth.  Such  abnormities  have  been  accounted  for  on  the  ground  of  heredity  ; 
sometimes  they  are  found  in  connection  with  other  anomalies  of  the  dermal 
system.  In  the  permanent  set,  the  upper  lateral  incisors  are  most  frequently 
found  missing.  Cases  are  reported  where  a  missing  tooth  has  been  found 
lying  horizontally  in  the  jaw.  Two  such  cases  have  fallen  under  my  own 
observation.  The  total  absence  of  teeth  is  an  exceedingly  rare  anomaly. 
There  are  but  a  few  cases  on  record,  and  some  of  these,  judging  from  their 
histories,  are  questionable. 

Multiple  Dentition. — In  medical  literature,  a  number  of  cases  of  a 
third  and  even  a  fourth  dentition  are  narrated.  Theoretically,  a  third 
dentition  is  not  impossible ;  but  in  the  cases  reported,  the  statements  of 
the  patients  and  their  relatives  constitute  the  only  evidence  of  this  abnor- 
mity, and  such  testimony  is  not  always  to  be  relied  upon. 

Supernumerary  Teeth. — The  number  of  teeth  is  not  infrequently  in- 
creased by  one  or  more  additional  teeth.  Supernumerary  teeth  are  generally 
small,  and,  although  usually  distinct,  are  sometimes  attached  to  otlier  teeth. 
They  are  more  frequently  located  in  the  anterior  part  of  the  mouth,  and  are 
more  common  in  the  upper  than  in  the  lower  jaw.  Supernumerary  milk- 
teeth  have  been  followed  by  corresponding  su])ernumcraries  in  the  perma- 
nent set.  The  mouth  of  a  medical  student  whom  I  recently  examined 
contained  five  lower  permanent  incisors.  The  teeth  were  all  in  tlie  dental 
arch  and  but  sliglitly  twisted  on  their  axes. 

Irregularities  in  the  Order  of  Eruption. — It  is  not  uncommon  for 
the  normal  order  of  eruption  to  be  violated.  The  upper  incisors  often  erupt 
first ;  and  when  such  is  the  case  their  appearance  is  usually  delayed.  The 
lateral  are  sometimes  cut  before  the  central  incisors.     In  rare  instances  the 


378  DEXTITIOX. 

molars  or  canines  precede  the  incisors,  a  posterior  molar  erupts  before  a 
canine,  or  a  canine  protrudes  prior  to  an  anterior  molar.  In  the  case  of  a 
child  brought  to  my  clinic,  the  upper  anterior  molars  were  the  first  to  erupt 
at  the  age  of  sixteen  months.  That  there  is  a  normal  order  of  eruption  is 
a  fact  recognized  even  amono-  savao^es.  Dr.  Livingstone  tells  us  that  amono; 
some  of  the  tribes  of  Central  Africa  a  child  that  cuts  the  upper  teeth  first 
is  believed  to  be  moiko  (unlucky)  and  certain  to  bring  death  into  the  family. 
Such  a  child  is  sold  to  the  Arabs.  In  some  civilized  countries  the  eruption 
of  the  upper  incisors  first  is  considered  a  bad  omen. 

Malposition  of  the  Teeth. — Malposition  of  individual  teeth  is  of 
much  less  common  occurrence  in  the  deciduous  than  in  the  permanent  set, 
and  M'hen  found  is  usually  limited  to  slight  torsion  or  overlapping  of  the 
upper  or  lower  incisors.  The  permanent  teeth  most  frequently  malposed 
are  the  inferior  incisors  and  canines ;  next,  the  superior  incisors ;  after 
these,  the  third  molars. 

All  sorts  of  irregular  arrangement  are  seen.  The  involved  teeth  may 
be  twisted  on  their  axes,  overlap  one  another,  or  be  displaced  within  or 
Avithout  the  dental  arch. 

Displacement  of  the  teeth  occurs  when  the  jaw  is  too  small  for  their 
proper  accommodation.  A  disproportionately  small  jaw  is  a  common  con- 
sequence of  rachitis.  In  a  certain  percentage  of  cases  heredity  seems  to  be 
an  undeniable  factor.  The  blending  of  types  by  intermarriage  of  different 
races  is  a  well-recognized  source  of  small  jaw  and  large  and  displaced  teeth. 

Persistent  thumb-sucking  is  said  to  cause  a  forward  direction  of  the 
upper  anterior  teeth  and  a  backward  inclination  of  the  lower  front  teeth, 
with  more  or  less  deformity  of  the  jaws. 

Malformations  of  the  Teeth. — There  are  numerous  departures  from 
what  may  be  regarded  as  the  typical  form  of  a  tooth.  Large  teeth  with 
very  small  roots,  an  increased  number  of  cusps  or  fangs,  outgroA\i:hs  from 
the  crown  or  fang,  twisting,  bending,  division  or  coalescence  of  the  roots, 
are  among  the  variations  in  shape. 

The  surface  of  a  tooth  is  often  marked  by  transverse  or  vertical  ridges 
and  furrows,  or  pittings,  the  enamel  being  apparently  perfect.  Under  the 
microscope,  however,  the  enamel  is  generally  found  to  be  defective.  These 
ridges  and  furrows  are  analogous  to  the  ridges  and  grooves  seen  on  the 
nails,  both  the  result  of  interrupted  nutrition. 

The  enamel  of  a  tooth  may  present  a  few  excavated  spots  or  a  general 
honey-combed  appearance  due  to  a  disorganization  of  this  structure.  Some- 
times the  crown  of  a  tooth  is  entirely  devoid  of  enamel. 

Pigmented  spots,  and  spots  having  the  appearance  and  consistency  of 
chalk,  are  not  uncommonly  observed. 

Defects  in  structure  are  due  to  some  morbid  condition  of  the  organism 
during  the  developmental  period  of  the  teeth, — in  the  course  of  intra- 
uterine life,  when  the  milk-teeth  show  imperfections,  and  in  the  first  few 
years  after  birth,  when  the  permanent  teeth  are  faulty. 


DEXTITIOX.  379 

A  large  proportion  of  artificially-fed  children  have  faulty  permanent 
teeth  later  in  life.  The  condition  of  the  teeth,  therefore,  would  in  a  general 
way  seem  to  be  an  indication  of  the  previous  health  of  the  individual. 
When  the  defects  are  seen  on  only  one  tooth,  the  cause  may  be  local. 

There  is  sometimes  an  absence  of  the  enamel  at  the  middle  of  the  biting 
edges  of  the  upper  central  incisors.  The  exposed  dentine  is  soft  and  but 
partly  calcified,  and  is  soon  worn  away,  leaving  a  crescentic  notch  in  the 
edge  of  each  tooth.  Xotched  milk-teeth  are  of  no  special  diagnostic  import. 
But  when  the  permanent  upper  central  incisors  are  notched,  they  are  almost 
invariably  an  indication  of  congenital  syphilis.  Mr.  Hutchinson  was  the  first 
to  call  attention  to  this  condition  of  the  teeth  in  inherited  syphilis.  They 
are  known  as  "  Hutchinson  teeth."  This  peculiarity  in  the  upper  central 
incisors  was  at  one  time  thought  to  be  caused  by  stomatitis,  but  at  present  it 
is  believed  to  be  the  result  of  an  arrest  of  development  in  the  central  or 
first-formed  portion  of  the  tooth. 

In  subjects  of  congenital  syphilis  both  the  temporary  and  the  perma- 
nent teeth  may  be  crescentic.  A  number  of  such  cases  have  come  under 
my  observation. 

SYMPTOMATOLOGY   AJ^D  ALLEGED  DISOEDERS   OF   DENTITION. 

At  one  time  dentition  was  held  accountable,  directly  or  indirectly,  for 
nearly  all  the  ills  of  infancy.  At  the  present  day,  owing  to  a  more  exten- 
sive knowledge  of  the  etiology  and  pathology  of  disease,  and  greater  pro- 
ficiency in  methods  of  diagnosis,  the  symptomatology  of  dentition  and  its 
power  as  an  etiological  factor  are,  with  the  majority  of  the  profession,  be- 
coming more  and  more  restricted,  and  by  some  totally  ignored.  There  are, 
however,  others  who  still  adhere  to  the  old  doctrine  of  dentition  as  tena- 
ciously as  do  the  laity,  and  in  their  practice  among  the  infant  population 
find  more  use  for  the  gum-lancet  than  for  common  sense. 

Dentition  is  a  purely  physiological  process,  and,  like  other  physiological 
processes,  is  subject  to  irregularities  from  local  and  constitutional  disorders. 
Its  affirmed  etiological  potency,  however,  is  questionable. 

It  is  true,  functional  derangements  and  organic  disease  are  more  common, 
and  the  mortality  greater,  between  the  ages  of  six  months  and  two  years 
than  at  any  other  period  of  childhood ;  but  hereditary,  dietetic,  hygienic, 
and  educational  influences  ftirnish  causes  more  rational  and  demonstrable 
than  the  presumed  irritation  of  a  hidden  tooth-germ. 

There  never  has  been  any  unanimity  of  opinion  on  the  subject  of  how 
teething  produces  the  numerous  disorders  attributed  to  it.  It  is  said  that 
dentition  is  more  severe  in  the  winter  tlian  in  the  summer,  and  rice  versa  ; 
more  so  in  large  cities  than  in  the  country ;  and  its  consequences  more  serious 
in  badly-nourished  children,  and  among  the  poor ;  that  diseases  occurring 
during  dentition  are  rendered  more  dangerous  by  this  process;  that  teeth 
erupt  with  more  difficulty  during  the  course  of  any  severe  malady  ;  tliat  the 
cutting  of  the  incisors,  on  account  of  their  sharp  edges,  is  more  painful  than 


380  DENTITIO]^. 

the  extrusion  of  the  molars ;  that  the  eruption  of  the  molars  causes  most 
pain  because  of  their  broad  crowns ;  that  the  eye-teeth,  owing  to  their  long 
fangs,  are  liable  to  give  rise  to  cerebral  distin'bances ;  that  the  protrusion 
of  the  stomach-teeth  is  likely  to  be  attended  with  vomiting  and  diarrhoea  or 
cough ;  that  it  is  the  evolution  of  the  molars  that  causes  most  cerebral  and 
intestinal  troubles.  Then,  again,  the  forward  pressure  of  the  advancing 
tooth-crown  on  the  superimposed  gum,  the  backward  pressure  of  the  fang 
on  the  nerves  of  the  subjacent  parts,  and  the  lateral  pressure  of  all  the  teeth 
together  are  thought,  by  their  respective  advocates,  to  account  for  the  many 
complicating  ailments  of  dentition. 

In  the  estimation  of  many  writers  the  semeiology  of  dentition  embraces 
drooling,  rubbing  of  one  jaw  on  the  other,  biting  on  the  fingers  or  any  hard 
substance  that  can  be  carried  to  the  mouth,  fever,  restlessness,  peevishness, 
fretfulness,  disturbed  sleep,  flushing  of  the  cheeks,  itching  of  the  nose, 
dilated  pupils,  conjunctivitis,  otalgia,  pain  and  inflammation  of  the  gums, 
aphtha,  thrush,  anorexia^  vomiting,  diarrhoea,  bronchitis,  convulsions,  local 
spasms  and  paralyses,  and  cutaneous  eruptions. 

Drooling  is  said  to  be  the  first  indication  of  approaching  dentition,  and 
is  thought  to  be  the  result  of  a  stimulation  of  the  salivary  glands  by  an 
irritation  transmitted  through  the  chorda  tympani  from  the  gums.  It  is 
believed  that  drooling  keeps  the  gums  soft,  relieves  the  congested  capillaries 
of  the  gums  and  mouth,  and  "  derives  the  blood  from  the  brain  and  moder- 
ates its  irritative  condition." 

Slavering  is  observed  to  commence  in  all  healthy  and  normally-developed 
infants  between  the  third  and  fifth  months,  and  generally  ceases  before  the 
eighteenth  month.  In  sickly  and  backward  children  it  usually  begins  later, 
and  may  continue  for  several  years. 

While  the  infant  is  fed  at  the  breast  there  is  no  requirement  for  either 
teeth  or  saliva ;  still,  the  development  of  both  the  teeth  and  the  salivary 
glands  must  of  necessity  be  well  advanced  towards  completion  before  the 
period  of  weaning.  Hence,  instead  of  regarding  this  copious  flow  of  saliva 
as  a  manifestation  of  a  morbid  action  of  the  salivary  glands  dependent  upon 
dental  irritation,  it  would  be  more  reasonable  to  assume  that  it,  like  the 
eruption  of  the  teeth,  simply  betokens  a  stage  of  developmental  activity  in 
which  there  is  a  preparation  of  the  digestive  organs  for  the  reception  and 
utilization  of  the  aliment  that  is  to  succeed  the  maternal  milk. 

Rubbing  of  one  jaw  on  the  other  and  biting  on  the  fingers  or  any  sub- 
stance that  can  be  carried  to  the  mouth  are  supposed  to  be  indicative  of  a 
feeling  of  uneasiness,  or  itching,  in  the  gums,  induced  by  the  upward  press- 
ure of  the  teeth ;  and  some  smooth  and  hard  material  is  recommended,  for 
the  child  to  bite  on,  with  the  view  of  allaying  the  pruritus  and  hastening 
the  absorption  of  the  superimposed  gum. 

Jacobi  says,  "  Is  it  astonishing  that  an  infant  will  during  the  time  of 
dentition  take  everything  to  its  lips  and  into  its  mouth,  after  it  has  done 
so  all  its  life  ?     The  principal  impressions  an  infiiut  obtains  depend  on  its 


DENTITION.  381 

relation  to  foods  and  drinks ;  eating  is  the  only  real  propensity  an  infant 
has,  and  the  mouth  is  known  by  experience  to  be  the  great  receptacle 
destined  for  the  reception  of  everything  around ;  not  to  speak  of  the  lips 
being  used  as  a  means  of  touching,  grasping,  and  learning  the  qualities 
of  things." 

The  grinding  of  the  teeth  in  children  who  have  completed  their  first 
dentition  is  evidently,  at  times,  due  to  some  derangement  of  the  economy. 
The  biting  motion  of  the  jaw  in  infants  before  and  during  dentition  may 
likewise  be  occasionally  excited  by  some  irritation,  but  not  necessarily  seated 
in  or  reflected  from  the  gums.  If  there  be  any  sensation  at  all  attending 
the  eruption  of  a  tooth,  it  probably  amounts  to  nothing  more  than  a  mod- 
erate degree  of  pruritus.  It  should  be  remembered  that  muscular  action  is 
essential  to  muscular  development ;  that  a  healthy  child  is  in  almost  con- 
stant motion  while  awake,  and  that  the  masticatory  movements  may  be,  and 
probably  are,  but  a  part  of  the  general  gymnastics  in  which  the  child  in- 
dulges. An  infant  cannot  walk,  neither  can  it  masticate  food,  yet  it  exer- 
cises both  the  muscles  of  locomotion  and  those  of  mastication,  developing 
and  educating  them  for  their  respective  functions  when,  at  a  later  period  of 
existence,  these  shall  become  necessary. 

Fever,  restlessness,  peevishness,  fretfulness,  and  disturbed  sleep  are  the 
commonest  manifestations  of  infantile  derangements.  Not  infrequently 
they  are  coincident  with  the  eruption  of  a  tooth  or  a  group  of  teeth.  When 
such  is  the  case,  a  superficial  examination  may  lead  the  physician  to  con- 
clude that  a  relationship  exists  between  the  two ;  w^hereas  a  careful  and 
thorough  investigation  will  generally  bring  to  light  some  associated  con- 
dition which  at  another  time  w^ould  be  considered  quite  adequate  to  pro- 
duce these  symptoms.  If  fever  and  general  irritability  be  symptomatic  of 
dentition,  they  should  be  continuous  throughout  its  whole  duration,  or 
coincident  with  the  eruption  of  each  group  of  teeth,  instead  of  appearing 
at  uncertain  times ;  and,  furthermore,  they  should  be  present  in  at  least  a 
mild  degree  in  every  child. 

Slight  disorders,  presenting  a  few  indefinite  symptoms,  occur  at  all  ages, 
and  the  diagnostician  is  now  and  then  at  a  loss  to  account  satisfactorily  for 
them.  To  rely  upon  tlie  age  of  the  patient  in  determining  whether  they 
sliall  be  attributed  to  a  physiological  process  or  to  some  much  more  prob- 
able cause  is  certainly  illogical.  Peripheral  impressibility  is  very  pro- 
nounced in  the  infant,  particularly  in  one  whose  power  of  resistance  is 
lessened  by  some  constitutional  vice ;,  and  any  slight  irritation,  as  from  in- 
digestible food  or  parasites  in  the  alimentary  canal,  constipation,  disarranged 
clothing,  a  misplaced  pin,  or  soiled  napkins,  may  give  rise  to  a  greater  or 
less  degree  of  fever  and  general  uneasiness. 

Very  often,  trifling  disorders  tliat  arc  viewed  as  evidence  of  difficult 
dentition  are,  directly  or  indirectly,  dependent  upon  rachitis.  Tin's  is  one 
of  the  most  common  of  cliildren's  diseases,  and  frequently  a  mild  form  of 
the  afiectiou  passes  unrecognized  because  its  symptoms  have  received  a 


382  DENTITION. 

wrong  interpretation.  The  local  and  general  disturbances^  in  the  estimation 
of  the  parents,  and  not  infrequently  in  that  of  the  physician  too,  merely 
mark  the  dreaded  teething  epoch,  the  attending  perils  of  which  every  infant 
is  destined  to  encounter.  The  tardy  dentition  and  lateness  in  walking  are 
regarded  as  nothing  but  harmless  freaks  of  nature,  and  instances  are  cited 
where  the  same  peculiarities  have  been  noticed  in  other  members  of  the 
family.  When  rachitis  is  recognized, — and  it  should  be,  before  any  deformi- 
ties of  the  bones  are  visible, — and  an  appropriate  line  of  treatment  adopted, 
recovery  generally  follows ;  the  teeth  are  cut  rapidly,  and,  owing  to  the 
extra  attention  bestowed  on  the  child,  few  if  any  of  the  ordinary  derange- 
ments of  infancy  occur. 

Vaso-motor  disturbances,  as  the  transient  flushing  of  the  cheeks,  or 
sudden  pallor  of  the  countenance,  are  often  noticed  during  the  time,  and,  it 
is  said,  in  consequence,  of  dentition.  But  it  should  be  remembered  that 
there  are  many  conditions  in  which  these  symptoms  are  present,  and  they 
must  receive  careful  consideration  before  makino:  a  diao-nosis  of  difficult 
dentition.     It  will  then  seldom  be  necessary  to  fall  back  on  teething. 

Conjunctivitis  is  said  now  and  then  to  occur  on  the  same  side  on  which 
the  teeth  are  protruding.  More  than  likely  this  is  a  coincidence.  But  the 
opinion  has  been  advanced  that  it  may  be  the  result  of  dental  irritation,  the 
extension  of  the  irritation  to  the  conjunctiva  being  favored  by  the  proximity 
of  the  apices  of  the  fangs  of  the  canine  and  first  molar  to  the  floor  of  the 
orbit,— a  rather  unsatisfactory  exj)lanation. 

Otalgia,  as  indicated  by  crying  and  the  carrying  of  the  hand  to  the  side 
of  the  head,  has  been  declared  one  of  the  reflex  disturbances  of  dentition. 
In  congestion  or  inflammation  of  the  middle  or  external  ear,  meningitis,  or 
cerebral  hypersemia,  the  child  carries  its  hand  to  the  neighborhood  of  the 
ear  and  gives  evidence  of  suflering.  Most  of  the  earaches  in  children  are 
dependent  upon  acute  otitis ;  and  many  an  otitis  is  neglected  until  the  organ 
of  hearing  is  irreparably  damaged  because  "  the  doctor  said  the  ear  would 
stop  running  when  he  [the  child]  cut  all  his  teeth."  "  The  doctor"  had 
evidently  forgotten  that  the  same  predisposing  and  exciting  causes  could  be 
operative  before  the  eruption  of  the  last  of  the  twenty  milk-teeth,  as  Avell 
as  afterwards. 

Redness,  swelling,  and  tenderness  of  the  gums  during  the  time  of  den- 
tition are  generally  held  to  be  symptomatic  of  some  difficulty  in  the  erup- 
tion of  the  teeth. 

Vogel,  in  writing  on  difficult  dentition,  remarks,  "  Redness,  pain,  swell- 
ing, and  increased  secretion  (or,  in  short,  catarrhal  stomatitis)  arc  present 
in  all  cases."  Jacobi  says,  "  There  is  no  stomatitis  ;  certainly  no  thrush  ; 
both  of  which  are  pathological  conditions." 

The  gums  of  a  healthy  child  are  of  a  pale  pink  hue.  As  a  tooth 
approaches  the  surface,  the  gum  in  that  locality  becomes  more  prominent, 
grows  paler  in  color,  until  it  is  almost  white,  and  is  anything  but  sensitive. 
Over  the  summit  of  a  tooth  just  before  it  reaches  the  surface  a  depression 


DENTITION.  383 

is  often  observed,  due  to  a  disappearance  of  the  epithelial  and  subepithelial 
layers,  by  a  necrotic  process. 

Sometimes  the  gum  over  the  crown  of  an  erupting  tooth  becomes  in- 
flamed and  tumid,  and  an  incision  may  give  exit  to  a  drop  or  two  of  thick, 
black  blood.  The  gum  around  the  top  of  a  tooth  that  is  partly  through 
the  gum  is  oftentimes  inflamed.  This  condition  I  have  repeatedly  seen 
follow  attempts  at  "  rubbing  the  tooth  through"  with  a  thimble,  finger-nail, 
or  other  hard  substance.  Ulceration  of  the  gum  over  a  tooth  now  and  then 
occurs  from  the  impingement  of  a  sharp  corner  of  a  corresponding  tooth 
that  has  erupted  in  the  opposite  jaw. 

It  is  doubtful  if  dentition  be  ever  the  sole  cause,  or,  indeed,  a  cause 
at  all,  of  a  gingivitis.  If  the  highly  sensitive  nerve-filament  that  forms  a 
part  of  the  pulp  of  a  milk-tooth  becomes  obliterated  together  with  the  sub- 
stance of  the  fang,  without  pain  or  inflammation,  to  make  wa,y  for  its  suc- 
cessor, it  is  not  unphilosophical  to  infer  that  the  less  sensitive  tissues  that 
lie  in  the  path  of  a  deciduous  tooth  are  disposed  of  in  a  manner  as  painless 
and  as  free  from  inflammatory  action ;  for  in  both  instances  the  same  result 
(absorption  of  vitalized  tissue)  is  achieved  by  processes  that  are,  so  far  as 
the  principle  of  action  is  concerned,  identical. 

When  stomatitis  is  present,  some  cause  other  than  dentition  should  be 
sought.  The  vast  majority  of  cases  of  stomatitis  occur  in  bottle-fed  children. 
It  is  generally  associated  with  some  derangement  of  the  organism,  particu- 
larly the  digestive  tract.  The  child's  diet  or  hygiene  is  usually  at  fault. 
The  use  of  foul  nursing-nipples,  dirty  teething-rings,  and  filthy  sugar-teats, 
thumb-  and  tongue-sucking,  and  irritants  taken  into  the  mouth,  as  hot  fluids, 
principally  tea  and  coifee,  drugs,  or  substances  the  child  may  pick  up  while 
wandering  around  on  the  floor,  may  give  rise  to  stomatitis. 

Diarrhoea  in  teething  children  has  by  some  writers  been  attributed  to 
the  swallowing  of  large  quantities  of  saliva,  the  salts  contained  in  it  being 
supposed  to  act  as  a  mild  aperient.  By  others  the  reputed  dental  diarrhoea 
is  thouglit  to  be  of  a  neurotic  character, — an  irritation  being  transmitted 
through  the  sympathetic  nerves  to  the  vagus,  influencing  the  glandular 
secretion  of  the  digestive  tube  or  producing  a  hyperperistalsis  of  the  intes- 
tines. 

Vogel  says,  "A  mild  diarrhoea,  five  or  six  evacuations  in  the  twenty- 
four  hours,  is  very  beneficial  to  teething  children,  for  cerebral  affections  are 
thereby  most  surely  prevented."  Many  children  are  sacrificed  annually 
through  a  belief  in  such  an  erroneous  doctrine.  Diarrhoea  may  occur  at  the 
time  a  tooth  is  protruding,  or  at  successive  periods  of  dental  evolution,  but 
never  in  consequence  thereof.  Children  who  are  fed  exclusively  at  the 
breast  at  proper  intervals,  and  wliose  hygiene  receives  careful  attention, 
seldom  suffer  witli  diarrhoea  before  the  period  of  weaning.  Tlien,  again, 
diarrhoea  is  strikingly  more  prevalent  in  one  season  than  in  another,  not- 
withstanding the  eruption  of  tectli  at  all  periods.  These  two  facts  rather 
militate  against  tlic  theoretical  existence  of  diarrhoea  from  dental  irritation. 


384  DENTITION. 

The  causes  of  intestinal  derangements  are  improper  feeding,  bad  hygiene, 
and  the  changes  produced  in  the  atmosphere,  especially  in  a  city,  by  a  high 
degree  of  solar  heat.  The  most  significant  of  these  factors  is  improper  feed- 
ing. Most  babies  at  the  breast  are  nursed  too  often.  Bottle-fed  infants,  in 
addition  to  being  fed  too  frequently,  labor  under  the  disadvantage  of  not 
being  provided  with  a  suitable  substitute  for  their  natural  food. 

Too  commonly,  undue  importance  is  attached  to  the  appearance  of  the 
first  tooth.  Its  presence  is  hailed  as  the  beginning  of  a  new  era  in  the 
child's  existence,  and  no  opportunity  is  lost  in  putting  the  anxiously- 
watched-for  organ  to  a  legitimate  use. 

Bronchitis,  it  is  said,  may  be  the  result  of  the  saturation  of  the -cover- 
ings of  the  chest  with  the  saliva  that  flows  from  the  child's  mouth, — a 
plausible  view.  It  is  also  thought  to  be  due  to  a  nervous  irritation  reflected 
from  the  gums. 

Because  an  attack  of  bronchitis  will  now  and  then  subside  with  the 
eruption  of  a  tooth,  it  does  not  follow  that  the  .cutting  of  the  tooth  is  the 
cause  of  the  bronchial  inflammation ;  for  a  mild  attack  of  bronchitis  will 
get  well  spontaneously  in  a  child  free  from  any  predisposition,  whether  a 
tooth  be  coming  through  or  not.  After  a  child  has  begun  to  creep  or  walk 
it  is  more  exposed  to  atmospheric  changes  than  earlier  in  life.  Hence  the 
greater  frequency  of  attacks  of  bronchial  catarrh  during  the  second  year. 
Rachitic  and  scrofulous  children  are  subject  to  recurring  attacks  of  bron- 
chitis ;  and  the  great  prevalence  of  rachitis  should  not  be  overlooked. 

Convulsions,  varying  in  form  from  slight  twitchings  of  particular  groups 
of  muscles  to  a  general  eclamptic  attack,  are  said  to  have  an  origin  in  den- 
tition. Frequently  a  child  will  sleep  Avith  the  eyes  half  open  and  the 
eyeballs  rolled  upward,  presenting  a  most  appalling  spectacle  to  the  inex- 
perienced mother.  Or  a  smile  will  occasionally  flit  over  the  infant's  coun- 
tenance, caused  by  the  contraction  of  the  facial  muscles, — a  pleasing  sight 
to  the  sentimental  mother  whose  creative  imagination  conjures  up  a  vision 
of  angels  Avhispering  to  her  sleeping  babe.  Her  apprehension  in  the  one 
event  or  her  happy  delusion  in  the  other  is,  however,  soon  dispelled  by 
some  v/iseacre  who  knowingly  unfolds  to  her  some  of  the  mysteries  of 
teething. 

Now  and  then  a  general  convulsion  will  occur, — perhaps  with  the 
eruption  of  a  tooth,  or  at  successive  periods  of  dental  protrusion. 

But  it  must  be  remembered  that  during  the  dentition  epoch  the  whole 
organism  is  in  a  state  of  active  development ;  that  the  nervous  system  has 
not  acquired  the  stability  of  equilibrium  of  the  youth  or  the  adult,  and  is 
therefore  extremely  susceptible  to  external  impressions,  as  is  evinced  in  the 
marked  manifestations  of  disturbed  function  that  are  produced  by  what, 
in  the  more  mature  individual,  would  be  considered  trifling  affairs.  The 
etiology  of  convulsions  is  consequently  much  more  extensive  in  infancy  and 
childhood  than  later  in  life,  and  it  is  very  doubtful  if  it  should  include 
dentition. 


DENTITION.  385 

Jacobi  ^  remarks,  "  We  must  not  forget  that  peripheral  irritability  in- 
creases from  the  fifth  to  the  ninth  month  considerably,  and  that  the 
inhibitory  centres  do  not  perform  all  their  functions  as  in  the  adult.  Thus 
it  is  even  possible  that  now  and  then  a  convulsion  will  occur ;  but,  so  far  as 
I  am  concerned,  I  have  not  seen  convulsions  dependent  upon  difficult  den- 
tition in  the  course  of  the  last  ten  years." 

In  the  majority  of  cases  convulsions  are  traceable  to  some  irritation  in 
the  alimentary  canal.  Rachitic  children  are  peculiarly  liable  to  convul- 
sions. In  some  cases  the  most  painstaking  examination  fails  to  reveal  the 
cause  of  the  convulsion ;  and  a  careful  and  thorough  autopsy  may  even  be 
barren  of  results  :  so  that  it  is  much  better  to  acknowledge  candidly  that 
occasionally  we  are  unable  to  determine  the  cause  of  a  convulsion  than  to 
attribute  it  to  some  presumed  cause  for  want  of  a  more  real  one. 

Cutaneous  eruptions — notably,  eczema,  lichen,  urticaria,  and  impetigo — 
are  very  common  between  the  sixth  and  twenty-fourth  months,  and,  like 
diarrhoea  and  convulsions,  may  appear  contemporaneously  with  the  cutting 
of  a  tooth. 

The  delicate  and  sensitive  nature  of  the  child's  skin  renders  it  suscep- 
tible to  disorders  from  slight  irritation.  Inherited  or  acquired  predispo- 
sition, derangement  of  tlie  digestive  organs,  usually  from  some  fault  in  the 
diet,  some  disturbance  of  the  nervous  system  (not  alwa}'s  to  be  accounted 
for  even  in  the  adult),  lack  of  cleanliness,  immoderate  bathing,  the  use  of 
strongly  alkaline  soaps  or  impure  toilet-powder,  rough  handling  in  wash- 
ing, drying,  or  dressing  the  child,  irritation  from  the  clothing  because  of 
either  its  quality  or  its  arrangement,  but  not  dentition,  may  give  rise  to 
cutaneous  eruptious. 

Since  the  first  dentition  has  been  considered  the  source  of  so  much  local 
and  constitutional  trouble  during  the  first  two  years  of  life,  it  is  only 
natuHal  that  in  the  second  dentition  should  be  sought  an  explanation  of 
many  of  the  disturbances  occurring  between  the  sixth  and  twenty-first 
years. 

The  various  forms  of  stomatitis,  tonsillitis,  sore  throat,  gastro-intestinal 
derangements,  febrile  disturbances,  bronchitis,  internal  rhinitis,  diseases  of 
the  eye,  of  the  ear,  of  the  skin,  chorea,  epilepsy,  neuralgia  of  the  fifth 
nerve,  facial  paralysis,  spastic  contraction  of  the  muscles  of  mastication, 
tetanus,  aphonia,  hysteria,  etc.,  have  all  been  imputed  to  the  second 
dentition. 

The  fa(^t  that  a  dead  tooth  in  the  jaw  is  not  infrequently  a  cause  of  some 
reflex  disturbance,  as  neuralgia  or  a  local  paralysis,  is  offered  in  support  of 
the  belief  that  the  above-mentioned  maladies  can  have  an  origin  in  dentition. 
But  it  is  difficult  to  perceive  an  analogy  between  the  two  conditions.  There 
is  a  vital  connection  between  a  2;rowim>:  tooth  and  the  structure  in  which  it 
is  enclosed,  with  an  harmonious  adjustment  of  its  growth  and  the  absor])- 


1  Intestinal  Diseases  of  Infoncv  and  Childhood. 
Vol.  1.— :i5 


386 


DENTITIOX. 


tion  of  superimposed  tissues ;  whereas  the  root  of  a  dead  tooth  retained  in 
the  gum  is  a  foreign  body,  likely  at  any  time  to  set  up  local  or  reflected 
disturbance. 

Generally  there  is  no  pain  or  gingivitis  attending  the  eruption  of  the 
permanent  teeth.  Even  the  eruption  of  a  tooth  at  an  abnormal  point,  be- 
cause of  either  lack  of  room  in  the  dental  arch  or  faulty  direction  of  the 
tooth-germ,  is,  as  a  rule,  unaccompanied  by  pain,  uneasiness,  or  local  in- 
flammatory action.  The  eruption  of  a  wisdom-tooth  is,  however,  not  in- 
frequently attended  with  pain  or  discomfort.  In  such  cases  there  is  usually 
insufficient  space  between  the  jaws  at  the  back  part  of  the  mouth,  a  result 
of  imperfect  development  of  the  bones  consequent  on  rachitis  in  early  life, 
so  that  as  the  tooth  advances  towards  the  surface  the  overlying  gum  is  sub- 
jected to  enormous  pressure  each  time  the  jaws  are  closed,  as  in  the  act  of 
biting,  and  a,  sometimes  severe,  gingivitis  is  the  result.  The  irritation  of 
the  gum  by  the  rough  edge  of  a  milk-tooth  that  is  about  ready  to  drop  ofi* 
sometimes  produces  inflammation  and  ulceration  of  the  gum  and  contiguous 

parts. 

MA:^rAGEMENT. 

Tradition  furnishes  many  absurd  notions  and  superstitions  in  relation  to 
the  care  of  children  during  the  dentition  epoch.  It  is  said  that  the  mothers 
of  Brittany  will  not  touch  their  infants'  gums,  lest  the  teeth  grow  crooked. 
It  was  also  said  that  the  first  teeth  must  not  be  thrown  away  when  they 
drop  out,  for  if  any  animal  got  such  a  trophy  the  next  tooth  would  be  like 
that  of  the  animal  finding  the  old  one.  To  facilitate  the  eruption  of  the 
teeth  and  lessen  the  severity  of  concomitant  ailments,  various  nonsensical 
and  obnoxious  procedures  have  at  one  time  or  another  been  held  in  high 
repute, — necklaces  of  beads  made  of  amber  or  difierent  roots  placed  on  the 
child's  neck,  daily  frictions  of  the  gums  with  the  fresh  brains  of  hares,  or 
with  blood  from  the  recently-wounded  cock's  comb,  unguents,  lotions,  and 
hard  and  soft  substances. 

The  modern  treatment  of  dentition  with  many  practitioners  comprises 
the  use  of  teething-rings,  drugging  with  the  bromides  or  opium, — the 
mother  very  often  administers  the  opium  on  her  own  responsibility  in  the 
form  of  a  death-dealing  soothing-syrup, — local  applications  of  laudanum  or 
cocaine  to  the  gums,  and  the  unlimited  and  unwarrantable  use  of  the  gum- 
lancet.  The  management  of  the  cliild  should,  in  fact,  begin  before  concep- 
tion. Healthy,  vigorous,  and  normally-developed  parents  beget  healthy 
children.  Freedom  from  hereditary  taint,  and  proper  care  as  regards  diet 
and  hygiene,  will  insure  the  child  against  most  of  the  ills  of  the  dentition 
period.  In  a  large  city,  however,  it  is  next  to  impossible  to  carry  out  all 
the  requirements  necessary  to  the  welfare  of  the  child.  An  unnatural  en- 
vironment increases  the  susceptibility  of  the  infant  organism  to  functional 
inharmony. 

The  clothing,  particularly  that  in  contact  with  the  skin,  should  be  well 
fitting,  made  of  some  soft  and  non-irritating  material,  and  in  amount  suit- 


DENTITION.  387 

able  to  the  season.  An  abundance  of  undisturbed  sleep,  plonty  of  fresh  air 
and  sunshine,  and  cleanliness,  are  indispensable  to  the  well-being  of  the 
child.  In  the  use  of  the  bath  anything  that  may  irritate  tlie  skin,  as  too 
hot  Avater,  impure  soap,  coarse  wash-cloths  or  towels,  or  rough  handling, 
must  be  scrupulously  avoided. 

Too  much  care  cannot  be  bestowed  on  the  nourishment  of  the  child.  It 
is  a  well-known  fact  that  the  maternal  milk  of  each  species  of  mammalia, 
because  of  certain  chemical  and  physical  properties,  is  peculiarly  adapted  to 
the  sustenance  of  its  own  particular  progeny,  and  the  lacteal  secretion  of 
any  other  race  proves  but  a  most  imperfect  substitute.  This  is  exemplified 
in  the  feeding  of  very  young  infants  on  pure  cow's  milk.  So  that,  unless 
contra-indicated  by  some  constitutional  disorder  that  cannot  be  speedily 
removed,  as  syphilis  (?)  or  phthisis,  the  mother  should,  if  her  breasts  con- 
tain milk,  nurse  her  own  baby,  observing  proper  intervals,  two,  three,  or 
four  hours  according  to  age,  in  so  doing.  Occasionally  between  nursings 
the  child  should  have  water  to  drink. 

The  indication  for  weaning  is  the  presence  of  at  least  twelve  teeth  in  the 
mouth.  Solid  food  may  then  be  gradually  added  to  the  child's  diet ;  but 
milk  should  still  be  the  principal  aliment  until  the  second  year. 

When  for  any  reason  it  is  impracticable  to  supply  the  infant  with  the 
milk  of  its  mother  or  that  of  a  wet-nurse,  cow's  milk  in  a  modified  form 
must  be  substituted.  A  discussion  of  the  very  important  subject  of  the 
artificial  feeding  of  infants  will  be  found  in  the  article  on  Infant  Feeding, 
to  which  the  reader  is  referred. 

The  slight  ailments  of  infancy  should  always  receive  immediate  and 
proper  attention.  A  mild  diarrhoea  must  never  be  regarded  as  salutary 
unless  it  be  due  to  the  irritation  of  some  indigestible  substance  in  the  intes- 
tines. Xature  may  then  be  assisted  in  removing  the  offending  matter,  after 
which  the  diarrhoea  must  be  checked.  When  a  group  of  indefinite  symp- 
toms, as  fever,  restlessness,  and  fretfulness,  loss  of  appetite,  etc.,  appear 
in  a  cliild,  and  are  not  traceable  to  derangement  of  the  digestive  organs,  a 
careful  and  thorough  examination  of  the  whole  body,  and  particularly  of 
the  thoracic  organs,  should  be  made  daily  until  a  correct  diagnosis  can  be 
reached.  Very  often  cases  of  so-called  difficult  dentition  turn  out  to  be 
nothing  less  than  pneumonia,  pleurisy,  diphtheria,  or  some  other  serious 
malady,  much  to  the  surprise  of  the  parents  and  to  the  mortification  of 
the  medical  attendant.  AVhen  dentition  is  delayed,  the  child's  general 
condition  requires  attention.  Errors  in  feeding  must  be  corrected,  and 
cod-liver  oil,  alone  or  in  combination  with  small  doses  of  pliosphorus,  ad- 
ministered. There  are  no  local  measures  that  can  facilitate  the  eruption 
of  the  teeth.  Nor,  indeed,  are  any  necessary.  A  teething-ring  furnishes 
the  child  with  something:  on  wliich  to  exercise  its  masticatory  muscles,  and, 
if  clean  and  perfectly  smooth  on  the  surface,  is  probably  harmless.  But  it 
docs  not  hasten  the  absorption  of  the  gum.  The  vile  practice  of  some 
mothers  of  supplying  children  with  cake  and  sugar-teats  for  constant  suck- 


388  DENTITION. 

iao-  is  both  filthy  and  injurious.     The  fermenting  sugar  is  a  cause  of  sprue, 
stomatitis,  digestive  derangements,  and  caries  of  the  milk-teeth. 

It  is  not  many  years  since  the  gum-lancet  was  considered  the  catholicon 
for  nearly  all  infantile  maladies.  At  the  present  day  it  has  fallen  into  well- 
merited  disrepute.  As  J.  Lewis  Smith  remarks,  it  is  used  more  by  the 
io-norant  practitioner,  w^io  is  deficient  in  the  ability  to  diagnosticate  obscure 
diseases,  than  by  one  of  intelligence,  who  can  discern  more  clearly  the  true 
pathological  state.  Gum-lancing  is  not  objectionable  because  of  pain,  the 
possibility  of  severe  hemorrhage,  injury  of  the  tooth,  or  any  difficulty 
attending  the  operation,  but  because  it  is  an  absolutely  useless  procedure  so 
far  as  it  aifects  the  eruption  of  a  tooth.  There  is  no  tension  of  the  over- 
lying gum ;  for  an  incision,  whether  linear,  crescentic,  or  crucial,  does  not 
gape.  A  pretty  story  is  related  of  a  child  having  experienced  such  great 
relief,  on  one  occasion,  from  having  her  gum  lanced,  that,  not  feeling  well, 
at  a  subsequent  visit  of  her  benefactor,  she  toddled  over  to  him  with  a 
table-knife  in  her  hand  and  by  various  gestures  expressed  a  desire  to  have 
the  operation  repeated.  Marvellous,  if  true.  Every  one  has  heard  of  cases 
where  a  cutaneous  eruption  disappeared,  convulsions  ceased,  diarrhoea  stopped, 
fever  abated,  irritableness  subsided,  and  quiet  slumber  ensued  after  the  gums 
had  been  lanced.  But  it  is  more  than  likely  that  in  every  instance  it  was  a 
pure  coincidence,  or  the  result  of  the  hemorrhage  (a  blood-letting),  or  of 
imagination  on  the  part  of  those  interested.  Every  intelligent  observer 
knows  that  infantile  derangements  frec|uently  get  well  spontaneously, — 
good  ground  for  being  sceptical  about  many  of  our  vaunted  therapeutic 
measm'es. 


PUBERTY :  ITS  PATHOLOGY  AND  HYGIENE. 

By  THOMAS   MOEE   MADDEi^,   M.D.,   F.E.C.S. 


Puberty  has  been  defined  as  the  period  of  life  within  which  reproductive 
capacity  becomes  established.  But,  as  in  many  instances  that  development 
does  not  occur  throughout  the  whole  course  of  existence, — however  long 
protracted  and  in  other  respects  normal  it  may  be, — in  the  following  ob- 
servations the  term  puberty  will  be  used  as  signifying  merely  the  epoch 
intervening  between  childhood  and  adult  age  or  manhood.  Under  ordinary 
circumstances,  this  period  is  marked  by  the  evolution  of  the  organs  of 
generation^  together  with  those  protean  physiological  changes  and  new  etio- 
logical relations  that  are  connected  therewith.  So  important  and  complex 
are  the  latter  that  of  all  the  successive  stages  of  growth,  maturity,  and 
decay,  into  which  the  brief  span  of  human  existence  is  biologically  divisi- 
ble, there  is  perhaps  no  one  epoch  the  pathological  aspects  of  which  are  of 
such  frequent  interest  to  the  medical  practitioner  as  that  which  forms  the 
subject  of  the  present  memoir. 

In  infancy  and  childhood  the  vital  powers  are  occupied  exclusively  with 
the  nutrition  and  o^rowth  of  organs  essential  to  the  existence  of  the  individual. 
During  puberty,  on  the  other  hand,  in  addition  to  this,  there  now,  as  a  rule, 
occurs  the  still  more  remarkable  evolution,  structural  and  functional,  which 
controls  the  perpetuation  of  our  species.  The  physiological  actions  which 
are  necessary  for  this  object  are,  as  was  well  observed  by  Dr.  Roget,  "  great 
and  commensurate  with  the  magnitude  and  importance  of  the  design,"  and 
they  give  rise  to  that  rapid  and  varied  succession  of  changes,  mental  as  well 
as  physical,  which  are  essential  for  the  perfected  development  of  that  mar- 
vellous trophy  of  creative  power, — "  the  living  microcosm  of  man's  body." 

Nor  are  these  developmental  changes  purely  physiological,  but,  on  the 
contrary,  inasmuch  as  "  the  seeds  of  death  are  inseparably  intermixed  with 
the  germs  of  life,"  they  are  closely  connected  with,  or  productive  of,  numer-. 
ous  special  pathological  proclivities  or  tendencies  to  disease,  which  will  be 
separately  considered  in  the  succeeding  pages. 

Circumstances  affecting-  Evolution  of  Puberty. — The  age  within 
which  the  vital  changes  usually  included  in  the  term  puberty  may  take 
place  does  not  admit  of  any  rigid  limitation,  as  their  occurrence  is  ncccs- 

r,89 


390  PUBERTY  :    ITS   PATHOLOGY   AND   HYGIENE. 

sarily  so  fixed  by  inherited  predispositions  or  family  temperament,  consti- 
tution, or  idiosyncrasy,  and  the  incidents  and  circumstances  of  life,  in  each 
individual,  as  well  as  by  the  agencies  of  disease,  and  above  all  by  the 
potent  influence  of  climate,  as  to  preclude  the  possibility  of  more  than  a 
mere  approximation  to  any  general  rule  in  reference  to  the  normal  date  of 
the  commencement  of  this  epoch. 

Period  of  Establishment  of  Puberty  in  Females. — The  advent  of 
female  adolescence  is  datable  from  the  first  appearance  of  the  catamenia, 
which,  cseteris  paribus,  occurs  earliest  in  warm  climates,  sanguine  tempera- 
ments, and  highly  civilized  and  luxurious  states  of  society,  and  is  retarded 
by  the  opposite  conditions.  Even  in  this  climate  the  period  of  first  men- 
struation varies  widely,  as  may  be  seen  by  the  table  on  the  opposite  page, 
being  largely  controlled  by  the  influence  of  the  various  extrinsic  or  acci- 
dental circumstances  just  referred  to.  Thus,  to  say  nothing  of  the  precocious 
evolution  of  puberty  which  is  normal  in  more  sunny  regions,  and  of  which 
I  have  seen  numerous  instances  during  my  long  residence  in  Southern  Spain 
and  Italy,  as  well  as  in  Northern  Africa  and  other  tropical  or  semi-tropical 
regions,  even  in  this  climate  I  have  observed  cases  of  reo;ular  menstruation 
in  patients  under  their  eleventh  year,  and  have  attended  the  accouchement, 
in  Dublin,  of  a  girl  under  fourteen.  jSIany  other  similar  and  still  more 
premature  manifestations  of  reproductive  power  in  this  climate  are  well 
authenticated, — such  as  those  recorded  by  Dr.  ]Macnaughtou  Jones,  in  his 
"Manual  of  the  Diseases  of  Women"  (London,  1888),  of  maternity  at  the 
thirteenth  year,  and  also  some  cases  mentioned  in  the  British  Iledical 
Journal  within  the  present  year. 

Another  remarkable  instance  of  the  same  kind  may  be  found  in  the 
Hospital  Gazette,  November,  1888,  in  which  an  account  is  given  of  a  case 
recently  recorded  by  M.  Diament  of  a  young  girl  who  began  to  menstruate 
regularly  from  the  age  of  two  years :  the  menses  took  place  up  to  a  short 
time  ago  without  intermission,  and  lasted  for  five  days.  The  child  was 
born  in  1882,  and  at  the  end  of  twelve  months  had  cut  all  its  teeth.  In 
1886  it  weighed  fifty-nine  pounds,  and  now  in  its  sixth  year  it  weighs 
sevent}'-nine.  Till  a  short  time  ago  it  was  robust  and  well.  The  head  and 
upper  extremities  are  similar  to  those  of  children  of  its  age,  but  the  buttocks 
and  thighs  are  remarkably  developed.  The  breasts  are  prominent,  and  the 
pubes  and  axillse  are  furnished  with  hair.  The  child  speaks  in  a  bass 
voice.  Up  to  Januar}',  1888,  the  health  of  the  child  continued  good,  but 
since  then  menstruation  has  ceased  ;  at  each  menstrual  period  the  child  is 
seized  with  epileptiform  attacks,  and  the  latter  have  tended  to  become 
more  serious  both  in  number  and  in  severity. 

More  frequently,  however,  in  cold  or  temperate  climates  such  as  ours  the 
evolution  of  menstruation  is  retarded  beyond  the  usual  period.  In  several 
instances  I  have  observed  the  first  appearance  of  the  catamenia  in  persons 
upwards  of  twenty  years  of  age,  and  in  one  of  them  this  function  was  not 
established  until  the  marriage  of  the  patient  in  her  twenty-sixth  year,  nor 


PUBERTY  :    ITS    PATHOLOGY    AND    HYGIEXE.  391 

did  she  then  ag-ahi  menstruate  until  after  her  confinement  in  the  fullowins: 
year,  from  which  time  she  menstruated  regularly. 

In  reference  to  the  ordinary  period  of  the  commencement  of  puberty, 
I  may  here  avail  myself  of  a  table  taken  from  a  former  article  of  mine  in 
Dr.  Quain's  "  Dictionary  of  Medicine,"  showing  the  result  of  my  own  in- 
quiries into  the  date  of  first  menstruation.  This  investigation,  I  may  add, 
extended  over  a  considerable  period  and  a  large  field  of  inquiry,  having 
been  commenced  during  my  connection  with  the  Rotunda  Lying-in  Hospital, 
and  subsequently  being  continued  in  the  gynaecological  wards  of  the  great 
institution  to  which  I  have  been  attached  for  the  last  twelve  years.  Small 
as  the  results  may  appear,  they  were  not  obtained  without  some  difficulty, 
as  in  the  great  majority  of  cases  the  statements  of  those  whose  menstrual 
history  was  investigated  proved  so  indefinite  or  unreliable  that  in  only  an 
infinitesimal  proportion  of  them — namely,  in  four  hundred  and  ninety-seven 
instances — was  I  able  to  obtain  any  accurate  data  on  this  point.  In  these 
latter  eases  the  ages  at  which  menstruation  first  occurred  were  as  follows  : 

Under  12  years  of  age     4  menstruated  for  the  first  time. 
At 


12   " 

17 

lo   " 

50 

14   "■ 

94 

15   '■ 

'^   138 

16   ■• 

"   105 

17   •• 

65 

18   '^ 

10 

18   " 

14 

Over 

From  the  foregoing  table  it  appears  that  of  fi^ur  hundred  and  ninety- 
seven  cases  where  the  date  of  the  first  catamenial  period  was  ascertained, 
menstruation  occurred  between  the  fifteenth  and  seventeenth  years  in  three 
liundred  and  thirty-seven  instances,  and  that  in  this  triennial  period  its  first 
manifestation  most  commonly  took  place  at  the  sixteenth  year,  which  may 
therefore  be  regarded  as  the  average  normal  date  of  the  commencement  of 
female  puberty. 

Evolution  of  Female  Puberty  considered. — The  transition  from  girl- 
hood to  jiuberty,  the  normal  date  of  which  has  been  just  referred  to,  is,  not- 
withstanding the  far  greater  complexity  of  the  physiological  changes  involved, 
much  more  direct  and  sudden  in  its  accomplishment  than  is  the  case  with 
the  corresponding  period  in  the  opposite  sex.  In  the  primary  stages  of 
life  the  functional  differences  between  the  sexes  are  com})aratively  slightly 
marked,  but  on  the  occurrence  of  puberty  in  the  female  these  become  sharply 
accentuatal,  and  are  denoted  by  the  sudden  development  of  the  reproductive 
or  sexual  organization,  including  the  accessory  parts,  such  as  the  mamma; 
and  external  genitals,  as  well  as  the  essential  organs  of  generation,  and  more 
especially  the  enlargement  of  the  ovaries,  the  maturation  of  their  Graafian 
follicles  and  contained  ova,  and,  in  fine,  the  evolution  of  the  entire  utero- 
ovarian  system,  the  predominant  influence  of  which  on  tlie  general  economy 


392  PUBERTY  :    ITS   PATHOLOGY   AND   HYGIENE. 

is  tersely  summed  up  in  the  old  aphorism,  "  Propter  uterum  est  muUerJ^ 
From  this  moment  the  girl  passes  at  once  from  childhood  to  full  procreativc 
maturity,  as  evinced  by  the  establishment  of  menstruation.  This  function, 
which  results  from  the  processes  of  ovulation  and  uterine  denudation,  leads 
to  that  periodic  sanguineous  discharge  by  the  regular  monthly  recurrence 
of  which,  during  the  ensuing  thirty  years  or  so  of  life,  the  term  of  woman's 
distinctive  sexual  or  reproductive  vitality  is  measurable. 

Period  of  Puberty  in  the  Male. — The  commencement  of  this  epoch 
in  man  is  less  definite  in  its  characteristics,  and  in  the  age  of  its  occurrence, 
than  is  the  case  with  the  opposite  sex.  In  Great  Britain,  and  I  believe  a 
similar  law  generally  prevails  in  the  United  States,  a  boy  is  not  legally 
considered  as  arrived  at  puberty  until  the  age  of  fourteen,  when  supposed 
sexual  capacity  and  legal  responsibility  for  the  crime  of  rape  commence. 

By  the  old  Roman  law,  however,  another  and  a  better  standard  of  ado- 
lescence was  provided,  this  term  being  thereby  considered  synonymous  with 
the  period  at  which  liability  to  military  service  began, — namely,  at  the  age 
of  fifteen,  the  ordinary  date  at  which  the  physiological  change  from  boy- 
hood to  puberty  occurs  in  all  temperate  climates.  The  approach  of  this 
epoch  is  now  denoted  by  a  characteristic  modulation  of  the  voice,  which 
becomes  altered  from  "  the  thin  childish  treble  to  the  deep  manly  base," 
caused  by  the  development  of  the  larynx  and  vocal  cords,  the  enlargement 
of  the  pomum  Adami,  and  the  elongation  of  the  thyroid  cartilage  and 
the  thyro-arytenoid  muscles.  About  the  same  time  is  also  noticeable 
the  first  appearance  of  that  downy  growth  on  the  face,  so  fondly  watched 
and  cultivated  by  its  proud  possessor  as  the  badge  of  emancipation  from 
the  pedagogue's  stern  rule,  and  the  evidence  of  the  advent  of  the  bright 
spring-time  of  life,  when 

''  A  young  man's  fancy  lightly  turns  to  thoughts  of  love." 

There  now  also  occur  the  growth  of  hair  on  the  pubes,  etc.,  the  com- 
mencement of  the  structural  and  functional  development  of  the  testes  and 
other  parts  of  the  genital  organs,  and  too  often  the  abnormally  early  first 
manifestation  of  the  sexual  instincts.  These  successive  changes,  however, 
proceed  so  gradually  that  their  full  completion  is  not  accomplished  until 
some  years  have  elapsed,  and  is  often  delayed  until  long  after  the  legal  term 
of  manhood  has  been  attained. 

Premature  Puberty  in  Males. — Although,  as  already  observed,  the 
vital  chano-es  connected  with  the  transition  from  childhood  to  adolescence 
are,  under  ordinary  circumstances,  seldom  accomplished  before  the  sixteenth 
year,  and  are  frequently  delayed  until  a  much  later  period  of  life,  occasion- 
ally this  customary  course  is  departed  from,  and  in  these  fortunately  ex- 
ceptional instances  the  whole  system,  physical  and  mental,  or,  as  more 
frequently  happens,  particular  powers  or  organs,  become  prematurely  de- 
veloped at  an  abnormally  early  age.  Thus,  numberless  instances  of  mental 
precocity  are  on  record,  from  the  time  of  "  the  Admirable  Crichtou"  down 


PUBERTY  :    ITS    PATHOLOGY    AND    HYGIENE.  393 

to  the  present  day,  which  has  been  so  prolific  in  over-gifted  children, — such 
as  Joseph  Hoffman,  Pape,  and  the  many  other  infant  prodigies  whose  ex- 
hibitions of  precocious  musical  or  histrionic  talent  have  recently  proved  so 
attractive  to  the  sensation- seeking  audiences  of  the  Old  and  Xew  Worlds. 

If  the  mental  faculties  may  in  such  cases  be  thus  early  developed,  with 
an  almost  absolute  certainty  of  their  subsequent  failure  at  a  correspondingly 
untimely  age,  it  is  not  to  be  wondered  at  that  a  like  extraordinary  precocity 
should  in  some  unfortunate  instances  exhibit  itself  in  a  premature  evolution 
of  the  sexual  functions,  the  unhappy  subjects  of  which,  instead  of  growing 
up  with  gradually-increasing  vigor  to  the  possession  of  a  healthy  manhood, 
sink  into  a  premature  old  age,  mentally  imbecile  and  physically  decrepit 
at  what  should  normally  have  been  the  period  of  vital  maturity. 

In  the  writings  of  the  older  physiologists  many  examples  of  physical 
as  well  as  mental  precocity,  and  of  their  generally  untoward  termination, 
may  be  found.  A  most  interesting  collection  of  such  cases  is  contained  in 
Dr.  Mason  Good's  erudite  but  now  forgotten  "  Study  of  Medicine ;"  and, 
as  this  work  is  not  generally  accessible  at  the  present  day,  a  reference  may 
be  here  permissible  to  some  of  these,  taken  principally  from  the  Journal  des 
Sgavans  for  1688  and  the  Philosophical  Transactions  for  1745.  In  the 
former  Boiset  gives  an  instance  of  this  disgusting  anticipation  in  a  boy  of 
three  years ;  in  the  latter,  the  subject  in  the  case  recorded  was  two  years  and 
eleven  months  old.  Similar  examples  at  a  similar  age  may  be  found,  to- 
gether with  various  others,  minutely  described  in  the  first  volume  of  the 
Jledico-Chirurgical  Transactions.  In  the  year  1748,  Mr.  Dawkes,  a  sur- 
geon at  St.  Ives,  near  Huntingdon,  published  a  small  tract,  called  "  Pro- 
digium  "VVilliughamense,"  or  an  account  of  a  surprising  boy  who  was  buried 
at  Willingham,  near  Cambridge,  upon  whom  he  wrote  the  following  epitaph  : 
"  Stop,  traveller,  and  wondering  know,  here  buried  lie  the  remains  of 
Thomas,  son  of  Thomas  and  Margaret  Hall,  who,  not  one  year  old,  had 
the  signs  of  nianhood ;  not  three,  was  almost  four  feet  high ;  endued  with 
uncommon  strength,  a  just  proportion  of  parts,  and  a  stupendous  voice ; 
before  six  he  died,  as  it  were,  of  an  advanced  age.  He  was  born  at  this 
village,  October  31, 1741,  and  in  the  same  departed  this  life,  Sept.  3,  1747." 
See,  also,  Phil.  Trans.,  1744-45.  As  Dr.  Elliotsou  has  observed,  this 
perfectly  authentic  case  removes  all  doubts  respecting  the  boy  at  Salamis 
mentioned  by  Pliny  (Hist.  Nat.,  lib.  vii.  c.  17)  as  being  four  feet  high  and 
having  reached  puberty  when  only  three  years  old,  and  respecting  the  man 
seen  by  Craterus,  the  brother  of  Antigonus  (cited  in  Blumcnbach's  Physi- 
ology, 4th  edition,  p.  535),  who  in  seven  years  was  an  infant,  a  youtli,  an 
adult,  a  fatlier,  an  old  man,  and  a  corpse ! 

Diseases  of  Puberty. — Of  the  various  factors  in  the  etiology  of  disease, 
there  is  none  more  obvious  in  its  effects  than  the  influence  of  a":e  in  the 
causation  of  the  chief  maladies  to  which  each  period  of  life  is  specially 
susceptible,  and  whicli  seldom  occur  at  otiier  epochs.  "Thus,"  as  Dr. 
Eliotson  remarked,  "  we  rarely  see  gout  in  an  infant,  nor  is  it  common  for 


394  PUBERTY  :    ITS   PATHOLOGY   AND   HYGIENE. 

old  persons  to  have  the  symptoms  of  acute  hydrocephalus."  This  elective 
affinity  of  certain  disorders  for  particular  ages  is  strikingly  exemplified 
during  puberty  by  the  special  tendencies  then  manifest  in  both  sexes  to 
the  development  of  strumous  or  tuberculous  disorders  and  gastro-intestinal 
complaints,  as  well  as  by  the  various  acute  inflammatory  and  hemorrhagic 
diseases — pulmonary,  cerebral,  and  hepatic — which  are  then  so  prevalent ; 
whilst  in  females  the  special  pathological  proclivities  accompanying  puberty 
are,  as  will  be  seen  in  the  next  section,  still  more  directly  connected  with 
the  newly-developed  functional  activity  of  the  utero-ovarian  system. 

Special  Disorders  of  Female  Puberty. — The  various  morbid  suscep- 
tibilities or  special  predispositions  to  disease  connected  with  the  establish- 
ment of  menstruation  have  been  elsewhere  discussed  by  myself  as  well  as 
by  countless  other  writers  since  the  time  when  they  were  clearly  described 
by  Sir  Thomas  Lay  cock  and  Dr.  Williams.  Man}^,  indeed,  and  serious,  as 
the  latter  points  out,  are  the  evils  liable  to  be  produced  by  external  causes 
which  check  the  development  of  this  function.  So  also,  when  established, 
this  function  has  its  nervous  as  well  as  vascular  relations,  and  where  it  is 
disordered  or  irregular  a  predisposition  is  given  to  various  maladies  affecting 
the  blood-vessels  and  their  contents,  the  secreting  organs,  and  the  nervous 
system.  It  would  be  impossible  to  discuss  the  pathological  relations  of  the 
special  function  that  marks  the  establishment  of  female  puberty  without 
some  reference  to  the  physiological  processes  by  which  this  evolution  is 
accomplished,  and  to  any  disturbance  in  which — whether  by  excess,  dimi- 
nution, or  arrest — the  complaints  to  be  now  considered  may,  in  many  in- 
stances, be  traceable. 

Some  doubt  has  been  thrown  by  Mr.  Lawson  Tait  and  some  other  recent 
Avriters  on  the  hitherto  generally  accepted  doctrine,  to  which  I  myself  still 
adhere, — viz.,  that  menstruation  is  dependent  on  ovarian  action  or  ovula- 
tion ;  and  hence,  as  the  question  is  one  bearing  directly  on  the  pathology 
of  female  puberty,  I  shall  here  briefly  recapitulate  some  of  my  former 
observations  on  this  point. 

The  chief  characteristic  of  the  change  from  girlhood  to  puberty,  which 
in  our  climate  generally  occurs  at  the  fifteenth  year  of  age  or  thereabouts, 
consists  in  the  regular  establishment  of  that  periodic  action  of  menstrua- 
tion for  the  accomplishment  of  which  the  conjoint  functional  activity  of  the 
ova,ries,  Fallopian  tubes,  and  uterus  is  essential.  This  process  commences 
in  ovulation,  or  the  maturation  of  a  Graafian  follicle,  followed  by  the  escape 
of  the  contained  ovum  and  its  transmission  by  the  Fallopian  tube  into  the 
uterus,  whereupon  there  also  occurs  a  disintegration,  or  shedding  of  the 
endo-uterine  lining  membrane,  which,  the  subjacent  surface  thus  unsealed, 
leads  to  a  hemorrhagic  exudation  or  discharge  per  vaginam,  amounting  to 
six  or  eight  ounces,  and  extending  over  a  period  of  from  three  to  five  days. 
Immediately  before  this  catamenial  epoch,  the  patient  suffers  from  more  or 
less  general  malaise,  languor,  and  heaviness ;  she  is  indisposed  to  exertion, 
and  complains  of  pain  in  the  back  and  loins,  and  down  the  thighs.     Occa- 


PUBERTY  :    ITS    PATHOLOGY    AND    HYGIEXE.  395 

sionally  there  is  uneasiness  and  a  sense  of  constriction  in  the  throat  and 
about  the  thyroid  gland.  There  is  a  peculiar  dark  shade  over  the  counte- 
nance, and  especially  underneath  the  eyes.  The  cutaneous  perspiration  and 
breath  have  a  faint  sickly  odor.  The  mammoe  are  enlarged  and  often  pain- 
ful, digestion  is  somewhat  impaired,  and  the  appetite  is  fastidious.  After 
these  symptoms  have  been  present  for  a  day  or  two,  under  normal  circum- 
stances the  menses  appear,  and  the  uneasiness  subsides. 

In  a  large  number  of  cases,  however,  the  nervous  disturbances  connected 
with  the  establishment  of  menstruation  are  of  a  more  serious  nature  than 
in  those  just  referred  to,  and  these  will  now  be  considered. 

Hysterical  Disorders  of  Puberty. — The  frequent  occurrence  of  hys- 
terical and  other  cerebro-nervous  disorders  in  females  about  the  asre  of 
puberty  is  evidently  strictly  consequent  on  the  complex  structural  and  func- 
tional changes  then  in  process  in  the  reproductive  system,  the  predominant 
influence  of  which  is  manifest  in  every  vital  action  from  the  dawn  of  puberty 
until  the  termination  of  the  period  when  utero-gestation  is  possible.  The 
commencement  of  this  epoch  is  marked  by  a  sudden  and  complete  revo- 
lution in  the  female  mental  as  well  as  physical  constitution.  At  each  suc- 
ceeding ovulation  there  also  is  a  coincident  recurrence  of  constitutional  and 
nervous  disturbance  acting  on  the  general  economy  through  the  wide-spread 
ramifications  of  the  vaso-motor  sympathetic  system,  so  that  comparatively 
few  women  whilst  menstruating  can  be  said  to  enjoy  the  mens  sana  in  cor- 
pore  sano  in  their  integrity. 

When  menstruation  has  become  established,  and  is  regular  in  every 
respect,  the  accompanying  nervous  disturbance  may  be  so  slight  as  to  escape 
observation.  But  the  earlier  catamenial  periods,  as  well  as  every  subse- 
quent deviation  from  normal  menstruation,  are  so  frequently  attended  with 
some  manifestation  of  hysteria  that  under  the  guise  of  nearly  every  com- 
plaint then  incidental  to  female  youth,  and  whether  the  trouble  be  spinal, 
cardiac,  pulmonary,  or  indeed  any  of  those  obscure  complaints  common  at 
that  age,  and  for  which  no  obvious  physical  evidence  is  apparent,  the  expe- 
rienced practitioner  may  very  frequently  be  able  to  trace  the  fons  et  origo 
malorum  to  the  sympathetic  nervous  disturbances  that  are  connected  with 
the  evolution  of  puberty.  It  need  scarcely  be  added,  however,  that,  whilst 
thus  prepared  to  meet  with  the  protean  forms  of  hysteria,  simulating  and 
complicating  the  most  common  diseases  prevalent  during  this  epoch,  the 
physician  must  be  no  less  forewarned  against  the  much  graver  error  of 
ignoring  or  neglecting  the  obscure  evidences  of  actual  jiliysical  disease  in 
any  patient,  however  hysterical  she  may  be. 

It  would  be  impossil)le,  witliin  the  limits  of  this  article,  to  refer  here  in 
any  way  to  the  widely-extended  list  of  authors,  of  every  age  and  country, 
by  whom  the  hysterical  disorders  of  puberty  have  been  described.  Still,  as 
a  matter  of  literary  rather  tlian  of  practical  interest,  I  may  venture  to  cite 
the  brief  allusion  made  to  tin's  subject  by  the  earliest  of  them,  viz.,  Hip- 
pocrates, who  observes,  "  Nubile  virgins,  particularly  about  the  menstrual 


396  PUBERTY  :    ITS   PATHOLOGY   AND    HYGIEXE. 

periods,  are  aifected  with  epileptic  paroxysms,  apoplexies,  and  groundless 
fears  and  fancies."  He  attributes  these  to  a  cougestiou  about  the  heart  and 
diaphragm  ("  noble  parts").  "  When  these  organs  are  oppressed,  rigors  and 
feverishness  supervene;  the  patient  raves  about  the  acute  inflammation, 
cries  out  on  account  of  putridity  ;  is  terrified  and  anxious  on  account  of  her 
dimness  of  vision ;  and,  from  the  oppression  about  the  heart,  thinks  suffo- 
cation is  impending.  The  mind  is  harassed  by  anxiety  and  weakness,  and 
becomes  diseased.  The  patients  call  out  in  great  alarm,  desire  to  leap  down 
or  throw  themselves  headlong  into  pits,  and  order  themselves  to  be  strangled, 
as  if  it  were  a  thing  beyond  all  others  to  be  desired.  Spectres  haunt  them, 
and  they  earnestly  long  for  death,  as  for  a  pleasure.  The  disease  is  easily 
cured  if  nothing  retard  the  flow  of  the  menses.  To  those  young  females 
affected  by  it,  I  recommend  that  they  marry  as  quickly  as  possible,  for  if 
they  conceive  they  will  escape  the  disease.  Unless  this  be  done,  they  are 
sure  to  suffer  from  it,  about  or  a  little  after  puberty."  In  another  part 
of  these  writings  ("  De  Morbis  Mulierum,"  lib.  i.)  is  a  graphic  description 
of  the  aggravated  form :  in  this  ischuria,  spinal  and  abdominal  tenderness, 
tympanites,  aphonia,  syncope,  etc.,  were  observed,  just  as  they  are  at  ji resent 
in  such  cases. 

At  the  present  time  the  forms  of  hysterical  disease  which  are  commonly 
observed  in  connection  with  the  evolution  of  puberty,  though  less  aggra- 
vated than  those  described  by  Hippocrates,  are  nevertheless  of  sufficient 
importance  to  deserve  more  consideration  than  is  generally  accorded  to 
them.  Thus,  even  the  ordinary  hystei'ical  paroxysm  associated  with  early 
menstrual  derangement,  and  usually  regarded  as  too  trivial  to  require  any 
special  medical  care,  may  be  an  indication  of  serious  utero-ovarian  irrita- 
tion or  disease,  the  neglect  of  which  may  possibly  eventuate  in  the  gravest 
forms  of  cerebro-nervous  disorder, — viz.,  epilepsy  and  insanity. 

The  Voice  in  Hysteria. — As  a  general  indication  of  hysteria,  the 
changed  character  of  the  patient's  voice  in  such  cases  may  be  mentioned. 
This  alteration  consists  in  a  loss  of  that  jjeculiar  softness  and  melody  which 
distinguish  the  female  from  the  male  voice.  In  hysteria  the  patient's  in- 
tonation either  becomes  more  rough  and  masculine  than  normal,  or  else 
becomes  more  shrill  and  piercing  or  metallic  than  usual,  as  well  as  more 
rapid  in  the  sequence  of  its  modulations.  The  hysteric  voice  is  not  easily 
described,  but  once  recognized  it  is,  I  believe,  an  unmistakable  evidence  of 
nervous  functional  disturbance  consequent  on  some  derangement  of  the 
utero-ovarian  functions. 

The  earlier  nervous  symptoms  that  frequently  occur  at  puberty  may  for 
a  time  be  unrecognized,  but  as  the  local  disease  progresses  these  come  into 
such  prominence  as  in  many  cases  to  obscure  all  the  evidences  of  their 
physical  exciting  cause.  The  most  important  of  these  manifestations  of 
hysteria  are  increased  nervous  susceptibility,  or  general  hyper£esthesia,  and 
diminution  of  inhibitory  nerve-force,  togetlier  Avith  perverted  moral  or 
mental  excitability,  and  in  some  cases  actual  delusions. 


PUBERTY  :    ITS   PATHOLO&Y   AXD    HYGIEXE.  397 

Hysterical  hvpersesthesia  is  more  frequently  coexistent  with  amenor- 
"rhoea,  or  dysnienorrhoea,  resulting  from  uterine  disease  or  displacement,  than 
with  any  pathological  increase  in  this  function. 

Hysterical  Insanity. — The  connection  between  mental  disease  and 
menstrual  disorders,  more  especially  amenorrhoea,  has  been  frequently  ob- 
served by  alienists  as  well  as  by  gynaecologists.  Thus,  in  a  case  related  by 
Pinel,  a  girl  suffering  from  insanity  was  placed  under  his  care  shortly 
before  the  ordinary  age  of  puberty,  which  passed  over  without  the  occur- 
rence of  the  usual  changes  connected  with  this  period.  After  a  consider- 
able lapse  of  years,  however,  one  day  on  rising  from  bed  she  ran  and 
embraced  her  mother,  exclaiming,  "  I  am  well !"  The  catamenia  had  just 
flowed  for  the  first  time,  and  her  reason  was  restored,  both  the  mental  and 
reproductive  systems  thenceforth  permanently  resuming  their  normal  func- 
tional conditions. 

Hysterical  Epilepsy. — As  I  pointed  out  in  a  former  memoir  of  mine, 
"  On  the  Cerebro-Nervous  Disorders  peculiar  to  Women,"  this  disease  is 
frequently  observed  in  girls  of  an  hysterical  temperament  at  the  period  of 
puberty,  nor  can  I  call  to  mind  a  single  case  of  any  of  the  different  forms 
of  epilepsy  or  hystero-epilepsy,  so  met  with,  that  was  not  accompanied 
with  some  derangement,  and  more  generally  suppression,  of  the  menstrual 
functions. 

Hysterical  Trance. — Hysterical  evidences  of  utero-ovarian  disorder, 
connected  with  the  evolution  of  puberty,  may  also  manifest  themselves  by 
diminished  nervous  activity  and  general  or  local  ansesthesia,  and  as  well  by 
the  opposite  condition.  Perhaps  the  most  remarkable  illustration  of  this 
fact  is  afforded  by  hysterical  trance,  or  cataphora,  in  which  the  ordinary 
phenomena  of  vitality  are  apparently  susj^ended  by  a  morbid  condition, 
undistinguishable  in  some  instances  from  death.  A  brief  account  of  some 
instances  of  lethargy  of  this  character  that  have  come  within  my  experi- 
ence will  perhaps  best  serve  to  illustrate  the  general  course  of  these  inter- 
esting cases.  Fuller  details  may  be  found  in  two  papers  of  mine  on  this 
subject  in  the  Dublin  Journal  of  3Iedical  Science. 

The  first  of  the  following  cases  is  an  instance  of  so-called  hysteric  trance. 
A  young  lady.  Miss  R.,  recently  arrived  at  puberty,  of  an  hysterical  tem- 
perament, but  otherwise  apparently  in  perfect  health,  M^cnt  into  her  room 
after  luncheon  to  make  some  change  of  dress.  A  few  minutes  afterwards 
she  was  found  lying  on  her  bed  in  a  profound  sleep,  from  which  she  could 
not  be  awakened.  When  I  first  saw  her,  twenty-four  hours  later,  she  was 
then  still  sleeping  tranquilly,  the  decubitus  being  dorsal,  respiration  scarcely 
perceptible,  pulse  70  and  extremely  small ;  her  face  was  pallid,  lips  motion- 
less, and  the  extremities  very  cold.  At  this  moment  so  death-like  was  her 
aspect  that  a  casual  observer  miglit  liave  doubted  the  possibility  of  the  vital 
spark  still  lingering  in  that  apparently  inanimate  frame,  on  which  no  external 
stimulus  seemed  to  produce  any  sensorial  impression,  with  the  exccj^tion, 
however,  that  the  pupils  responded  to  light.     Sinapisms  were  applied  over 


398  PUBEETY  :    ITS    PATHOLOGY   AND   HYGIENE. 

the  heart  and  to  the  legs,  where  they  were  left  on  until  vesication  was 
occasioned  without  causing  any  evidence  of  pain.  Faradization  was  also 
resorted  to  without  eifect. 

In  this  state  she  remained  from  the  evening  of  the  31st  of  December 
until  the  afternoon  of  the  3d  of  January,  when  the  pulse  became  com- 
pletely imperceptible,  the  surface  of  the  body  was  icy  cold,  the  respiratory 
movements  apparently  ceased,  and  her  condition  was  to  all  outward  appear- 
ance undistinguishable  from  death.  Under  the  influence  of  repeated  hypo- 
dermic injections  of  sulphuric  ether  and  other  remedies,  however,  she  rallied 
somewhat,  and  her  pulse  and  temperature  again  improved.  But  she  still 
slept  on  until  the  morning  of  the  9th,  when  she  suddenly  woke  up,  and,  to 
the  great  astonishment  of  those  about  her,  called  for  her  clothes,  which  had 
been  removed  from  their  ordinary  place,  and  wanted  to  come  down  to  break- 
fast, without  the  least  consciousness  of  what  had  occurred.  Her  recovery, 
I  may  add,  was  rapid  and  complete. 

In  the  second  instance  of  the  same  kind  that  I  have  seen,  the  patient, 
after  a  lethargic  sleep  of  twenty-seven  days,  recovered  consciousness  for  a 
few  hours,  and  then  relapsed  into  her  former  comatose  condition,  in  which 
she  died. 

In  another  case  of  hysteric  lethargy  in  a  young  lady  under  my  care,  the 
trance  lasted  for  seventy  hours,  during  which  the  flickering  vital  spark  was 
preserved  from  extinction  only  by  the  involuntary  action  of  the  spinal  and 
ganglionic  nervous  centres.     In  this  instance  the  patient  finally  recovered. 

The  last  instance  of  profound  cataphora  or  lethargy  that  has  come 
within  my  own  observation  occurred  last  autumn  in  the  IMater  Misericordise 
Hospital,  in  the  case  of  a  young  woman  under  the  care  of  my  distinguished 
colleague  Dr.  Boyd.  In  that  instance,  despite  all  that  medical  skill  could 
suggest  or  unremitting  attention  could  do,  it  was  found  impossible  to  arouse 
the  patient  from  the  apparently  hysterical  lethargic  sleep  in  which  she  ulti- 
mately sank  and  died. 

I  have  referred  to  the  foregoing  cases,  occurring  in  one  pliysician's 
experience,  as  disproving  the  general  opinion  that  hysterical  lethargy  or 
trance  is  so  rarely  met  with,  and  is  then  of  such  trivial  pathological  impor- 
tance as  to  be  of  little  if  any  practical  interest.  On  the  contrary,  from  my 
own  experience,  I  can  vouch  that  these  conditions  are  of  far  more  frequent 
occurrence  than  is  generally  supposed  to  be  the  case,  as  well  as  for  the  fact 
that  all  the  ordinary  external  signs  of  apparent  death  may  occasionally  be 
thus  counterfeited  with  wonderful  similitude.  I  would  therefore  take  this 
opportunity  of  urging  the  necessity  of  bearing  this  in  view,  so  as  to  avoid 
what  I  fear  is  the  not  infrequent  possibility  of  living  interment  in  some 
cases  of  too  hurried  burial  under  such  circumstances,— ra  calamity  the 
horrors  of  which,  I  may  here  repeat,  no  effort  of  imagination  can  exag- 
gerate, and  for  the  prevention  of  which  no  pains  can  be  excessive  and  no 
precautions  superfluous. 

Hysterical  Paralysis. — In  many  instances  the  nervous  symptoms  of 


PUBERTY  :    ITS   PATHOLOGY   AND    HYGIENE.  399 

utero-ovariau  functional  disturbance  at  the  period  of  puberty  may  also  be 
manifested  in  the  simulation  of  every  form  of  paralysis,  from  the  most 
trivial  local  loss  of  power  to  complete  paraplegia.  Of  the  latter  I  recently 
met  with  a  well-marked  example  in  the  case  of  a  young  lady,  aged  nineteen, 
who  had  never  menstruated,  and  who,  when  I  first  saw  her,  had  been  for 
nearly  eighteen  months  confined  to  bed  with  apparent  complete  loss  of 
power  of  the  extremities.  During  this  period  she  had  been  actively  treated 
by  several  practitioners,  by  whom  she  had  been  alternately  submitted  to 
faradization,  the  various  nerve-tonics,  blistering,  cold  and  hot  baths  and 
douches,  as  well  as  ultimately  being  enclosed  in  a  plaster  jacket,  to  remedy 
the  supposed  spinal  cause  of  her  condition.  None  of  these  remedies,  how- 
ever, proved  of  the  smallest  use  until,  after  an  interval  of  nearly  two  years 
from  the  commencement  of  the  attack,  her  changes  for  the  first  time  made 
their  appearance,  and  from  that  date  she  rapidly  regained  her  former 
health  and  strength. 

Menstrual  Disorders  of  Puberty. — The  normal  course  of  the  evolu- 
tion of  puberty  is  specially  liable  to  derangements  arising  from  the  various 
morbid  conditions  by  which  the  due  performance  of  the  function  of  men- 
struation may  be  interfered  with.  This  disturbance  is  most  frequently 
occasioned  by  amenorrhoea,  or  the  total  absence  or  diminution  of  the  cata- 
meuial  discharge ;  secondly,  by  dysmenorrhoea,  or  the  difficult  and  painful 
accomplishment  of  this  function ;  and  thirdly,  and  less  commonly,  by 
menorrhagia,  or  abnormal  activity  in  the  utero-ovarian  changes  connected 
with  ovulation,  and  consequent  excess  in  the  resulting  menstrual  discharge. 
But  although  the  effects  of  these  disorders  are  more  marked  during  puberty 
than  perhaps  at  any  subsequent  epoch,  inasmuch  as  their  occurrence  is  by 
no  means  restricted  to  this  period,  it  would  be  beyond  the  scope  of  the 
present  article  to  attempt  any  discussion  of  their  general  pathology  and 
treatment. 

With  regard  to  the  first-named  of  these  disorders — viz.,  amenorrhoea — 
it  may,  however,  be  here  observed  that  very  undue  importance  is  commonly 
ascribed  to  the  non-appearance  of  menstruation  at  the  usual  age,  or  to  its 
subsequent  interruption  or  diminution,  as  the  supposed  general  cause  of 
nearly  all  the  ills  to  which  female  flesh,  about  the  jaeriod  of  puberty,  is 
heir.  In  the  great  majority  of  the  cases  of  amenorrhoea  for  which  at  this 
epoch  we  are  so  frequently  consulted  by  anxious  mothers,  the  functional 
irregularity  is  merely  symptomatic  of  systemic  morbid  conditions,  to  the 
rational  treatment  of  which,  by  apj)ropriate  constitutional  remedies,  rather 
than  to  any  futile,  if  not  injurious,  utero-ovarian  or  local  stinudation,  the 
efforts  of  the  physician  should  in  such  cases  be  directed. 

Dysmenorrhoea  is  hardly  less  frequently  associated  than  am(>norrhooa 
with  the  special  hysterical  and  other  constitutional  disorders  incidental  to 
puberty.  Under  these  circumstances,  difficult  menstruation,  although  occa- 
sionally resulting  from  uterine  flexions  or  dis])lacements,  or  from  stenosis 
or  other  obstructive  causes,  as  well  as  from  local  inflammatory  conditions,  is 


400  PUBERTY  :    ITS   PATHOLOGY   AND   HYGIENE. 

far  more  commonly  merely  a  complication  of  coexisting  general  nervous 
disorder  or  constitutional  hypersesthesia,  on  the  cure  of  which  the  dysmenor- 
rhoeal  trouble  will  at  once  subside. 

In  this  connection  I  may  add  a  word  of  warning  against  the  popular 
custom,  so  prevalent  among  all  classes,  of  treating  the  dysmenorrhoea  of 
puberty  by  wine  or  brandy.  From  long  experience  I  am  convinced  that, 
as  I  have  elsewhere  observed,  intemperance  in  women  may  very  frequently 
be  traced  back  to  the  first  painful  menstrual  period,  when  alcoholic  stimu- 
lants are  often  forced  on  the  young  sufferer.  The  pain  of  dysmenorrhoea 
being  thus  relieved,  the  girl  at  the  next  similar  epoch  naturally  and  no 
longer  reluctantly  seeks  the  same  solace,  until  in  this  way  the  victim  of 
dysmenorrhoeal  alcoholism  may  gradually  become  an  habitual  and  perhaps 
an  incurable  drunkard. 

Space  forbids  any  further  allusion  in  this  place  to  the  disorders  of  men- 
struation, to  the  influence  of  which  the  period  of  puberty  is  so  susceptible. 
In  the  next  section  we  must,  however,  refer  at  greater  length  to  a  condition 
generally  connected  with  menstrual  derangements,  and  the  occurrence  of 
which  is  peculiar  to  the  epoch  that  forms  the  subject  of  the  present  article. 

Chlorosis — or  chloransemia,  as  green-sickness  is  more  properly  termed 
— is  the  most  frequent  of  all  the  morbid  conditions  specially  incidental  to 
female  puberty.  This  complaint  may  be  regarded  as  a  specific  form  of 
anaemia,  the  aglobulism  in  these  eases  being  primarily  dependent  on  a 
neurosis  of  the  ganglionic  nervous  system,  and  as  a  rule  is  connected  with 
either  amenorrhoea  or  dysmenorrhoea.  The  history  of  the  disease,  its  symp- 
toms, and  the  line  of  treatment  by  which  these  may  be  relieved,  all  point 
to  the  accuracy  of  Kuchenmeister's  conclusion, — viz.,  that  the  essential 
cause  of  the  chlorotic  condition  is  the  retention  of  carbonic  acid  in  the 
blood.  This  theory  is  sustained  by  the  fact  that  the  chlorotic  are  very 
commonly  persons  of  the  poorer  classes,  who  have  been  subjected  to  priva- 
tion of  fresh  air,  sunlight,  and  exercise,  and  in  whom  by  the  consequent 
diminution  of  pulmonary  exhalation,  aided  by  the  lessened  menstrual  evacu- 
ation in  such  cases,  the  blood  is  surcharged  with  carbonic  acid  as  well  as 
poor  in  red  corpuscles. 

Chlorosis  is  characterized  not  so  much  by  the  sallow  or  slaty  pallor  of  the 
cutaneous  surface  (for  this  is  not  essential  to  the  disease,  and  the  skin  may 
be  deadly  white,  without  a  greenish  tinge),  as  by  a  universal  and  decided 
debility  of  the  whole  frame,  and  sometimes  even  a  degree  of  torpor  of 
particular  organs.  There  is  a  general  weakness  of  the  muscular  system, 
and  weariness  and  languor  of  body,  with  listlessness  of  mind,  the  patient 
being  indisposed  for  any  exertion,  easily  overcome  by  fatigue,  nervous,  low- 
spirited,  and  frequently  a  prey  to  singularities  of  temper.  There  is  gener- 
ally severe  recurrent  headache  or  vertigo,  and  sometimes  an  impaired  state 
of  the  memory  and  of  the  faculty  of  attention  ;  the  sleep  is  disturbed, 
the  chlorotic  sufferer  being  either  preternatural ly  wakeful  or  abnormally 
drowsy.     The  eye,  in  well-marked  cases,  is  dull  and  heavy.     The  lips  and 


PUBERTY  :    ITS    PATHOLOGY    AND    HYGIENE.  401 

tongue  are  at  first  exsanguine  and  pallid,  and  subsequently  present  a  pecu- 
liar slaty  hue.  The  temperature,  more  especially  that  of  the  extremities,  is 
depressed.  The  pulse  is  small  and  weak,  often  rapid,  and  easily  fluttered. 
There  is  frequently  palpitation,  recurring  in  attacks,  or  of  a  more  perma- 
nent character ;  more  frequently  still,  there  is  a  sense  of  sinking  in  the  pr86- 
cordia,  with  irregular  action  of  the  heart,  or  imperfect  syncope.  There  is 
usually  a  degree  of  breathlessness  experienced  on  any  exertion ;  sometimes 
fits  of  dyspnoea ;  sometimes  a  sonorous  cough.  The  appetite  is  abnormal ; 
(K'casionally  it  is  morbidly  increased,  but  more  usually  anorexia  is  present, 
and  the  patient  loathes  food,  or  is  sick  after  eating,  or  much  troubled  with 
flatulence  and  gastrodyuia.  Often  there  is  a  desire  for  indigestible  sub- 
stances, particularly  chalk,  magnesia,  or  even  cinders.  The  bo^vels  are  cos- 
tive, often  obstinately  so  ;  or,  if  not,  the  stools  are  dark  and  offensive.  The 
abdomen  is  not  uncommonly  tumid,  swollen,  and  variable  in  size.  The 
hands  and  feet  swell  at  night,  with  oedema  of  the  eyelids,  if  not  of  the  whole 
face,  particularly  in  the  morning.     The  urine  is  scanty,  though  clear. 

In  addition  to  the  foregoing,  many  other  of  those  obscure  symptoms 
which  in  girls  are  so  frequently  met  with  about  the  time  of  puberty  may 
also  be  found  connected  with  chlorosis.  Of  this  kind  is  that  severe  left-side 
pain,  otherwise  inexplicable,  so  often  complained  of  at  this  age,  as  well  as 
those  intense  nervous  headaches,  breathlessness,  and,  in  fine,  that  host  of 
hysterical  symptoms  by  which  all  the  features  of  organic  and  functional 
disease,  whether  pulmonary,  gastric,  or  cardiac,  may  be  simulated. 

Treatment. — With  regard  to  the  treatment  of  chlorosis  I  would  here 
repeat  that  our  attention  should  be  primarily  directed  to  the  rectification  of 
that  error  of  digestion  which  is  a  chief  cause  of  the  characteristic  aglobu- 
lism,  and,  secondly,  to  the  depuration  of  the  vitiated  blood  by  the  excretory 
organs,  rather  than,  as  is  too  often  done  in  such  cases,  to  the  restoration  of 
the  catameuial  discharge,  the  suppression  of  Avhich  should  be  regarded  as 
merely  a  symptom — albeit  a  primary  and  most  important  one — of  the  con- 
stitutional disorder. 

In  accordance  with  this  view,  the  rational  treatment  of  chlorosis  must 
therefore  be  approached  by  means  capable  of  strengthening  the  general 
system,  and  more  especially  improving  the  tone  of  the  organs  of  digestion 
and  excretion.  For  the  first  purpose,  open-air  exercise,  free  exposure  to 
sunlight,  and  suitable  food  are  obviously  more  essential  than  any  of  the 
pharmaceutical  resources  at  our  command.  Even  if  our  main  object  were 
the  cure  of  the  amenorrhoea  connected  with  the  chlorotic  condition,  and 
even  if  we  had  medicines  more  certainly  emmenagogue  than  we  possess, 
we  might,  when  we  succeeded  in  this,  attribute  our  success  chiefly  to  such 
means  as  tend  to  improve  the  general  healtli  and  strength.  Wc  would, 
then,  recommend  regular  exercise,  proportioned  to  the  ability  of  the  patient ; 
the  use  of  the  warm  or  tepid  salt-water  bath  eveiy  day,  succeeded  by  fric- 
tion with  dry  flannel  or  a  soft  brush  ;  sufficient  clothing,  and  particularly  a 
flannel  dress ;  a  nourishing  and  digestible  diet ;  the  administration  of  bitter 
Vol.  I.— 26 


402  PUBERTY  :    ITS   PATHOLOGY   AND    HYGIENE. 

and  tonic  medicines  in  varied  forms,  preparations  of  iron,  such  as  chalybeate 
waters,  tincture  of  muriated  iron,  or  the  subcarbonate  of  iron,  alone  or 
combined  with  myrrh,  or  sulphate  of  iron  with  quinine,  or  a  grain  of  iodide 
of  iron  in  a  bitter  infusion,  and  arsenic. 

The  use  of  chalybeate  mineral  waters,  internally  as  well  as  externally, 
is  of  self-evident  service  in  the  chlorotic  state,  unless  the  patient  be  of  a 
full  habit,  in  which  case  purgatives  must  be  premised,  and  afterwards  con- 
joined, so  far  as  necessary. 

Tuberculosis  and  Strumous  Disorders  of  Puberty. — Having  dis- 
cussed in  the  preceding  sections  the  most  important  of  the  special  disorders 
directly  connected  with  the  organic  and  functional  evolution  of  the  repro- 
ductive system,  we  must  now  briefly  consider  some  other  forms  of  dis- 
ease to  which  the  period  of  puberty  is  specially  liable,  even  although  their 
occurrence  is  not  limited  to  this  age  and  their  etiology  must  in  some  instances 
be  sought  in  causes  operating  at  an  antecedent  epoch.  Of  these  maladies 
the  most  important  in  this  connection  are  the  various  forms  of  strumo- 
tuberculous  complaints  which  constitute  so  large  a  proportion  of  the  dis- 
eases of  puberty. 

Within  the  last  few  years  the  frequency  of  such  affections,  as  observed 
in  my  hospital  practice,  has  become  notably  increased.  The  explanation  of 
this  fact  must,  I  think,  be  looked  for  in  circumstances  preceding  the  devel- 
opment of  puberty,  and  is  mainly  referable  to  the  dietetic  and  hygienic  mis- 
management of  childhood,  more  especially  to  the  frequent  employment 
of  unsuitable  condiments,  such  as  tinned  and  other  artificial  so-called  milk- 
preparations  as  substitutes  for  the  natural  food  essential  for  the  healthy 
nutrition  of  children. 

The  acute  forms  of  tuberculosis  which  are  most  common  during  youth 
have  been  observed  by  Cohnheim  and  Klebs  to  resemble  the  infective  dis- 
eases in  their  zymotic  origin  from  a  specific  virus,  whether  generated  in  the 
body  from  caseous  matter  or  introduced  from  without.  The  latter  is  prob- 
ably generally  the  case  in  the  tubercular  diseases  so  common  among  the 
children  of  the  poorer  classes,  into  whose  dietary  tinned  or  preserved  milk 
now  enters  largely ;  for  there  can,  I  think,  be  no  guarantee  that  the  cows 
furnishing  this  supply  are  not  suifering  from  perlsucht,  or  bovine  tuber- 
culosis, as  the  disease  is  very  prevalent  and  does  not  materially  affect  the 
quantity  of  milk. 

The  foregoing  views  as  to  the  frequent  origin  of  tuberculosis  from  in- 
fected milk,  to  which  I  called  attention  in  "  The  Transactions  of  the  In- 
ternational Medical  Congress  of  1881"  (vol.  iv.),  have  been  strongly 
corroborated  by  the  recent  researches  of  Prof  Bollinger  ( Wiener  Medizin. 
Presse,  September  16,  1888).  Regarding  the  frequency  of  tuberculosis. 
Prof.  Bollinger  maintains  that  in  large  cities  from  forty  to  fifty  per  cent. 
of  all  deaths  may  be  attributed  to  this  disease.  Recent  experiments  in 
his  laboratory  show  that  milk  may  prove  infections,  whether  taken  from 
cows  sufferina;  with  local  or  from  those  suffering  with  general  tuberculosis. 


PUBERTY  :    ITS   PATHOLOGY   AND   HYGIEXE.  403 

As  in  other  infectious  diseases,  the  quantity  of  tuberculous  material  intro- 
duced into  the  economy  strongly  influences  the  severity  of  infection.  Only 
a  few  drops  of  undiluted  milk  from  a  tuberculous  cow  proved  sufficient 
to  produce  typical  miliary  tuberculosis  in  animals,  but  when  this  quantity 
underwent  any  material  dilution  its  effects  were  negative.  This  latter  ob- 
servation would  suggest  the  use  of  milk  taken  from  many  cows  rather 
than  from  one  cow.  The  non-infectiousness  of  meat  from  tuberculous 
animals  was  proved  by  taking  the  muscles  of  twelve  tuberculous  cows 
and  injecting  the  liquid  obtained  into  the  peritoneal  cavities  of  sixteen 
guinea-pigs  :  no  tuberculosis  resulted. 

With  regard  to  the  curability  of  tuberculosis,  Bollinger  refers  to  many 
necropsies  made  on  individuals  in  whom  lesions  of  a  former  tuberculosis 
are  found. 

Inoculations  made  with  material  obtained  from  twelve  capsulated  caseous 
patches  on  twenty-six  animals  resulted  in  the  development  of  tuberculosis 
in  twenty  of  the  animals.  The  experimental  results  show  that  in  twenty- 
six  suspected  cases  of  tuberculosis  of  the  pulmonary  apices,  seven  only 
(twenty-seven  per  cent.)  were  non-infectious.  For  the  microscopical  ana- 
tomical diagnosis  the  fact  is  important,  that  all  apical  affections  of  the  lung 
are  to  be  regarded  as  infectious,  as  long  as  caseous  or  caseous-calcareous 
patches  are  present.  Those  cases  only  can  be  denominated  as  cured  in  which 
simple  cicatrices  are  present,  with  or  without  calcareous  infiltration. 

Another  cause  of  the  increasing  frequency  of  scrofulous  and  tubercular 
disorders  is  the  physical  deterioration  of  our  people  arising  from  that  wide- 
spread intemperance  which  is  almost  as  general  among  women  as  it  is  among 
men,  and  the  consequent  toxicological  effect  of  alcoholism  on  tlie  wretched 
offspring  of  these  drunken  parents,  who  further  pay  the  penalty  of  their 
progenitors'  excesses  by  the  development  of  scrofula  and  tuberculosis  as  the 
result  of  semi-starvation  and  neglect  during  the  first  years  of  life.  Probably 
also  local  circumstances  have  much  to  do  with  the  prevalence  of  scrofulous 
and  tubercular  diseases  in  other  large  towns  as  well  as  in  Dublin.  Nor  can 
there  be  any  doubt  that  the  situation  of  that  city  in  the  low-lying,  badly- 
drained  valley  of  the  Liffey,  and  the  densely-inhabited  squalid  tenements, 
too  generally  devoid  of  the  most  necessary  sanitary  requirements,  in  which 
the  poorest  class  of  a  poverty-stricken  population  are  crowded  togetlier,  have 
a  deteriorating  influence  on  the  physical  condition  of  the  ill-lodged,  ill-fed, 
and  ill-clad  scrofulous  children  who  from  thence  recruit  our  hospitals  and 
prematurely  fill  our  cemeteries. 

It  would  be  impossible  to  consider  here  so  wide  a  question  as  the  relation 
of  scrofula  to  tuberculosis ;  but  I  may  venture  to  reiterate  my  adherence  to 
the  older  doctrine  on  this  subject,  wliich  I  have  elsewlicre  discussed,  and 
which  was  first  impressed  on  my  mind  when  a  student  in  the  scrofula-haunted 
hospitals  of  Algiers, — namely,  that  the  scrofulous  diathesis  is  the  prolific 
and  primary  source  of  all  tuberculous  disease,  whatever  part  of  the  body 
may  be  thus  aflfected,  whether  it  be  the  lungs,  the  meninges  or  substance 


404  PUBERTY  :    ITS    PATHOLOGY    AND    HYGIENE. 

of  the  brain  or  .spinal  cord,  the  mesenteric  glands,  the  cancellous  structure 
or  articulating  surfaces  of  the  bones,  or  the  external  glandular  system. 

In  my  work  on  "  Change  of  Climate,"  the  first  edition  of  which  was 
published  many  years  ago,  I  dwelt  on  the  evident  connection  between 
scrofula  and  phthisis,  and  also  pointed  out  the  contagious  or  infectious 
character  of  these  diseases  under  certain  conditions.  I  may  therefore  be 
permitted  to  claim  some  interest  in  finding  similar  views  now  adopted  on 
these  questions  by  the  most  eminent  recent  pathologists. 

One  of  the  most  frequent  forms  of  pulmonary  tubercular  disease  that 
come  under  treatment  at  the  Dublin  Children's  Hospital  is  miliary  tubercu- 
losis, or,  as  the  old  writers  well  termed  it,  acute  or  galloping  consumption. 
In  many  instances  I  have  seen  miliary  tuberculization  of  the  lungs  pass 
through  all  its  stages,  from  its  first  recognition  until  the  patient's  death, 
within  less  than  a  month.  The  rapidity  of  the  race  towards  death,  and  the 
accompanying  similar  tubercular  infiltration  of  the  meninges  and  substance 
of  the  brain,  peritoneum,  liver,  etc.,  in  such  cases,  leave  little  room  to  ques- 
tion the  fact  that  acute  tuberculosis  is  essentially  an  auto-infective  disease. 
Within  the  last  few  years  a  new  light  has  been  thrown  on  the  causes  and 
method  of  development  of  tubercular  disorders,  concerning  which,  until 
recently,  the  views  of  Buhl  as  to  their  origin  from  auto-inoculation  with 
caseous  matter  in  the  body  were  generally  accepted.  Tliis  doctrine  has  been 
disturbed  by  the  discovery  by  Koch  (in  1882)  of  the  specific  bacillus  of 
tubercle,  and  by  the  more  recent  researches  of  other  pathologists  in  the 
same  direction,  which  enable  us  in  some  measure  to  understand  the  extraor- 
dinary rajDidity  with  which  pulmonary  tuberculosis  too  often  supervenes 
on  an  attack  of  broncho-pneumonia,  particularly  in  strumous  patients  at  the 
age  of  puberty.  Nor  is  it  to  be  wondered  at  if,  in  children  thus  previously 
enfeebled  by  diathesis,  the  struggle  for  existence  between  the  specific  micro- 
organisms of  disease  and  the  colorless  blood-corpuscles  or  leucocytes,  which 
have  been  recently  graphically  described  by  Dr.  Latham  and  by  Metschin- 
koff,  should  so  speedily  result  in  favor  of  the  almost  incredibly  rapidly- 
multiplying  bacilli. 

Treatment — Be  the  pathogenesis  of  tuberculosis  what  it  may,  there  can, 
I  think,  be  no  question  of  the  fact  that  the  disease  is  most  generally  devel- 
oped at  puberty  in  patients  of  an  otherwise  evidently  strumous  diathesis, 
and  that  its  primary  predisposing  cause  is  generally  traceable  to  malnutri- 
tion, general  or  local,  in  such  cases.  Under  these  circumstances,  and  bear- 
ing in  mind  the  facts  ascertained  by  recent  investigations  just  referred  to,  it 
is  obvious  that  our  primary  therapeutic  eiforts  should  be  directed  towards 
endeavoring  so  to  enrich  or  improve  the  condition  of  the  circulating  fluid  as 
to  increase  its  capability  of  resisting  and  destroying  the  micro-organisms  by 
which  tuberculosis  is  developed,  and  that  for  this  purpose  we  must  seek  to 
rectify  any  existing  error  of  nutrition  that  may  result  from  defective  nutri- 
ment as  well  as  from  impaired  powers  of  digestion  and  assimilation.  These 
indications  should  be  borne  practically  in  view  in  the  selection,  for  such 


PUBERTY  :    ITS   PATHOLOGY    AXD    HYGIEXE.  405 

patients,  of  a  dietary  not  only  easy  of  digestion  and  assimilation,  but  also 
specially  rich  in  those  elements  needed  to  strengthen  the  constitution  against 
the  inroads  of  the  prolific  micro-organisms  by  which  tuberculosis  is  devel- 
oped. The  arrangement  of  that  dietary  must,  however,  be  so  largely  con- 
trolled by  the  circumstances  of  each  case  as  to  render  it  imjiossible  to  lay 
down  any  general  directions  on  this  point.  I  may,  however,  observe  that 
some  of  the  special  requirements  in  this  respect  of  strumo-tubercular  youth 
are  to  a  large  extent  supplied  by  the  food-medicines  with  which  modern 
polypharmacy  has  no^v  armed  us  for  the  struggle  with  tubercular  disease, 
\vherein  pharmaceutical  remedies  must  be  assigned  a  place  entirely  subsidiary 
to  hygienic  as  well  as  dietetic  management,  by  articles  such  as  cod-liver  oil, 
raaltine,  and  the  various  preparations  of  malt.  Among  the  many  other  reme- 
dies of  a  somewhat  similar  class  which  are  specially  available  in  these  cases, 
none  are  more  generally  serviceable  than  the  officinal  syrups  of  iodide  and 
phosphate  of  iron,  or  the  many  valuable  combinations  of  this  with  other  salts, 
such  as  Parrish's,  or  Squire's,  or  Dusart's  syrup,  or  that  which  I  have  found 
specially  useful  in  the  chronic  wasting  disorders  of  tuberculous  or  strumous 
youth, — namely,  Fellows's  syrup  of  the  hypophosphites  of  iron,  lime,  and 
potash, — with  other  tonics.  In  this  connection  I  may  again  observe  that  as 
a  food-medicine  in  such  cases  there  is  nothing  more  generally  beneficial  than 
Irish  moss.  This  species  of  algse  (the  Chondrus  crispus),  of  which  the 
sea-shores  of  Ireland  furnish  an  inexhaustible  supply,  was  recommended 
upwards  of  half  a  centur)?^  ago  by  Dr.  Todhunter,  of  Dublin,  as  an  anti- 
strumous  remedy.  But  at  the  present  day  the  value  of  Irish  moss  in  this 
M'ay,  and  as  an  article  of  diet,  appears  generally  ignored  or  unknown ; 
and  hence  I  take  this  opportunity  of  bearing  my  testimony  to  its  utility  as 
an  abundant,  cheap,  easily-prepared,  palatable,  and  generally  serviceable 
article  of  food  for  those  suffering  from  any  of  the  chronic  diseases  which 
are  connected  with  the  scrofulous  diathesis  during  puberty. 

In  the  way  of  medicine,  iodine  is  still  the  only  drug  for  which  anything 
like  a  specific  property  can  be  claimed  in  these  cases ;  and  the  reason  that 
more  benefit  is  not  generally  derived  from  its  employment  is  probably  that 
it  is  now  seldom  given  in  the  metallic  form  and  in  the  long-continuetl 
minute  doses  originally  advised  by  Lugol,  in  whose  hands  such  benefit  was 
obtained  from  its  use. 

The  hygienic  and  climatic  treatment  of  the  clironic  strumo-tubercular 
disorders  of  puberty  is  a  subject  of  considerable  practical  importance,  and, 
altliougli  we  can  only  extend  the  benefit  of  favorable  liygienic  and  climatic 
conditions  to  a  comparatively  small  class  of  strumous  patients,  still,  so 
great  are  the  remedial  advantages  of  sucli  treatment  that  it  obviously  de- 
mands our  carefnl  consideration.  On  this  ])oint  I  may  venture  to  speak 
with  some  confidence,  having;  devoted  mucli  attention  to  the  influence  of 
change  of  climate  and  the  uses  of  mineral  waters  in  the  treatment  of  chronic 
scrofulous  and  tubercular  complaints  during  several  years  passed  in  various 
distant  health-resorts,  and  repeated  visits  to  foreign  spas. 


406  PUBERTY  :    ITS   PATHOLOGY   AND   HYGIENE. 

Change  of  climate  and  the  use  of  mineral  waters  are  especially  advau- 
taffeous  in  the  treatment  of  the  chronic  tuberculous  and  scrofulous  diseases 
of  early  life,  in  which  no  brief  course  of  treatment,  however  judicious,  can 
be  expected  to  counteract  the  constitutional  effect  of  years  of  disease. 

The  mineral  waters  most  generally  serviceable  in  the  chronic  disorders 
of  strumous  youth  are  the  iodated  and  bromated  saline  springs,  of  which 
Wildegg  in  Switzerland  is  that  from  which  I  have  found  the  greatest  benefit 
derived. 

The  simple  chalybeate  mineral  waters  are  very  generally  useful  in  the 
manao;ement  of  most  of  the  strumo-tubercular  diseases  of  early  life.  Waters 
of  this  class,  containing  the  carbonate  of  the  jDrotoxide  of  iron  in  the  most 
easily  assimilated  form,  with  excess  of  carbonic  acid  gas,  are  powerfully 
tonic  and  stimulating,  increasing  directly  the  number  of  red  corpuscles  and 
the  amount  of  hsemoglobin,  both  of  which  are  so  much  diminished  in  these 
cases. 

The  thermal  arseniated  waters  are  also  especially  beneficial  in  the  treat- 
ment of  the  strumous  disorders  of  puberty,  as  well  as  in  the  anomalous 
hysteric  affections  of  chlorotic  girls  at  this  age. 

Cold  sulphurous  waters  are  also  serviceable  in  some  forms  of  these 
chronic  affections.  But  the  thermal  springs  of  this  class,  although  occa- 
sionally prescribed  with  much  benefit  in  cases  of  scrofulous  complaints 
(being  powerfully  stimulating  in  their  action  on  the  vascular  and  cerebro- 
spinal nervous  system),  always  require  great  caution  in  their  use,  and  are 
especially  contra-indicated  in  cases  of  active  tuberculous  disease. 

In  change  of  climate  we  have  another,  and,  as  I  believe,  a  most  effect- 
ual, remedy  for  chronic  tubercular  disease.  There  are  no  cases  in  which 
the  beneficial  influence  of  change  of  climate  may  be  so  confidently  hoped 
for  as  in  youth  of  either  sex  predisposed  to  consumption  by  the  scrofulous 
diathesis.  In  such  cases  the  constitution,  being  yet  unformed,  may  be  ex- 
pected to  receive  and  retain  whatever  impression  a  pure,  bracing,  or  mild 
air  can  produce,  and  thus  they  may  be  enabled  to  pass  safely  the  critical 
period  intervening  between  childhood  and  puberty.  The  climates  suitable 
for  this  predisposition  to  phthisis  should  be  dry,  moderately  warm,  and 
bracing, — dryness  of  atmosphere  being  the  essential  condition. 

At  present  the  health-resorts  most  in  vogue  for  this  class  of  patients, 
and  in  many  cases  very  judiciously  selected  for  them,  are  the  cold,  dry, 
tonic  climates  of  Alpine  districts,  such  as  Davos-Platz,  in  the  elevated  table- 
land of  the  Upper  Engadine,  and  other  similarly  situated  mountain  sanitaria, 
of  which  there  are  several  in  the  United  States  as  well  as  in  the  Old  World, 
— ^the  Adirondack  Mountains  in  New  York,  Asheville  in  North  Carolina, 
and  numerous  elevated  reo;ions  of  Colorado  and  the  Rockv  INIountains. 

The  primary  effect  of  a  cold,  dry  climate  and  of  a  pure  mountain-atmos- 
phere is  unquestionably  tonic  and  bracing  in  the  case  of  a  still  moderately 
strono;  albeit  strumous  vouth,  in  whom  a  tendcncv  to  tuberculous  disease 
exists,  and  has  been  fostered  by  life  in  the  impure,  variable,  and  humid 


PUBERTY  :    ITS   PATHOLOGY   AND   HYGIENE.  407 

atmosphere  of  any  of  our  overcrowded  centres  of  population.  When  such  a 
patient  is  removed  from  one  of  these  hot-beds  of  tuberculosis  to  a  dry,  cold 
climate,  the  respiration  becomes  more  energetic,  more  oxygen  being  required, 
and  more  carbonic  acid  exhaled,  to  supply  which  increased  food,  especially 
of  a  fatty  character,  is  consumed.  Thus  the  blood  is  directly  enriched,  the 
proportion  of  haemoglobin  and  red  corpuscles,  the  oxygen-carriers,  being 
augmented,  and  the  general  nutrition  of  the  system  is  improved.  But,  on 
the  other  hand,  those  whose  constitutions  have  been  longer  and  more  seriously 
affected  by  the  scrofulous  cachexia  or  its  local  manifestations  must  be  injured 
by  exposure  to  the  cold  rarefied  atmosphere  of  an  Alpine  height.  In  such 
a  climate,  if  the  patient's  vital  energies  had  been  previously  lowered  by 
chronic  disease,  the  blood  repelled  from  the  surface  of  the  body  by  cold  must 
be  driven  back  on  the  internal  organs ;  and  if  active  pulmonary  disease  be 
developed,  then  the  diminished  pressure  of  the  atmosphere  in  these  Alpine 
health-resorts,  and  the  sudden  and  frequent  variations  in  the  electrical  con- 
dition and  temperature,  as  well  as  the  pressure  of  the  air  to  which  such 
places  are  necessarily  subject,  must  affect  the  balance  of  the  circulation,  and 
produce  more  or  less  pulmonary  irritation,  if  not  congestion  or  haemoptysis. 

Hence,  from  extensive  personal  experience  of  the  effects  of  change  of 
climate,  I  would  venture  to  deprecate  the  too  general  adoption  of  mountain 
sanitaria  in  all  cases  of  consumption  which  is  now  coming  into  fashion ; 
nor  indeed  does  it  need  any  such  experience  to  show  that  change  of  climate, 
like  all  other  remedies,  must  be  prescribed  on  rational  principles  and  with 
due  regard  to  tlie  special  condition  of  each  individual  patient. 

In  selecting  a  winter  residence  for  children  suffering  from,  or  predisposed 
to,  any  chronic  tuberculous  disease,  primary  consideration  should  be  given 
to  the  comparative  facilities  and  inducements  for  open-air  exercise  which  are 
afibrded  by  different  health-resorts.  As  a  general  rule,  consumptive  children 
are  disinclined  or  unable  to  undergo  any  fatigue,  and  love  to  hang  over 
tlie  fire,  wlieuce  their  friends  fear  to  disturb  them,  "  lest  they  might  catch 
fresh  cold."  But  how  mistaken  this  view  is  needs  no  argument  :  for  such 
children  free  exposure  to  pure  fresh  air  and  sunlight  are  all-essential. 
Hence,  in  choosing  a  health-resort  in  these  cases,  preference  must  be  given 
to  whatever  place  the  climate  of  which  will  permit,  with  safety,  of  the 
maximum  exposure  to  the  open  air,  and  the  situation  of  which  will  afford 
the  greatest  inducements  and  opportunities  for  out-door  exercise. 

General  Hygiene  and  Culture  of  Puberty. — It  would  be  difficult  to 
overestimate  the  practical  importance  of  the  physico-moral  management  and 
training  of  "the  spring-time  of  life,"  as  this  epocli  is  aptly  termed.  For 
within  its  limits  must  be  implanted  the  fructifying  seeds  of  health,  mental, 
moral,  and  pliysical,  by  which  alone  the  future  well-being  of  the  individual 
may  be  assured ;  or  else,  on  the  other  hand,  will  l)e  tlien  sown  the  no  less 
potent  morbific  germs  by  whose  development  the  sanitary  integrity  of  mind 
or  })ody  must  evontually  be  impaired  or  destroyed. 

The  pathological  influence  on  the  course  of  puberty  of  some  of  the  latter 


408  PUBERTY  :    ITS    PATHOLOGY    AND    HYGIENE. 

agencies  was  well  described  by  the  late  Dr.  James  Johnson,  of  London,  in 
his  "  Economy  of  Health."  As,  however,  that  work  is  long  out  of  print, 
and  has  been  largely  used  without  acknowledgment  by  some  recent  writers, 
I  may  here  briefly  recapitulate  a  few  observations  which  appear  specially 
applicable  to  the  circumstances  by  which  the  health  of  puberty  is  most 
frequently  thus  modified. 

"  It  is,"  remarks  the  writer  just  named,  "  in  this  stage  of  rapid  develop- 
ment, corporal  and  mental,  that  the  greatest  difficulty  is  experienced  in  pre- 
serving the  physique  within  the  bounds  of  health  and  confining  the  morale 
within  the  limits  of  virtue.  How  many  minds  are  wrecked,  how  many 
constitutions  ruined,  during  the  third  septennial !  At  so  early  a  period  of 
life,  when  passions  so  much  predominate  over  principles,  it  is  hardly  to 
be  expected  that  the  force  of  precept  can  be  so  efficient  a  preventive  as  the 
fear  of  bodily  suffering.  If  the  youth  of  both  sexes  could  see  through  the 
vista  of  future  years,  and  there  behold  the  catalogue  of  afflictions  and  suf- 
ferings inseparable  attendants  on  time  and  humanity,  they  would  pause  ere 
they  added  to  the  number  by  originating  maladies  at  a  period  when  Nature 
is  endeavoring  to  fortify  the  material  fabric  against  the  influence  of  those 
that  must  necessarily  assail  us  in  the  progress  of  life  !  Yet  it  is  in  this  very 
epoch  that  some  of  the  most  deadly  seeds  of  vice  and  disease  are  implanted 
in  our  spiritual  and  corporeal  constitutions, — seeds  which  not  merely  '  grow 
with  our  growth  and  strengthen  with  our  strength,'  but  acquire  vigor  from 
our  weakness  and  obtain  victory  in  our  decay.  This  melancholy  reflec- 
tion is  applicable  to  all  classes  and  both  sexes.  The  sedentary  and  insal- 
utary  avocations  to  which  young  people  of  both  sexes  in  the  middle  and 
lower  classes  of  society  are  confined,  between  the  ages  of  fourteen  and 
twenty-one,  occasion  dreadful  havoc  in  health  and  no  small  deterioration 
of  morals.  The  drudgery,  scanty  clothing,  bad  food,  and  exposure  to  the 
elements,  of  our  laboring  or  factory  population,  as  well  as  the  still  greater 
miseries  of  the  too  numerous  unemployed  poor  in  these  countries,  are  but 
little  more  injurious  to  health  and  life  than  the  sedentary  habits,  unsanitary 
surroundings,  and  depressing  passions  of  the  various  species  of  artisans, 
mechanics,  and  shopkeepers  in  the  classes  immediately  above  them.  The 
infinite  variety  of  new  avocations  among  these  grades  has  given  rise  to  a 
corresponding  infinity  of  physical  and  moral  maladies,  of  which  our  fore- 
fathers were  ignorant,  and  for  which  it  requires  much  ingenuity  at  present 
to  invent  significant  names.  The  incalculable  numbers  of  young  females 
confined  to  sedentary  avocations  from  morning  till  night,  and  too  often  from 
night  till  morning,  become  not  only  unhealthy  themselves,  but  afterwards 
consign  debility  and  disease  to  their  unfortunate  offspring.  It  is  thus  that 
infirmities  of  body  and  mind  are  acquired,  multiplied,  transmitted  from 
parent  to  progeny,  and  consequently  perpetuated  in  society.  He  would  be 
blind  indeed  who  did  not  perceive  the  outward  working  of  these  causes  in 
our  own  day.  Nations  are  only  aggregations  of  individuals,  and  whatever 
be  the  influence,  whether  good  or  evil,  that  operates  on  a  considerable  num-. 


PUBERTY  :    ITS   PATHOLOGY   AND    HYGIENE.  409 

ber  of  the  populatiou,  that  influence  Avill  radiate  from  ten  thousand  centres, 
and  diffuse  its  effects,  sooner  or  later,  over  the  whole  surface  of  the  com- 
munity." 

In  viewing  the  ascending  links  of  society,  there  is  no  great  cause  for 
gratulation.  The  youth  of  both  sexes,  doomed  to  the  counter,  the  desk, 
and  the  school-room,  are  little  elevated,  in  point  of  salubrity,  above  their 
humbler  contemporaries.  It  is  during  puberty  that  the  destiny  of  youth 
is  fixed  for  all  the  various  professions  and  pursuits,  into  the  training  for 
which  the  young  are  now  too  often  prematurely  forced  by  the  increasing 
exigencies  of  the  struggle  for  existence,  w' ealth,  or  distinction,  in  all  densely- 
crowded  centres  of  population.  What  wonder,  then,  that  under  such  cir- 
cumstances the  intellectual  advantages  thus  secured  are  too  dearly  pur-, 
chased  at  the  expense  of  health?  The  physical  stamina,  as  well  as  the 
mental  powers,  are  too  frequently  thus  so  overstrained  in  this  fierce  compe- 
tition that  both  thereby  become  prematurely  exhausted,  and  if  not  perma- 
nently at  least  temporarily  debilitated  and  incapacitated  for  their  ordinary 
functions.  These  results  are,  moreover,  very  commonly  consequent  on 
errors  in  the  mental  or  physical  training  of  children  in  the  period  immedi- 
ately antecedent  to  puberty,  the  results  of  which,  being  manifest  at  this 
epoch,  must  be  here  referred  to. 

The  Mental  Training-  or  Education  of  youth  and  early  puberty  is  a 
question  always  of  great  importance,  but  of  special  interest  at  the  present 
time.  We  are  all,  of  course,  agreed  as  to  the  duty  of  suitably  educating 
the  young  so  as  to  fit  them  for  the  daily  increasing  requirements  and  com- 
petition of  modern  life,  but  as  to  the  extent  to  which  this  should  be  carried 
in  early  childhood  there  is,  unfortunately,  a  great  discrepancy  between  the 
doctrinaires  of  the  Education  Department  and  the  views  of  those  who  have 
any  knowledge  of  the  laws  of  nature  or  Avho  as  physicians  have  to  deal  in 
disease  with  the  consequences  of  their  violation.  The  red-tape  officialism 
of  the  former  is  often  supreme  over  medical  experience.  And  hence,  whilst 
children,  before  the  age  of  puberty,  are  thereby  overworked  into  disease  or 
deatli,  the  physician  must  still  raise  his  protesting  voice. 

The  first  years  of  life  should  be  mainly  occupied  by  moral  and  physical 
training,  and  during  this  period  the  amount  of  mental  cultivation  wliicli  a 
child's  brain  is  capable  of  receiving  with  permanent  advantage  is  mucli  less 
than  is  commonly  believed.  No  greater  physiological  mistake  is  possible 
tlian  the  prevailing  idea  of  attempting  any  considerable  degree  of  mental 
culture  until  the  sufficient  development  of  the  physical  stamina  and  moral 
faculties  is  accomplished.  The  organ  of  the  mind  is  as  mucli  a  part  of  the 
body  as  the  hand,  and  ere  either  can  function  properly  its  vital  force  must 
be  developed  and  maintained  by  nutrition.  Hence  arises  a  very  important 
practical  question  in  connection  with  compulsory  elementary  education.  A 
large  proportion  of  those  who  must  come  witliin  the  provisions  of  the  law 
in  most  large  cities  are  ill-fed  children  of  the  poorest  classes,  and  are  those 
with  whom  for  the  past  sixteen  years  I  have  daily  had  to  deal  in  the  Hos- 


410  PUBERTY  :    ITS   PATHOLOGY   AND    HYGIENE. 

pital  for  Sick  Children.  As  a  matter  of  fact,  I  may  accordingly  observe 
that  children  thus  debilitated  by  privation  are  necessarily  as  much  incapaci- 
tated for  any  mental  strain  as  they  are  for  the  accomplishment  of  any  feat 
of  physical  strength,  and  that  it  is  as  inhuman,  injudicious,  and  impolitic 
to  expect  the  former  as  it  would  be  to  look  for  the  latter  from  children 
so  circumstanced. 

If,  therefore,  the  state,  for  reasons  of  public  policy,  determines  that  all 
children  shall  be  compulsorily  educated  from  their  earliest  years,  it  should 
certainly  aiford  the  means  by  which  this  may  be  least  injuriously  and  most 
effectually  carried  out,  by  providing  sufficient  food  as  well  as  education  for 
every  pauper  child  compelled  to  attend  school. 

Among  the  results  of  over-pressure  in  schools  referred  to  in  Sir  Crichton 
Browne's  admirable  report  on  this  subject,  are  cerebral  diseases  in  all  forms, 
— viz.,  cephalitis,  cerebritis,  meningitis,  as  well  as  headache,  sleeplessness, 
neuroses  of  every  kind,  and  other  evidences  of  cerebro-nervous  disorders. 

It  would  be  difficult  to  overestimate  the  pathological  consequences  of 
thus  directing  all  the  available  energies  of  the  system  to  the  brain  during 
early  youth,  to  the  irreparable  injury  of  the  over-stimulated  cerebral  organi- 
zation, and  at  the  expense  of  the  other  functions  and  organs  of  the  body. 
Time,  however,  does  not  permit  of  my  dwelling  on  the  ill  effects  of  mental 
over-pressure  brought  under  my  own  observation,  nor  of  any  reference  here 
to  the  many  most  painful  scenes  of  misery  thus  occasioned,  with  which  long 
and  sad  experience  has  made  me  but  too  familiar.  I  now  allude  to  this 
subject  merely  with  the  view  of  pointing  out  the  imminence  of  the  danger 
and  the  importance  of  its  avoidance. 

The  deterioration  of  the  physical  and  mental  stamina,  thus  observable, 
is,  as  I  may  repeat,  mainly  due  to  the  fact  that  a  large  part  of  the  first  years 
of  life,  which  should  be  primarily  devoted  to  religious  or  moral  as  Avell  as 
physical  training,  is  now  given  up  to  the  development  of  the  mental  powers. 
The  child  is  too  early  compelled  to  attend  some  school  where  the  immature 
brain  is  forced  into  abnormal  and  disastrous  activity.^ 

Ill  Results  of  Sexual  Precocity  during-  Puberty. — In  no  particular 
are  the  pathological  eff'ects  of  the  killing  pace  at  which  the  race  of  life  is 
nowadays  too  often  run,  from  its  start  to  its  untimely  finish,  more  apparent 
than  in  the  premature  break-down  of  constitution  consequent  on  the  abnor- 
mally precocious  indulgence  or  abuse  of  the  sexual  instincts  or  appetites. 
To  these  abuses,  on  which  (as  they  will  be  better  considered  in  other  por- 
tions of  this  work)  it  will  not  be  here  necessary  to  dwell  in  any  detail,  is 
unquestionably  due  a  large  and  increasing  proportion  of  many  of  the 
maladies  by  which  the  course  of  after-life  is  embittered  or  its  duration 
shortened.     I  do  not  now  refer  to  the  specific  diseases  which  at  the  earliest 

1  The  system  of  kindergarten  now  so  much  in  vogue  in  this  country,  and  the  wonder- 
ful strides  which  have  been  made  in  physical  training,  even  in  our  elementary  schools,  will 
undoubtedly  have  the  effect  of  reducing  the  death-rate  from  cerebral  disease  in  childhood, 
and  will  aid  in  giving  our  youth  of  both  sexes  sound  minds  in  sound  bodies. — Editok. 


PUBERTY  :    ITS   PATHOLOGY   AXD   HYGIENE.  411 

period  of  puberty,  as  at  auy  other  epoch,  may  follpw  sexual  vice,  or  which 
may  even  be  manifested  long  before  the  normal  date  of  the  evolution  of 
the  sexual  functions,  as  I  have  recently  seen  illustrated  in  one  disgusting 
instance  of  primary  syphilis  in  a  boy  only  ten  and  a  halT  years  of  age,  now 
in  hospital,  under  the  care  of  my  colleague,  Mr.  Chance. 

What  I  particularly  here  refer  to  are  those  remote  or  secondary  constitu- 
tional effects  of  sexual  precocity  which  must  be  familiar  to  every  experienced 
physician  who  in  almost  daily  practice  may  encounter  the  wretched,  cachectic, 
and  mentally  as  well  as  physically  debilitated  victims  of  early  erotic  excesses 
and  abuses.  To  these  causes  must,  I  fear,  be  largely  ascribed  the  failure 
of  physical  stamina,  as  well  as  that  nervous  hypersesthetic  condition  and 
lamentable  lack  of  mental  power  and  determination  of  character  too  often 
noticeable  among  youth  of  the  present  day,  and  which  clearly  mark  the 
Xemesis  of  a  wide-spread  epidemic  of  precocious  sensuality.  The  means 
by  which  this  epidemic  may  be  best  mitigated  is,  however,  a  subject  which 
cannot  be  adequately  here  considered,  as  its  treatment  is  beyond  the  reach 
of  the  physician,  and  belongs  rather  to  the  domain  of  the  moral  teacher  or 
the  minister  of  religion. 

Consequences  of  Abuse  of  Alcohol  and  Tobacco  during  Puberty. 
— Another  phase  of  the  results  of  the  too  common  untimely  abridgment 
of  early  puberty  by  precocious  indulgence  in  the  habits  and  vices  of  adult 
life  is  exemplified  by  the  painful  exhibitions  of  juvenile  drunkenness  daily 
witnessed,  especially  among  the  neglected  street  Arabs,  who  during  and 
even  before  the  first  stage  of  puberty  are  forced  into  the  thoroughfares  of 
our  great  cities,  there  to  eke  out  a  living  as  best  they  may,  and  the  patho- 
logical consequences  of  whose  acquired  or  inherited  alcoholism  are  brought 
under  clinical  observation  in  tlie  form  of  gastric  and  hepatic  disorders,  and 
especially  cirrhosis  of  the  liver,  as  well  as  in  the  protean  forms  of  cerebro- 
spinal disease,  and  the  various  neuroses  which  are  so  frequently  noticed  in 
hospitals  for  children. 

In  the  British  Medical  Journal  and  elsewhere  I  have  reported  several 
instances  of  juvenile  alcoholism  that  came  under  my  care  in  the  Children's 
Hospital,  and  latterly  some  deaths  from  this  cause  have  occurred  among 
mere  lads.  In  the  majority  of  cases  of  juvenile  alcoholism  this  tendency 
appears  inherited,  and  is  most  marked  in  those  whose  mothers  were  in- 
ebriates,— intemperance  in  Avomen  also  bearing  in  other  ways  on  the  diseases 
treated  in  hospitals  for  children,  where  its  effects  are  strikingly  evinced  by 
the  moral  and  physical  deterioration  of  the  offspring  of  the  drunken,  and 
by  their  special  predisposition  to  strumous,  tubercular,  and  other  constitu- 
tional taints. 

The  evil  thus  resulting  from  the  prevailing  intemperance  of  the  young 
as  well  as  the  old  sliould  induce  us  to  warn  tliose  whom  our  counsel  may 
influence  against  that  custom  of  giving  alcoholic  stimulants  to  children, 
which  is  so  general  in  its  practice  among  all  classes  and  so  calamitous  in  its 
results.     Even  in  those  exceptional  cases  in  which  such  stimulants  may  be 


412  PUBERTY  :    ITS    PATHOLOGY    AXD    HYGIENE. 

necessary,  we  sliould  never  sanction  their  administration  save  under  the 
guise  and  in  the  definite  doses  of  other  remedial  agents ;  and  my  experi- 
ence in  hospital  and  private  practice,  at  home  and  abroad,  has  amply  con- 
firmed the  view  expressed  in  a  work  of  mine  published  many  years  since, 
that  it  is  physiologically  wrong,  as  well  as  morally  unjustifiable,  ever  to 
allow  a  healthy  youch  to  taste  alcohol  in  any  form. 

With  regard  to  the  eifects  of  the  abuse  of  tobacco  during  early  puberty, 
of  which  we  see  so  many  instances,  especially  among  the  neglected  children 
of  the  poor,  I  may  refer  to  an  observation  I  long  before  made  on  the  stunted 
and  prematurely  aged  apj)earance  of  children  in  Portugal,  where  smoking 
is  indulged  in  from  the  earliest  possible  age.  There,  in  the  streets  of  Lisbon, 
I  have  often  seen  with  astonishment  boys  obviously  much  under  the  age 
of  puberty  gravely  sucking  a  strong  cigar  with  apparently  the  same  gusto 
which  our  less  precocious  progeny  derive  from  the  forbidden  delights  of  the 
sugar-stick.  There  can  be  no  doubt  that  the  influence  of  the  nicotine  thus 
absorbed  must  be  most  injurious  at  this  age ;  and  this  is  evident  in  the 
physical  aspect  of  the  youths  referred  to.^ 

Special  Hygiene  and  Culture  of  Female  Puberty :  its  Practical 
Importance. — In  a  previous  section  we  have  described  the  special  func- 
tional disorders  incident  to  female  puberty,  and  must  now  refer  to  certain 
other  causes  of  those  various  nervous  and  constitutional  ailments  that  are 
prevalent  during  this  period.  Of  these  causes  some,  although  of  a  moral 
rather  than  of  a  physical  character,  are  yet  so  intimately  connected  with  the 
production  and  course  of  the  complaints  referred  to  as  to  demand  a  brief 
notice. 

Among  the  subjects  thus  included  in  this  connection  are  the  influences 
on  female  health  in  puberty  of  the  moral,  mental,  and  physical  training  or 
education  during  or  immediately  before  this  period ;  secondly,  the  ill  effects 
of  the  customary  modes  of  dress  and  habits  and  occupations  of  girls  at  this 
time  ;  thirdly,  the  results  of  premature  or  abnormal  stimulation  of  the  sexual 
system,  whether  by  too  early  marital  life  or  in  any  other  way  at  that  age.  As 
was  observed  by  Dr.  Johnson,  female  life  at  auy  period,  cseteris  paribus,  is 
fully  as  good,  in  respect  to  probable  duration,  as  that  of  the  male, — perhaps 
even  a  little  better.  In  this  point  of  view  woman  has  a  longer  senectitude 
than  man.  More  men  are  annually  born  than  women,  aud  consequently 
more  must  die.  It  is  in  the  period  of  puberty  that  the  seeds  of  female  dis- 
eases are  chiefly  sown,  or  at  least  that  the  soil  is  specially  prepared  for  their 
reception  and  groAvth.  The  predisposition  to  infirmities  aud  disorders  of 
various  kinds  is  affected  by  acts  of  omission  and  commission, — in  the  first 
class  beius:  included  the  deficiencv  of  healthv  exercise  of  the  body  in  the 
open  air,  and  of  intellectual  exercise  injudicious  studies.  The  ill  results  of 
these  are  perhaps  most  apparent  among  girls  of  the  upper  classes  of  society. 

1  Dr.  Xore  Mudden  on  "Change  of  Climate  in  the  Treatment  of  Chronic  Disease," 
3d  edit.,  London,  1874. 


PUBERTY  :    ITS    PATHOLOGY    AND    HYGIENE.  413 

The  increasing  exigencies  of  modern  life,  and  the  desh'e  to  render  girls 
accomplished  at  all  hazards,  have  originated  a  system  of  forced  mental  train- 
ing, which  greatly  increases  the  irritability  of  the  brain,  whilst  at  the  same 
time  sedentary  employments  are  followed  frequently  as  amusements,  to  the 
exclusion  of  active  exercise  out  of  doors.  The  slow  but  powerful  influ- 
ences of  music,  dancing,  vivid  colors,  and  odors,  on  the  nervous  system,  but 
especially  on  the  reproductive  system,  are  quite  overlooked.  Many  hours  of 
severe  application  are  occupied  in  the  acquisition  of  pieces  of  music  which 
are  forgotten  as  soon  as  possible  after  marriage,  when  music  would  be  least 
hurtful,  or  rather  most  useful.  Dr.  J.  Johnson  very  justly  asks,  "Is  it 
probable  that  so  potent  an  excitant  as  music  can  be  daily  applied  for  many 
hours  to  the  sensitive  system  of  female  youth  .with  impunity  ?"  The  same 
writer  points  out  that  "  the  stimulus  of  music  is  of  a  very  subtle  and  dif- 
fusible nature,  and  the  excitement  which  it  produces  in  the  nervous  system 
is  of  a  peculiar  character,  and  one  by  no  means  generally  understood." 
Any  excessive  exposure  to  this  potent  stimulation  is  therefore  liable  to  be 
productive  of  some  of  the  various  hypersesthetic  morbid  conditions  of  mind 
and  body  so  prevalent  during  the  period  of  female  puberty. 

The  excessive  attention  given  to  music  in  female  education  is,  moreover, 
indirectly  hurtful  by  not  leaving  sufficient  time  for  other  and  more  service- 
able employments  of  mind  and  body,  by  which  the  former  may  be  strength- 
ened against  the  vicissitudes  of  fortune  and  the  moral  crosses  to  which 
female  life  is  doomed,  nor  for  healthful  physical  exercise,  by  which  the 
material  fabric  may  be  fortified  against  the  thousand  causes  of  disease  con- 
tinually assailing  it.  The  consequence  of  all  this  is,  that  the  young  female 
too  often  returns  from  school  to  her  home  an  hysterical,  wayward,  capricious 
girl,  imbecile  in  mind,  habits,  and  pursuits,  prone  to  hysteric  paroxysms 
upon  any  excessive  mental  excitement.  This,  I  may  add,  appears  very 
liable  to  be  superinduced  by  the  pernicious  novels  of  the  erotic  and  sensa- 
tional school,  which  are  the  popular  literature  of  young  females,  and  by 
which  the  impressionable  mind  of  girlhood  is  perverted,  the  passions  stimu- 
lated, and  the  foundations  laid  for  the  future  development  of  various  morbid 
conditions  of  mind  and  body,  and  more  especially  erotomania  and  nympho- 
mania. 

I  shall  not  now  refer  to  the  latter  of  these  disorders.  As  to  the  former, 
I  shall  only  repeat  that  it  may  be  regarded  as  an  exaggeration  of  the  pecu- 
liar sentimentality  which  is  generally  inherent  in  female  youth,  and  which 
is  usually  so  evanescent  as  to  require  little  if  any  medical  attention.  In 
some  instances,  however,  this  excess  of  natural  sentiment  is  of  graver  con- 
sequences, the  mind  becoming  so  occupied  by  its  predominant  illusion  as  to 
impair,  more  or  less  completely  and  permanently,  the  exercise  of  the  rational 
faculties,  and  not  alone  produce  mental  derangement  but  also  react  injuri- 
ously on  the  general  health  and  more  especially  on  the  utero-ovarian  func- 
tions of  the  love-sick  girl.  Instances  of  this  kind  are  familiar  to  nearly 
every  practitioner.     There  are  few  among  us  who  have  not  been  consulted 


414  pubehty  :  its  pathology  and  hygiene. 

by  some  anxious  mother,  alarmed  by  symptoms  of  mental  dejection  and 
nervous  or  mental  functional  disturbances,  for  which  no  physical  cause  can 
be  discovered,  arising  from  cardiac  causes  beyond  stethoscopic  diagnosis. 
This  condition  is,  in  its  inception,  entirely  distinct  from  erotomania,  but  if 
allowed  to  develop  unchecked  may  in  some  instances  ultimately  result  in 
the  latter. 

If  neglected  mental  training  is  of  so  much  account  in  the  causation  of 
hysterical  disorders,  on  the  other  hand  to  the  excessive  and  misdirected 
application  of  the  female  mind  may  in  many  instances  be  traced  the  origin 
of  the  morbid  nervous  conditions  already  discussed. 

The  robust  unmarried  female  in  easy  circumstances  may  escape  many 
of  these  evils,  but  after  the  age  of  eighteen  the  reproductive  organs  arc 
fully,  probably  largely,  developed,  and  strong  passions,  indolence,  and 
luxury  fail  not  to  produce  their  effects  on  the  system,  and  to  develop  some 
form  of  hysteria. 

The  transition  from  girlhood  in  those  of  the  more  affluent  classes  of 
society  is  generally  accompanied  by  a  complete  revolution  in  the  patient's 
habits  and  mode  of  life,  which  now  become  changed  from  the  early  hours 
and  open-air  exercise  and  simpler  fare  of  the  girls'  school  to  the  too  lux- 
urious living,  late  hours,  constrained  movements,  and  unsanitary  dress  of 
the  debutante  in  the  world  of  fashion. 

The  Influence  of  Dress  on  the  physical  health  of  female  youth  is 
unquestionable,  and  this  subject  has  accordingly  been  fully  discussed  by 
countless  authorities,  although  the  practical  result  of  all  that  has  been  thus 
written  has  apparently  been  nil.  The  two  cardinal  points  to  be  here  borne 
in  mind  with  reference  to  female  clothing  are,  first,  that  the  material  should 
be  such  as  may  serve  to  retain  the  necessary  animal  warmth,  and,  secondly, 
that  its  form  be  so  arranged  as  to  occasion  neither  undue  visceral  com- 
pression nor  any  interference  with  impeded  muscular  action.  Hence,  what- 
ever little  influence  the  physician  may  exercise  in  this  matter  should  be 
employed  to  induce  his  clients  at  this  epoch  to  adopt  underclothing  of 
flannel  or  merino,  or  Jaeger's  undyed  woollen  fabric,  as  well  as  to  persuade 
them  to  eschew  those  dearly-prized  compressing  corsets,  elastic  garters,  and 
tightly-fitting  high-heeled  boots,  by  which  young  ladies  seek  to  reduce  their 
natural  proportions,  however  robust,  and  at  whatever  cost  of  comfort  or 
health,  within  the  limits  prescribed  as  "  the  pink  of  fashion  and  the  mould 
of  form."  This  advice  we  should  give  whenever  the  occasion  offers,  seldom 
as  our  counsel  may  be  followed,  for  in  such  matters  fashion  and  the  modiste 
will  probably  continue  to  the  end  of  the  chapter  to  reign  triumphant  over 
common  sense  and  the  doctor. 

The  injurious  consequences  of  the  absurd  modes  prevalent  in  the  dress 
of  female  youth  are  exemplified  in  the  effects  of  tiglit  lacing  on  the  pulmo- 
nary functions,  for  the  normal  accomplishment  of  which  free  expansion  of 
the  chest  and  unimpeded  action  of  all  the  muscles  connected  with  respira- 
tion are  so  essential.     The  results  of  errors  of  this  kind  are  most  a]3parent 


PUBERTY  :    ITS    PATHOLOGY    AND    HYGIEXE.  415 

at  the  period  of  puberty,  when  the  young  lady  exchanges  the  comparatively 
easy  garb  of  girlhood  for  that  imposed  by  the  requirements  of  fashionable 
life.  And  these  errors  reach  their  extreme  in  the  attire  of  the  ball-room  or 
theatre,  or  what,  on  the  lueus  a  non  lacendo  principle,  is  now  regarded  as 
full  dress.  "  At  these  assemblies,"  as  Dr.  Barlow  has  well  observed,  "  the 
tightly-laced  stays,  the  exposed  chest,  and  thin  draperies  furnish  a  combina- 
tion of  influences,  the  combined  effects  of  which  no  constitution  could  with- 
stand ;  while  to  these  is  yet  to  be  added  that  of  respiring  for  hours  a  heated 
and  vitiated  atmosphere,  and,  after  this,  of  passing,  when  relaxed  and  ex- 
hausted, into  the  cold  currents  of  a  frosty  night  air.  So  far  from  wonder- 
ing that  many  suifer  from  these  egregious  imprudences,  our  surprise  should 
be  that  any  escape ;  and  instead  of  the  inherent  delicacy  so  often  imputed 
to  the  constitution  of  females  as  explanatory  of  their  peculiar  ailments,  we 
have  ample  proof,  in  their  powers  of  resisting  such  noxious  influences,  that 
they  possess  conservative  energies  not  inferior  to  those  of  the  most  robust 
male.  Were  men  to  be  so  laced,  so  imperfectly  exercised,  so  inadequately 
clothed,  so  suffocated,  so  exposed,  their  superiority  of  bodily  vigor  would 
soon  cease  to  have  any  existence." 

Defect  of  clothing,  though  most  signal  in  the  chest  and  shoulders,  is  not 
confined  to  the  upper  part  of  the  body.  The  feet  require  warmth,  which 
subservience  to  fashion  prevents.  They  cannot  be  compressed  but  at  the 
cost  of  much  suffering,  some  distortion,  and  the  infliction  of  positive  dis- 
ease. Fashion  also  jjermits  the  legs  to  be  covered  with  only  the  thinnest 
materials.  Thus  the  capillary  circulation  of  the  feet,  rendered  sufficiently 
languid  by  the  general  weakness,  becomes  further  impeded  by  the  pressure 
of  tight  shoes  and  the  debilitating  effects  of  cold.  The  crippled  state,  too, 
thus  occasioned,  is  a  further  obstacle  to  efficient  exercise,  and  so  adds  to  the 
general  debility. 

Occupation  in  Relation  to  Health  of  Female  Puberty. — Formerlv 
the  period  of  puberty  in  w^omen  was  less  subject  than  the  same  epoch  in  the 
opposite  sex  to  some  of  the  predisposing  causes  of  reflex  cerebro-nervous 
disorders  other  than  those  connected  with  their  utero-ovarian  liealth.  This, 
however,  is  hardly  the  case  at  the  present  day,  in  which  Avomen  are  not  only 
liable  to  those  special  functional  derangements  productive  of  nervous  dis- 
turbances, but  moreover  in  too  many  cases  are  also  now  exposed  to  all 
tlie  accidental  causes  of  cerebro-nervous  disorders  to  whidi  formerly  only 
the  ruder  sex  was  sul))cet. 

General  Treatment  of  Nervous  Disorders  of  Female  Puberty. — 
It  would  be  beyond  the  scop* of  this  article  to  discuss  in  any  detail  even 
the  general  principles  which  should  guide  us  in  the  treatment  of  the  protean 
forms  of  nervous  disorder  incident  to  female  puberty,  and  to  some  of  the 
causes  of  whicli  we  have  just  referred.  I  may,  however,  notice  a  few  points 
which  appear  to  me  applicable  to  the  management  of  tlie  ordinary  phases 
of  hysterical  disease  at  this  period.  I  would,  in  tlie  first  ])laee,  observe 
that,  under  these  circumstances,  any  special  local  uterine  treatment  should  be 


416  PUBERTY  :    ITS    PATHOLOGY   AND    HYGIENE. 

avoided  as  far  as  possible,  and  is  seldom  either  necessary  or  expedient  in 
these  cases,  unless  in  those  exceptional  instances  where  the  hysterical  symp- 
toms are  the  reflex  effects  of  some  uterine  displacement. 

Foremost  among  the  remedies  by  which  we  may  hoj)e  to  allay  the  per- 
verted molecular  activity  of  the  nerve-centres  in  the  hysterical  disorders  of 
puberty  are  the  various  special  nerve-sedatives,  more  especially  the  different 
bromides  and  the  valerianates  of  quinine  and  zinc.  Mere  hypnotics  are  of 
little  value,  and  narcotics,  more  particularly  opium  and  its  alkaloids,  are 
worse  than  useless,  for  this  purpose.  The  curative  effects  of  change  of 
climate  and  the  utility  of  chalybeate  and  other  mineral  and  thermal  waters, 
though  obvious  in  all  chronic  diseases,  are  in  none  so  essential  as  in  the 
nervous  and  hysterical  disorders  of  puberty.  In  such  cases,  by  the  very 
journey  to  a  foreign  and  distant  health-resort  the  patient  is  afforded  the 
benefit  of  change  of  climate,  occupation,  and  mode  of  living.  The  new 
scenes  and  variety  of  places  suggest  new  thoughts,  by  which  the  attention 
of  the  hysterical  girl  is  diverted  from  her  morbid  fancies  and  exagger- 
ated sensations,  until  at  length,  by  ceasing  to  dwell  on  her  self-created 
complaints,  they  gradually  may  cease  to  trouble  her. 

It  may  be  observed  that  no  cases  so  much  demand  the  exercise  of  the 
highest  qualities  of  the  physician  as  those  now  under  consideration.  In 
such  instances  the  practitioner  must,  above  all,  rise  above  any  narrow  gynae- 
cological or  other  specialism.  He  should,  of  course,  seek  to  remove  any 
local  disease  or  to  restore  any  disordered  function  of  which  the  hysterical 
disturbance  may  be  the  result.  But,  as  already  remarked,  in  doing  this  he 
should  also  carefully  avoid  the  imminent  possibility  of  increasing  whatever 
vaginal,  uterine,  or  ovarian  hypersesthesia  may  be  present  by  any  topical 
examination  or  treatment  that  is  not  absolutely  and  obviously  indispensable. 

In  dealing  with  those  suffering  from  any  of  the  hysterical  conditions  of 
puberty  now  referred  to,  the  physician  should  strive  to  act  upon  the  moral 
as  well  as  the  physical  constitution  of  his  patients.  He  must,  therefore, 
insist  on  healthy  occupation  of  mind  and  body,  and  fit  the  latter  for  this  by 
the  appropriate  remedies  called  for  by  the  special  requirements  of  each  case. 
If  the  nervous  derangement  is  consequent  on  disordered  menstruation,  this 
condition  must,  if  possible,  be  rectified.  If  it  results  from  premature  or 
undue  stimulation  of  the  sexual  organs,  he  must  point  out  distinctly  the 
physical  and  moral  evils  consequent  on  such  abuses. 

In  conclusion,  it  only  remains  for  me  to  add  that  in  the  foregoing  attempt 
to  describe  the  many-sided  medical  aspects  of  the  epoch  of  puberty  (con- 
cerning some  of  which  my  views  have  already  elsewhere  been  published) 
my  object  has  been  accuracy  rather  than  originality.  Hence  I  shall  rest 
content  if  adjudged  to  have  been  in  any  wise  successful  in  the  humble 
task  of  welding  together  in  a  homogeneous  form  the  dejecta  fragmenta  of 
special  knowledge  on  the  subjects  included  in  this  article,  from  whatever 
sources  these  might  be  collected,  and  supplemented,  as  far  as  possible,  by 
the  light  of  my  own  experience. 


PART    II. 

FEVERS   AND    MIASMATIC    DISEASES. 


FEVER 


GENERAL  CONSIDERATIONS  AND  TREATMENT -SIMPLE 
CONTINUED  FEVER -THERMIC  FEVER. 

By   WILLIAM   PASTEUE,  M.D.,  F.R.C.P. 


Definition  and  Nature. — The  term  "  fever"  is  used  in  its  widest  sense 
as  denoting  a  complex  of  symptoms  or  group  of  symptoms  of  which 
heightened  temperature  is  the  most  striking  and  the  most  constant. 

Disorder,  then, — in  the  direction  of  increase, — of  the  body-heat,  is  the 
essential  condition  of  fever. 

In  health  the  maintenance  of  a  normal  temperature  involves  three  co- 
operant  factors, — a  source  of  heat,  channels  for  the  discharge  of  heat,  and 
a  regulating  mechanism  which  shall  maintain  a  stable  balance  between  heat- 
production  and  heat-loss.  Owing  to  the  integrity  of  this  mechanism,  any 
variations  in  heat-production  are  immediately  compeusated  by  concurrent 
variations  in  heat-discharge,  so  that  the  temperature  of  the  body,  as  a  whole, 
is  not  appreciably  affected. 

In  fever,  heat-production  and  heat-loss  are  both  increased,  and  it  has 
also  been  demonstrated  that  the  febrile  rise  of  temperature  cannot  satisfac- 
torily be  accounted  for  by  increased  production  alone,  or  by  temporary  dimi- 
nution of  heat-loss  alone  (retention-theory  of  fever).  It  has  been  shown 
experimentally  that  during  fever  the  variations  of  the  two  processes  are 
no  longer  interdependent, — that  the  regulating  mechanism  is  out  of  gear. 
In  consequence  of  this  the  rates  of  heat-production  and  heat-loss  vary 
irregularly,  so  that  the  elevation  of  temperature  cannot  be  regarded  as  a 
true  measure  eitlier  of  increase  of  the  former  or  of  diminution  of  the  latter. 
Under  circumstances  deterniiuing  a  diminution  of  heat-loss,  a  high  tempera- 
VoL.  I.-27  417 


418  FEVER. 

ture  may  coexist  with  a  low  rate  of  heat-prodnction ;  and  conversely,  if 
lieat  is  being  rapidly  parted  with,  there  may  be  a  considerable  increase  of 
lieat-production  without  any  commensurate  elevation  of  temperature.  So 
that  we  must  conclude  that  although  the  clinical  thermometer  aifords  unmis- 
takable evidence  of  some  derangement  of  the  heat-maintaining  apparatus, 
it  throws  little  or  no  light  on  the  nature  or  direction  of  the  disturbance. 
It  is  true  that  in  the  adult  the  height  of  the  temperature  is  to  some  extent 
an  index  of  the  severity  of  the  disease ;  but  I  shall  have  occasion  to  point 
out  that  in  children,  for  various  reasons,  no  such  reliance  can  be  placed  on 
this  indication. 

In  fever,  as  in  health,  the  source  of  heat  is  the  same,  at  least  in  kind. 
It  is  stated  with  admirable  clearness  by  Professor  Forster :  "  We  may  at 
once  affirm  that  the  heat  of  the  body  is  generated  by  the  oxidation  not  of 
any  particular  substance,  but  of  the  tissues  at  large.  Wherever  metabolism 
of  protoplasm  is  going  on,  heat  is  being  set  free.  ...  In  growth  and  in 
repair,  in  the  deposition  of  new  material,  in  the  transformation  of  lifeless 
pabulum  into  living  tissue,  in  the  constructive  metabolism  of  the  body,  heat 
may  be  undoubtedly  to  a  certain  extent  absorbed  and  rendered  latent ;  the 
energy  of  the  construction  may  be  in  part,  at  least,  supplied  by  the  heat 
present.  But  all  this,  and  more  than  this, — namely,  the  heat  present  in  a 
potential  form  in  the  substances  so  built  up  into  the  tissue, — is  lost  to  the 
tissue  during  its  destructive  metabolism  :  so  that  the  whole  metabolism,  the 
whole  cycle  of  changes  from  the  lifeless  pabulum,  through  the  liying  tissue, 
back  to  the  lifeless  products  of  vital  action,  is  eminently  a  source  of  heat." 

Thus  it  is  in  increased  destructive  metabolism  that  we  must  look  for  the 
origin  of  fever-heat,  and  its  chief  seat  is  the  muscles.  In  health  it  is  esti- 
mated that  they  yield  four-fifths  of  the  whole  body-heat,  and  in  fever  their 
relative  contribution  is  probably  larger.  Both  clinical  and  pathological 
observations  bear  witness  to  the  profound  manner  in  which  they  are  affected. 
Among  these  may  be  mentioned  the  characteristic  pains  and  weakness,  the 
marked  wasting,  often  so  striking  in  the  fever  of  children,  and  the 
associated  increase  of  the  salts  of  potash,  of  urea,  and  of  other  nitrogenous 
substances  in  the  urine. 

Kecent  ex]>eriments  on  animals  show  good  ground  for  believing  that  the 
muscles  possess  a  heat-generating  function  which  is  to  some  extent  inde- 
pendent of  their  motor  function  and  under  the  control  of  a  twofold  nervous 
mechanism, — the  one  part  exciting  thermogenesis,  accompanied  by  destruc- 
tive metabolism,  the  other  staying  thermogenesis  and  subserving  constructive 
metabolism.  "  The  processes  which  issue  in  motion  on  the  one  hand  and 
in  thermoo-enesis  on  the  other  are  of  course  associated  with  chemical  move- 
ments  in  the  muscle,  with  metabolisms  whose  terminal  steps  are  the  accre- 
tion of  oxygen  and  the  excretion  of  carbonic  acid  and  water.  .  .  .  The 
'  contractile  stuff'  in  the  muscle  is  not  the  same  as  the  '  thermogenic  stuff.' 
Both  of  them  are  stored  in  the  muscle  :  so  far  as  function  goes,  they  are  tlie 
muscle.     The  store  of  each  can  be  exhausted  by  rcpoatcd  stimulation,  but 


FEVER.  41 9 

in  some  cases  the  thermogenic  store  sooner  than  the  other.  Both  can  be  up- 
built again  by  the  circulating  blood,  but  in  some  cases  the  contractile  store 
sooner  than  the  thermogenic.  Both  the  metabolisms  are  affected  by  cold,  but 
the  thermogenic  much  sooner  and  much  more  intensely  than  the  contractile. 
We  know  little  of  the  exact  nature  of  the  chemical  changes  involved  in 
cither  form  of  metabolism.  Oxygen  is  taken  up  in  each  and  carbonic  acid 
is  discharged,  but  the  processes  passed  through  between  these  terminal 
stages  are  much  more  complex  than  simple  oxidations.  The  evidence  rather 
goes  to  show  that  it  is  the  living  substance  as  a  whole,  contractile  stuff  and 
thermogenic  stuff,  which  is  continually  being  decomposed  and  as  continually 
being  recomposed  by  the  blood.  The  net  balance  shows  only  gain  of  car- 
bonic acid  and  loss  of  oxygen,  but  the  nitrogenous  parts  also  of  the  working 
substance  have  in  the  process  undergone  partial  destruction  and  equivalent 
reconstruction.  This  is  in  health ;  but  if  the  reconstructive  part  of  the 
l)rocess  is  inadequate  or  absent,  the  balance  of  accounts  will  give  evidence 
of  a  nitrogenous  residuum  which  is  morbid.  The  muscle-substance  Mnll 
appear  to  be  itself  consumed ;  it  will  no  longer  be  what  I  may  call  merely 
the  circulating  medium  of  consumption.  The  cast-out  nitrogenized  mole- 
cules of  the  muscle  are  not  really  excretionary  in  the  sense  that  carbonic 
acid  is  excretionary.  They  have  merely  failed  of  that  immediate  upbuilding 
into  muscle-substance  again  which  is  characteristic  of  the  healthy  metal>- 
olisra.  This  incessant  upbuilding  of  the  muscle-substance  which  is  a 
necessary  consequence  of  the  fact  that  no  increase  of  urea  or  other  nitro- 
genous matter  is  produced  in  the  ordinary  processes  of  muscular  metabolism 
must  require  the  expenditure  of  a  certain  amount  of  energy.  If  in  any 
measure  the  upbuilding  is  checked  or  abolished,  so  much  energy  is  of 
course  unexpended."  (MacAlister.) 

This  whole  line  of  investigation  is  most  suggestive,  but,  so  long  as  the 
interpretation  of  the  results  is  not  perfectly  clear,  we  should  be  very  guarded 
in  drawing  far-reaching  conclusions. 

As  regards  the  amount  of  heat  contributed  by  the  al^dominal  viscera, 
we  may  safely  assume  that,  in  so  far  as  it  depends  on  processes  connected 
with  the  metabolism  of  foods,  it  is  diminished  in  fever. 

The  channels  for  the  dissipation  of  heat  are  the  skin, — by  radiation, 
conduction,  and  evaporation, — and  the  lungs,  by  evaporation  and  warming 
of  the  expired  air.  As  sweating  is  not  common  in  the  fever  of  children, 
evaporation  necessarily  plays  a  less  important  role  than  in  the  fever  of 
adults.  The  pungency  of  skin  which  is  often  met  with  may  be  in  part  due 
to  this  peculiarity.  It  is  usually  associated  with  a  preternaturally  dry  skin 
and  contracted  cutaneous  vessels,  conditions  which  tend  to  prevent  a  rapid 
loss  of  heat  and  therefore  favor  elevation  of  the  surface-temperature.  We 
are  all  familiar  with  the  remarkable  way  in  which  the  aspect  and  feel  of 
the  skin  may  vary  during  an  attack  of  simple  fever.  In  less  than  an  hour 
a  pale,  dry,  pungent  skin  may  become  flushed  and  moist.  A  febrile  blush 
so  intense  as  to  arouse  suspicions  of  an  acute  exantliem  may  vanish  alto- 


420  FEVER. 

gether  in  a  few  minutes.  Phenomena  such  as  these  not  only  suggest  very 
pointedly  that  heat-discharge  is  largely  under  the  control  of  the  nervous 
system, — acting  through  the  vaso-motor  nerves, — but  also  point  with  equal 
emphasis  to  the  profound  disturbance  of  that  control.  It  is  probable  that 
about  sixty  per  cent,  of  the  heat  leaving  the  body  does  so  by  radiation. 
The  laws  of  this  loss  have  recently  been  investigated  with  striking  results. 
When  a  portion  of  skin  is  uncovered  it  naturally  becomes  cooler,  but  the 
cooling  does  not  take  place  according  to  physical  laws.  It  is  found  that 
radiation  increases  steadily  as  the  temperature  falls,  until  a  certain  limit 
is  reached ;  that  it  varies  directly  with  the  activity  of  the  processes  of 
nutrition  and  metabolism,  and  is  therefore  more  active  in  children  than  in 
adults ;  and,  further,  there  is  some  ground  for  believing  that  it  is  subject 
to  nervous  control.  These  considerations  have  a  practical  bearing.  If  I 
read  them  aright,  they  plead  strongly  in  favor  of  light  clothing  and  light 
coverino;  and  of  cool  well-ventilated  sick-rooms. 

The  nature  of  the  relations  of  the  central  nervous  system  to  thermo- 
genesis  and  thermolysis  is  still  very  imperfectly  understood.  Our  knowl- 
edge in  this  direction  is  chiefly  based  upon  experimentation  on  animals. 
Careful  experiments  have  demonstrated  the  presence  at  the  anterior  part  of 
the  caudate  nucleus,  near  its  median  convexity,  of  a  tract  which,  whenever 
it  is  stimulated  by  puncture  with  a  fine  needle  or  by  an  electric  current, 
gives  rise  to  an  increase  in  the  body-temperature  which  persists  for  some 
time  and  is  attended  by  an  increase  in  the  amount  of  the  oxygen  absorbed 
and  of  the  carbonic  acid  given  oif  by  the  animal.  It  has  been  shown  by 
calorimetric  experiments  that  this  pyrexia  is  not  due  to  vaso-motor  disturb- 
ance causing  retention  of  heat,  but  that  there  is  an  increase  in  heat-pro- 
duction. At  the  same  time  the  pulse-  and  respiration-rates  are  raised  and 
the  elimination  of  urea  is  increased.  It  appears,  therefore,  that  puncture  of 
the  caudate  nucleus  produces  in  certain  animals  a  pyrexia  which  possesses 
all  the  essential  properties  of  fever  regarded  as  abnormal  elevation  of  tem- 
perature. The  value  of  this  experiment  in  support  of  the  neurotic  origin 
of  fever  can  hardly  be  overestimated.  Some  valuable  evidence  is  also  forth- 
coming on  the  clinical  side.  In  this  connection  it  will  suffice  to  recall  the 
fact  that  there  are  on  record  well-attested  cases  of  cerebral  tumor,  pontine 
hemorrhage,  softening  and  hemorrhage  in  or  about  the  basal  ganglia,  injuries 
of  the  spinal  cord,  tumors  of  the  spinal  meninges  and  others,  in  which  very 
high  temperatures  have  been  observed, — temperatures  for  which  no  other 
cause  was  discoverable  than  the  nervous  lesion  with  which  the  patient  was 
affected. 

In  this  very  brief  reference  to  the  nature  of  pyrexia,  attention  has  been 
directed  to  the  close  relation  of  the  nervous  system  with  heat-production 
and  heat-regulation.  The  interpretation  of  many  facts  is  still  doubtful. 
But  we  may  accept  as  beyond  question  that  "  there  exist  in  the  body  chem- 
ical processes  resulting  chiefly  in  the  production  of  heat ;  that  these  processes 
are   under  direct  control  of  the  nervous  system  and  possibly  of  special 


FEVER.  421 

thermal  nerves ;  and,  lastly,  that  there  are  regions  in  the  central  nervous 
system  which  are  in  some  way  connected  with  these  nerves  and  through 
them  control  the  chemical  processes  resulting  in  heat-j)roduction."   (Welch.) 

The  nervous  theory  of  fever  certainly  seems  to  offer  the  best  working 
hypothesis  yet  advanced  to  explain  the  various  phenomena  of  the  disorder. 
Viewed  in  this  light,  the  disturbance  of  the  regulating  mechanism  alone 
will  give  rise  to  irregular  risings  and  fallings  of  temperature  as  the  inde- 
jjendent  variations  of  production  and  loss  are  concurrent  or  the  reverse, 
without  wasting,  failure  of  nutrition,  or  other  signs  of  increased  thermo- 
genesis, — thermal  ataxia.  If  both  the  regulating  and  heat-producing  mech- 
anisms are  disturbed,  we  have  true  fever,  with  excessive  thermogenesis  and 
wasting.  The  temperature  rises,  and  after  a  while  the  discharging  mechan- 
ism is  set  going,  and  if  not  itself  disordered  presently  overtakes  the  work 
thrown  upon  it.  This  is  what  occurs  in  ordinary  fever.  If,  however,  the 
thermolytic  mechanism  is  not  capable  of  being  stimulated  to  increased 
activity  by  the  antecedent  excessive  thermogenesis,  the  temperature  rises  to 
a  dangerous  or  even  fatal  height.     This  is  hyperpyrexia.     (MacAlister.) 

Causes  of  Fever. — To  formulate  a  classification  of  the  causes  of  fever 
which  shall  be  at  once  simple  and  comprehensive  is,  in  the  present  state 
of  our  knowledge  of  the  etiology  of  the  various  fevers,  almost  impos- 
sible. Experimental  investigations  on  ferments  and  putrid  intoxicants  have 
thrown  much  light  on  the  nature  of  inflammatory  fever.  The  discovery 
and  investigation  of  the  so-called  cadaveric  alkaloids  have  revealed  to  us 
an  impoiiant  group  of  fever-producing  agents.  But  the  nature  of  the 
relationship  of  many  of  the  acute  specific  febrile  diseases  to  the  invasion 
and  multiplication  within  the  body  of  pathogenic  micro-organisms  still 
remains  to  be  solved.  In  common  with  ferments  and  putrid  intoxicants, 
the  poisons  of  the  majority  of  these  diseases  exert  a  pyrogenic  effect  after 
being  received  into  the  circulation.  Their  precise  mode  of  action  is  still 
matter  for  speculation.  It  is  supposed  by  some  that  they  act  on  the  nervous 
system,  directly  or  indirectly ;  by  others,  that  they  lead  to  increased  heat- 
production  by  a  direct  action  on  the  blood  and  tissues ;  but  even  in  such  an 
event,  as  already  pointed  out,  we  must  assume  that  the  equililjrium  of  the 
thermal  nervous  system  is  in  some  way  disturbed.  It  is  possible  that  all 
pyrogenic  substances  act  by  producing  a  common  change  in  the  body. 

The  first  group  of  fever-producing  agents  comprises  substances  which, 
if  not  actually  identical  with  physiological  ferments,  are  readily  produced 
by  them,  independently  of  the  action  of  bacteria.  Some  of  them  are 
normally  present  in  small  amount  in  the  body,  otliers  may  be  jjroduced  in 
the  disintegration  of  extravasated  blood  or  by  the  abnormal  disintegration 
of  tissue,  and  if  absorbed  in  sufficient  quantity  or  under  suitable  conditions 
are  held  to  be  the  cause  of  the  febrile  states  known  as  ferment  intoxica- 
tions. As  probable  members  of  this  group  may  be  cited  cases  of  the  so- 
called  aseptic  fever  which  follow  extensive  injuries  or  lacerations  in  spite  of 
rigorous  antiseptic  precautions,  and  the  febrile  reaction  attending  subcuta- 


422  FEVEE. 

neous  injuries  and  extravasations,  especially  fractures  of  the  large  bones.  It 
is  probable  that  the  pyrexia  which  accompanies  certain  forms  of  ansemia  and 
possibly  some  obscure  varieties  of  simple  fever  also  belong  to  this  category. 

The  second  group  comprises  substances  which  are  the  product  of  micro- 
organisms not  in  themselves  pathogenic ;  that  is,  not  capable  of  further 
multiplication  when  inoculated  in  pure  cultivation  into  the  body.  These 
saprophytic  bacteria  are  very  widely  distributed  both  in  and  out  of  the 
body,  and  may  exert  their  influence  in  several  ways.  Their  presence  in 
foul  wounds  leads  to  the  formation  of  chemical  substances  which,  when 
absorbed  into  the  circulation,  give  rise  to  pyrexia  with  toxic  symptoms, — 
putrid  intoxication.  Under  this  head  are  included  the  febrile  states  which 
subside  after  the  thorough  cleansing  of  a  foul  wound,  and  the  whole  class  of 
septic  fevers  which  result  from  the  absorption  of  poisonous  substances  pro- 
duced in  necrotic  or  disintegrating  tissues  or  exudations  or  extravasated 
blood  by  the  action  of  purely  saprophytic  bacteria.  Of  this  nature  are 
probably  also  the  secondary  fever  of  variola  and,  in  part  at  least,  the  fever 
of  typhoid  after  the  end  of  the  second  week. 

Fermentative  and  putrefactive  bacteria  are  noraially  present  in  the 
alimentary  canal,  and  it  is  probable  that  under  certain  circumstances  the 
products  of  their  activity  may,  by  their  absorption,  give  rise  to  febrile 
attacks,  which  are,  however,  for  the  most  part  of  a  milder  type  than  those 
just  mentioned.  Here  the  essential  morbid  conditions  appear  to  be  due 
partly  to  the  character  of  the  ingesta,  partly  to  alterations  in  the  digestive 
juices.  Of  this  order  are  doubtless  a  large  number  of  the  transient  febrile 
,  attacks  of  children  which  occur  in  association  with  various  disorders  of 
digestion.  Dentition  fever  is  often  cited  as  a  type  of  pyrexia  due  to  reflex 
neurosis ;  but  even  here  evidence  is  not  wanting  to  show  that  other  causes 
may  be  operative.  In  support  of  this  may  be  mentioned  the  occasional 
enlargement  of  the  glands  at  the  angle  of  the  jaw ;  the  not  infrequent  asso- 
ciation of  middle-ear  catarrh,  indicating  an  extension  of  inflammation  along 
the  Eustachian  tube ;  and  the  presence  in  some  instances  of  a  considerable 
degree  of  stomatitis. 

Of  far  graver  significance  are  the  putrid  intoxications  which  result  from 
the  ingestion  of  substances  which  have  undergone  outside  the  body  putre- 
faction or  changes  which  lead  to  the  formation  of  ptomaines.  These  sub- 
stances have  been  separated  from  putrefying  materials  in  states  of  tolerable 
purity.  Some  of  them  appear  to  be  harmless,  but  the  introduction  of  others 
into  the  circulation  is  attended  by  pyrexia  with  toxic  symptoms.  They 
may  be  absent  in  advanced  decomposition,  and  in  general  the  most  virulent 
ptomaines  are  formed  in  the  earliest  stages  of  putrefaction. 

There  are  also  differences  according  to  the  kind  of  bacteria  present, 
according  to  the  nature  of  the  substances  decomposed,  and  according  to 
various  other  circumstances,  such  as  the  presence  of  oxygen,  the  tempera- 
ture, etc.  Of  this  nature  are  some  of  the  cases  of  poisoning  which  have 
been  caused  by  eating  unsound  meat,  fish,  cheese,  etc.     The  absorption  of 


FEVER.  423 

poisons  of  a  similar  kind,  not  necessarily  the  product  of  pathogenic  bacteria, 
would  afford  a  rational  explanation  of  the  symptoms  of  profound  intoxica- 
tion met  with  in  many  cases  of  diphtheria  and  hospital  sore  throat,  as  well 
as  of  the  constitutional  disturbance  which  is  not  uncommon  in  scarlet  fever 
towards  the  end  of  the  third  week,  in  association  with  the  onset  of  nephritis. 
This  view  would  receive  support  from  the  presence  in  such  cases  of  some 
local  morbid  condition,  whether  inflammatory  or  necrotic,  and  would  explain 
the  success  claimed  for  local  antiseptic  measures  in  preventing  or  moderating 
the  severity  of  the  symptoms,  at  least  in  the  two  first-named  diseases. 

In  the  third  group  are  included,  for  convenience  of  classification,  the 
poisons  of  the  acute  specific  febrile  diseases.  Of  them  we  know  that  they 
are  specific, — i.e.,  that  the  diseases  which  they  produce,  and  of  which  pyrexia 
is  a  constant  concomitant,  never  pass  the  one  into  the  other ;  that  they  prevail 
epidemically  or  endemically ;  that  they  are  in  large  proportion  infectious  or 
contagious ;  that  they  may  gain  admission  to  the  body  by  various  routes, 
some  by  inoculation,  some  by  the  respiratory  mucous  membrane,  some  by 
the  gastro-intestinal  tract.  The  nature  of  many  of  these  poisons  is  still 
uncertain. 

That  micro-organisms  are  present  in  the  blood  and  tissues  in  several 
of  these  diseases  is  universally  admitted,  and  in  the  case  of  a  very  few  the 
evidence  adduced  in  support  of  a  causal  relationship  may  be  received  as 
adequate.  Such  are  erysipelas,  pyaemia,  and  diphtheria.  But  in  regard  to 
others  competent  observers  are  by  no  means  agreed.  Thus,  in  several 
quarters  the  belief  is  held  that  the  micro-organisms  observed  in  relapsing 
and  malarial  fevers  are  epiphenomena,  appearing  as  a  consequence  rather 
than  as  a  cause  of  the  morbid  processes  constituting  the  fever ;  and  similar 
objections  have  been  raised  in  regard  to  several  others.  So  that  until  more 
unequivocal  proof  is  forthcoming  in  regard  to  the  nature  of  their  poisons, 
it  would  be,  to  say  the  least,  premature  to  include  all  these  affections  under 
one  generalization,  as  depending  on  the  invasion  and  multiplication  of  patho- 
genic bacteria  within  the  body. 

That  there  are  causes  of  pyrexia  other  than  the  presence  of  pyrogenic 
substances  in  the  blood  seems  beyond  question,  A  passing  reference  has 
already  been  made  to  the  direct  effect  of  certain  lesions  of  the  central 
nervous  system  on  the  body-temperature,  as  well  as  to  the  nature  of  hyper- 
pyrexia. And  although  reasons  have  been  given  for  believing  that  many 
cases  of  dentition  fever  are  of  inflammatory  origin,  instances  of  this  and 
other  affections  are  not  wanting  in  which  the  older  doctrine  of  peripheral 
irritation  still  affords  the  simplest  and  apparently  the  most  rational  explana- 
tion, especially  when  we  consider  the  instability  of  temperature-regulation 
in  children. 

The  rise  of  tem]:)erature  wliicli  may  accompany  a  fit  of  crying,  a  con- 
vulsion, or  excitement  of  any  kind  during  convalescence  from  acute  disease, 
or  in  weakly  children,  would  also  seem  to  find  a  place  here.  Increased 
muscular  activity  may  be  in  part  responsible  in  the  two  first-named,  but 


424  FEVER. 

in  all  there  is  a  reasonable  suspicion  of  some  direct  disturbing  nervous 
influence. 

It  has  been  maintained  that  the  process  of  growth  may  cause  pyrexia. 
The  evidence  brought  forward  in  support  of  this  belief  is,  at  the  best,  of  a 
somewhat  flimsy  order  and  altogether  insufficient.  It  cannot  be  doubted, 
however,  that  during  the  period  of  active  growth  heat-regulation  is  highly 
unstable  and  the  temperature  consequently  more  labile  than  at  other  periods 
of  life. 

Effects  of  Fever. — Opinion  has  varied  considerably  at  different  times 
in  regard  to  the  effects  of  fever  on  the  body.  Formerly  the  view  was  very 
generally  held  that  the  disorders  of  function  and  the  morbid  tissue-changes 
which  attend  fever  were  entirely  due  to  elevation  of  temperature ;  and  this 
opinion  found  support  in  experiments  made  at  the  time,  but  under  con- 
ditions which  have  since  been  shown  to  have  somewhat  vitiated  the  conclu- 
sions drawn  from  them.  At  the  present  time  there  is  a  decided  reaction 
against  this  view,  a  reaction  which  in  some  quarters  goes  to  the  extent  not 
only  of  denying  that  there  is  danger  in  moderate  pyrexia,  but  also  of  assert- 
ing that  a  moderate  degree  of  fever  should  not  be  checked.  Among  the 
causes  which  have  led  to  this  change  of  opinion  the  failure  of  antipyretic 
treatment  to  curtail  or  even  to  control  certain  fevers  undoubtedly  holds  a 
prominent  place.  Besides  this,  a  careful  reconsideration  of  the  experi- 
mental evidence  in  the  light  of  fresh  experiments  has  drawn  attention  to 
the  important  rdle  played  in  fever  by  other  factors,  such  as  infection  or 
intoxication.  The  increased  frequency  of  the  respiratory  act,  the  heightened 
pulse-rate,  and  possibly  constipation,  are  probably  direct  effects  of  the  high 
temperature,  whilst  the  variations  in  arterial  tension  and  the  disorders  of 
the  alimentary  and  nervous  systems  are  in  large  part  dependent  on  infection 
or  some  factor  of  fever  other  than  high  temperature.  The  muscular  pains 
and  weakness  are  to  be  looked  upon  as  the  expression  of  abnormal  inner- 
vation and  nutritive  changes  accompanying  thermogenesis,  whilst  a  part 
only  of  the  increased  nitrogenous  disintegration  of  fever  is  to  be  ascribed 
to  pyrexia. 

With  regard  to  the  granular  or  fatty  degeneration  of  organs,  and  of  the 
heart  in  particular,  which  is  generally  held  to  constitute  one  of  the  chief 
dangers  to  life  in  prolonged  fever,  high  temperature  is  probably  an  impor- 
tant factor,  but  is  certainly  not  the  only  one.  Similar  changes  are  of  not 
infrequent  occurrence  in  some  forms  of  anaemia,  and  may  be  induced  by  a 
variety  of  poisons,  with  little  or  no  pyrexia.  And,  further,  granular  degen- 
eration is  more  often  found  after  acute  specific  fevers  than  in  other  febrile 
diseases.  In  other  words,  there  are  strong  reasons  for  suspecting  that  it 
bears  a  close  relation  to  the  kind  and  degree  of  the  infection  in  any  given 
case. 

Whatever  may  ultimately  prove  to  be  the  exact  share  of  pyrexia  in 
the  causation  of  the  phenomena  noAV  under  consideration,  it  appears  highly 
probable  that  during  fever  many  causes  are  at  work,  which  may  tend  to 


FEVER.  425 

lessen  the  resisting  power  of  the  individual  to  the  injurious  effects  of 
prolonged  high  temperature. 

The  case  of  hyperpyrexia  is  different.  Here,  without  doubt,  the  main 
source  of  danger  is  the  high  temperature,  which  seems  to  be  in  great  part 
due  to  an  excessive  disturbance  of  the  thermal  nervous  mechanisms,  amount- 
ing to  almost  complete  paralysis.  Such,  no  doubt,  is  the  nature  of  the 
excessive  rise  which  may  usher  in  death  in  some  diseases, — an  indication  of 
commencing  dissolution  in  the  higher,  more  recently  evolved,  and  therefore 
less  stable  nervous  mechanisms. 

Significance  of  Heightened  Temperature  in  Children. — The  tem- 
perature of  children  in  health  is  characterized  by  a  relative  instability, 
which  renders  it  liable  to  disturbance  by  a  variety  of  causes,  many  of 
them  of  the  most  trivial  nature.  This  is  to  be  accounted  for  partly  by  the 
undeveloped  state  of  the  nervous  system,  partly  by  its  state  of  active 
growth.  A  mere  nothing  will  send  an  infant  into  a  high  fever ;  a  very 
little  restores  it  again  to  health.  But  as  the  child  grows  its  temperature 
becomes  less  liable  to  disturbance,  until  with  years  it  gradually  acquires 
the  stability  w^hich  distinguishes  the  temperature  of  adults.  The  nervous 
mechanisms  which  subserve  heat-regulation  are,  during  infancy  and  child- 
hood, undergoing  a  progressive  evolution  towards  relative  stability.  Being 
at  this  period  of  life  among  the  least  organized,  least  automatic  mechanisms, 
they  are  readily  thrown  out  of  gear. 

The  readiness  with  which  physiological  tissue-activity  in  a  child  gives 
place  to  pathological  activity,  in  the  presence  of  disturbing  causes,  is  also 
a  reason  why  fever  is  a  frequent  concomitant  of  disease  in  children.  As 
examples  of  this  tendency  may  be  mentioned  acute  lymphadenitis,  that 
common  cause  of  fever,  and  the  proneness  of  inflammation  to  issue  in 
suppuration. 

In  the  same  way  instability  is  the  key-note  to  the  peculiarities  of  the 
febrile  temperature  of  children.  It  contrasts  with  the  pyrexia  of  adults, 
less  on  account  of  any  differences  in  range  and  height,  than  because 
of  its  striking  tendency  to  present  sudden  and  temporary  remissions.  It 
may  rise  and  fall  several  times  in  the  course  of  the  twenty-four  hours. 
Periods  of  high  and  low  temperature  may  alternate  in  the  most  uneven  and 
irregular  manner.  The  type  or  pattern  of  the  chart  may  vary  almost  from 
day  to  day.  The  height  of  the  temperature  bears  little  or  no  relation  to 
the  severity  of  the  disease.  A  trivial  cause  may  send  the  temperature  to 
104°  F.,  or  even  higher,  Avithout  apparent  discomfort  to  the  patient,  whereas 
a  fatal  case  of  pneumonia  may  run  its  course  without  the  temperature  ex- 
ceeding 102°  F.  Enough  has  been  said  to  shoAv  that  temperature-observa- 
tions cannot  afford  the  same  indications  as  to  diagnosis  and  prognosis  as  we 
are  accustomed  to  derive  from  them  in  the  fevers  of  adults.  For  example, 
during  the  second  week  of  typhoid,  in  striking  contrast  with  the  sustained 
higli  temperature  of  adults,  the  daily  remissions  may  be  so  marked  as  to 
afford  no  assistance  whatever  in  distinguishinfj;  the  case  from  one  of  tuber- 


426  FEVER. 

culosis,  a  disease  from  which  the  diifereutial  diagnosis  is  often  so  difficult  in 
the  early  stages.  Xor,  assuming  the  diagnosis  of  typhoid  to  be  established, 
would  the  occurrence  of  large  remissions  towards  the  end  of  the  second 
w^eek  justify  us  in  prognosticating  an  early  deferv^escence.  It  is  in  menin- 
gitis and  other  forms  of  nervous  disease  that  we  encounter  irregular  and 
ambiguous  temperatures  ])ar  excellence.  These  cases  appear  to  conform  to 
no  rule.  In  tubercular  meningitis  low  temperatures  are  perhaps,  on  the 
whole,  more  frequent.  Cases  of  this  disease  are  on  record  in  which  the 
association  of  repeated  convulsion  with  high  temperature-range  seems  to 
suggest  a  causal  relation  between  them.  The  well-established  fact  that 
convulsion  qua  convulsion  may  cause  a  rise  of  several  degrees  lends  some 
color  to  the  supposition.  But  that  this  association  is  by  no  means  constant 
is  strikingly  illustrated  by  the  case  of  a  boy,  aged  four,  who  died  of  tuber- 
cular tumor  of  the  cerebellum,  with  meningitis,  after  a  prolonged  illness. 
The  prominent  symptoms  were  repeated  convulsion,  extreme  wasting,  optic 
neuritis,  and  frequent  and  prolonged  vomiting,  yet  the  temperature  never 
exceeded  99°  F.  It  may  fairly  be  asked  whether  the  height  of  the  tem- 
perature in  an  attack  of  convulsions  possesses  any  prognostic  value.  Any 
rise  of  temperature  due  to  the  convulsion  itself  speedily  subsides  on  its 
cessation ;  and,  speaking  generally,  the  higher  the  temperature  the  greater 
the  probability  that  the  convulsion  is  essential  rather  than  sym^^tomatic. 

One  other  point  deserves  mention.  It  has  been  found  that  the  highest 
and  lowest  temperatures  may  occur  at  almost  any  time  in  the  twenty-four 
hours.  Consequently,  if  a  chart  is  to  represent  with  any  faithfulness  the 
daily  wanderings  of  the  temperature,  the  observations  must  be  recorded  at 
regular  and  comparatively  short  intervals.  A  morning  and  evening  record 
may  yield  a  fairly  steady  temperature  when  in  reality  there  has  been  a  daily 
excursion  of  several  degrees. 

In  young  children  and  infants  it  is  best  to  take  the  temperature  in  the 
rectum  or  in  the  groin.  In  older  children  it  may  be  taken  in  the  mouth  or 
axilla,  if  due  precautions  are  observed.  The  rectal  temperature  is  about 
.7°  F.  higher  than  that  in  the  axilla  and  .5°  F.  higher  than  that  in  the 
mouth. 

The  following  criteria  have  been  laid  down  on  the  significance  of 
pyrexia  in  children  :  "  The  pyrexia  is  good,  csetcrk  panbus,  which  is  lower 
in  the  morning  than  in  the  evening;  which  is  equable  or  with  but  slight 
variations  from  day  to  day ;  which  has  a  single  rise  and  a  single  fall  in  the 
twenty-four  hours ;  and  whose  lowest  morning  level  approaches  the  normal 
line.  The  pyrexia  is  bad,  cseteris  paribus,  which  is  highest  in  the  morning ; 
which  ascends  from  evening  through  the  small  hours ;  which  has  two  or 
more  rises  or  falls  for  one  day  and  night ;  which  either  maintains  its  level 
above  103°  F.  pretty  equably  for  many  hours  together,  or  else  is  very 
variable  from  day  to  day  and  conformable  to  no  pattern.  Add  to  this — 
what  was  early  known,  yet  what  of  itself  would  suffice  to  save  tlie  ther- 
mometer from  ever  falling  into  neglect — that  the  temperature-register  gives 


FEVER.  427 

the  first  warning  of  impending  mischief  after  injuries  and  surgical  opera- 
tions ;  that  it  supplies  our  sole  means  of  watching  and  of  measuring  hyper- 
pyrexia ;  and  that  in  conjunction  with  other  signs  (by  no  means  by  itself) 
it  helps  to  distinguish  certain  fevers  and  to  estimate  their  progress  and 
severity.     These  latter,  however,  are  but  occasional  uses."     (Sturges.) 

Stages  and-  Types  of  Pyrexia. — Three  stages  are  generally  recognized, 
— the  initial  stage,  that  of  rising  temperature ;  the  fastigium,  or  stage  of 
sustained  high  temperature  ;  and  defervescence,  during  which  the  tempera- 
ture returns  to  the  normal  level.  The  duration  and  pattern  of  each  stage 
vary  considerably  in  different  diseases  and  in  the  same  disease  according  to 
circumstances.  A  rapid  and  continuous  rise  is  the  rule  in  scarlet  fever  and 
ague,  whilst  in  measles  and  typhoid  fever  the  rise  is  more  gradual  and  often 
broken  by  a  series  of  remissious.  A  severe  convulsion  at  the  onset  may 
intensify  the  initial  rise ;  severe  vomiting  may  delay  or  even  lessen  it.  The 
temjjerature  of  children  during  the  acme  or  fastigium  is  chiefly  noticeable 
on  account  of  the  frequency  of  remissions.  Crisis  is  the  more  common  mode 
of  defervescence.  The  actual  crisis  may  be  preceded  by  one  or  more  sharp 
and  deep  remissions ;  this  is  sometimes  seen  in  acute  pneumonia.  Typhoid 
fever  affords  a  good  example  of  defervescence  by  lysis.  After  defervescence 
the  temperature  is  often  subnormal  for  a  few  days,  and  is  characterized 
during  convalescence  by  its  greater  instability  and  liability  to  disturbance 
by  causes  which  would  make  little  or  no  impression  on  the  temperature  of 
a  healthy  child. 

In  the  terms  continued,  remittent,  aud  intermittent,  which  are  still  in 
common  use,  we  have  a  survival  of  the  nomenclature  of  an  ao-e  in  which 
fever  was  regarded  as  a  disease — a  morbid  entity — jjresenting  different 
types.  In  the  present  time  these  terms  are  used  to  qualify  the  pattern  of 
a  pyrexia,  rather  than  as  a  basis  of  classification.  They  are  too  well  known 
to  need  special  description.  The  remittent  type  is  especially  common  in  the 
fevers  of  children.  Hectic  fever  is  the  name  given  to  the  remittent  or  inter- 
mittent fever  which  occurs  in  some  wasting  diseases,  more  especially  when 
these  are  accompanied  by  chronic  suppuration  with  profuse  discharge  of 
pus.  It  is  often  present  in  pulmonary  and  in  abdominal  tuberculosis,  with 
or  without  ulceration.  In  the  earlier  stages  there  may  be  intermissions 
during  the  day  with  fe])rile  disturbances  towards  evening.  As  the  disease 
progresses,  the  fever  assumes  a  remittent  type,  with  exacerbations  at  night 
and  perhaps  in  the  morning.  The  rise  of  temperature  may  be  preceded 
by  chilliness  and  end  in  a  profuse  sweat,  especially  about  the  head  aud 
shoulders. 

Symptoms  of  Fever. — Prcxlromal  symptoms  may  be  present,  but  are 
often  absent  or  pass  unnoticed.  Tliey  are  peevishness  or  apathy,  distaste 
for  food,  languor,  and  sometimes  headache  in  older  children.  The  onset  is 
often  quite  sudden. 

An  initial  rigor  is  very  rare,  even  in  septicaemia,  acute  necrosis,  and 
ague.     It  is  generally  absent  in  erysipelas  and  in  the  eruptive  fevers  and 


428  FEVER. 

pneumonia.  Older  children  occasionally  complain  of  chilliness.  Dusky 
pallor  of  the  face  and  lips,  with  cold  extremities  and  burning  heat  of  the 
body,  is  not  uncommon  at  the  onset  of  a  sharjD  attack  of  fever.  AVe  have 
perhaps  here  the  true  homologue  of  the  rigor  of  adults. 

Much  has  been  both  written  and  taught  concerning  the  convulsive  onset 
of  the  fevers  of  children.  Without  any  desire  to  detract  from  the  im- 
portance of  this  symptom,  I  would  suggest  that  its  occurrence  is  perhaps 
less  frequent  than  one  might  suppose  from  the  amount  of  attention  and 
description  it  has  received.  Discussing  the  causes  of  convulsion  in  chil- 
dren, Hughlings-Jackson  makes  the  following  reference  to  that  now  under 
consideration  :  "  It  scarcely  comes  in  my  way  to  do  more  in  this  paper  than 
urge  the  recognition  of  these  rarer  possibilities  in  the  crowd  of  the  more 
probable  causes."  Convulsion  as  an  initial  symptom  may  occur  in  almost 
any  acute  febrile  disease,  but  is,  on  the  whole,  more  common  in  the  eruptive 
fevers.  It  does  not  materially  aifect  the  ultimate  prognosis.  We  must  not 
lose  sight  of  the  fact  that  children  are  liable  to  convulsion  under  many 
diiferent  circumstances :  such  are  rickets,  states  of  exhaustion,  dentition, 
diarrhoea,  and  organic  disease  of  the  brain,  besides  the  convulsive  seizures 
termed  essential.  All  these  possible  causes  have  to  be  reckoned  with  when 
we  are  called  upon  to  pronounce  an  opinion  on  a  case  of  convulsion.  If 
the  temperature  is  high  during  the  convulsion  and  continues  to  rise  as  the 
seizure  passes  off,  we  may  suspect  the  onset  of  some  acute  fever.  An  inquiry 
into  the  family  or  personal  history  will  often  throw  light  on  the  cause.  A 
clue  may  be  found  on  examining  the  chest,  which  shoukl  always  be  done  as 
a  matter  of  routine.  Albuminuria  immediately  following  a  convulsion  is 
of  little  diagnostic  value  at  the  onset  of  a  fever.  It  may  be  due  to  the 
direct  effects  of  the  convulsion. 

The  question  may  arise  whether  a  convulsion  indicates  the  onset  of  acute 
cerebral  disease, — especially  tubercular  meningitis.  This  is  only  likely  to 
occur  where  convulsion  is  the  first  symptom  for  which  we  are  consulted. 
Tubercular  meningitis  is  a  disease  of  gradual  and  insidious  onset,  and  very 
rarely  begins  with  convulsions.  The  status  epilepticus  must  be  carefully 
distinguished  from  tubercular  meningitis.  In  this  condition,  which  results 
from  a  quick  succession  of  fits,  the  temperature  sometimes  attains  a  con- 
siderable height,  106°  F.,  and  the  urine  may  be  albuminous.  Of  far  more 
serious  import  are  convulsions  occurring  during  the  eruptive  stage  of  scarlet 
fever,  measles,  and  variola.  For  information  on  this  point  the  reader  is 
referred  to  the  special  articles  on  these  diseases.  In  the  later  stages  of  fever, 
when  the  patient  is  much  exhausted,  there  is  again  manifested  a  tendency  to 
convulsions,  which  occasionally  usher  in  the  fatal  event. 

Vomiting  is  a  \QYy  frequent  early  symptom.  It  may  take  place  after  a 
meal  or  without  relation  to  the  ingestion  of  food.  When  severe  and  re- 
peated, it  is  apt  to  induce  collapse.  The  association  of  repeated  vomiting 
with  headache  and  drowsiness  will  raise  suspicions  of  meningeal  trouble. 
This  grouping  of  symptoms,  however,  is  sometimes  seen  in  simple  continued 


FEVER.  429 

fever,  and  has  been  known  to  precede  the  crisis  of  acute  pneumonia.  Here 
is  a  case  in  point.  A  girl,  four  years  of  age,  after  ailing  for  about  ten  days, 
was  seized  with  severe  occipital  headache  and  repeated  vomiting.  In  a  few 
hours  she  became  cold  and  collapsed.  AVlieu  I  saw  her  for  the  first  time  on 
the  following  morning  the  expression  was  pinched  and  anxious,  and  she 
complained  continually  of  the  pain  at  the  back  of  the  head.  The  pujDils 
were  dilated,  sluggish,  and  unequal,  and  there  was  a  slight  convergent 
strabismus.  The  temperature  was  102°  F.  The  abdomen  was  natural, 
the  tache  cerebrah  being  well  marked  ;  the  bowels  were  confined.  She  was 
ordered  effervescing  mixture  and  a  grain  of  calomel.  She  vomited  eight 
times  during  the  day.  Towards  evening  the  headache  was  worse,  the  tem- 
perature 104°  F.,  and  the  child  more  drowsy.  During  the  night,  however, 
the  temperature  began  to  fall  rapidly ;  on  the  following  morning  all  bad 
symptoms  had  disappeared,  and  the  patient  made  a  rapid  recovery. 

The  skin  is  usually  dry  and  hot,  sometimes  harsh, — especially  in  tuber~ 
cular  disease.  Sweating  is  decidedly  rarer  than  in  adults.  The  perspira- 
tion of  acute  rheumatism  is  often  limited  to  the  palms  and  soles,  that  of 
rickets  to  the  head.  Pyaemia  may  run  its  course  almost  without  a  s\veat. 
Except  at  the  crisis  of  a  fever,  the  occurrence  of  profuse  sweats  is  an 
unfavorable  sym^itom.  They  are  sometimes  met  with  in  lung-aifections 
attended  by  marked  cyanosis, — broncho-pneumonia,  for  instance, — recalling 
the  analogous  condition  of  skin  in  the  suffocative  bronchitis  of  old  people. 
Sweats  are  apt  to  occur  in  chronic  tubercular  disease  with  suppuration  and 
in  the  later  stages  of  tubercular  affections  of  the  chest  and  abdomen.  Asr 
a  general  rule,  however,  phthisical  children  do  not  sweat  in  excess.  Oc- 
casionally there  is  an  eruption  of  sudamina  on  the  chest  which  may  lead 
to  branny  desquamation.  Miliaria  rubra  probably  never  develops  except 
where  poultices  or  hot  fomentations  have  been  employed.  Bed-sores  seldom 
occur. 

The  aspect  of  the  skin  is  very  variable.  Some  children  are  pale  at  the 
onset  of  fever,  others  look  hot  and  flushed.  The  two  conditions  may  alter- 
nate in  the  same  patient.  When  the  skin  is  unusually  flushed,  the  con- 
dition is  sometimes  designated  as  the  "  febrile  blush."  In  some  cases  it 
presents  a  close,  though  superficial,  resemblance  to  the  rash  of  scarlet  fever, 
and  has  more  than  once  led  to  a  mistaken  diagnosis,  even  at  the  hands  of 
competent  observers.  Not  a  few  cases  are  admitted  each  year  into  fever- 
hospitals  as  scarlatinal  which  ultimately  prove  to  be  cases  of  si'nple  con- 
tinued fever  or  develop  into  typhoid.  The  febrile  blush  is  generally  an 
early  phenomenon.  Its  duration  is  very  varial)le.  Lasting  in  some  cases 
but  an  hour  or  two,  in  others  it  persists,  with  varying  intensity,  for  several 
days.  Sometimes  it  is  followed  by  bratmy  desquamation.  A  high  tem- 
perature is  by  no  means  necessary  to  its  occurrence.  The  febrile  blush  is 
usually  well  developed  on  the  face,  neck,  and  upper  part  of  the  chest.  It 
also  affects  the  dependent  parts  of  the  body,  the  back,  buttocks,  and  backs 
of  the  arms  and  legs.     It  is  usually  faint  on  the  lower  abdomen  and  inner 


430  FEVER. 

aspect  of  the  thighs.  When  fully  developed  it  consists  of  a  bright  reddish- 
pink  blush,  uniformly  diflFused  beneath  the  surface  and  fading  momentarily 
on  pressure.  It  is  very  evanescent  and  apt  to  shift  from  place  to  place. 
Exposure  of  the  chest  often  causes  it  to  disappear  entirely  in  a  few  minutes, 
to  return  again  as  soon  as  the  clothing  is  replaced.  In  some  cases  it  occurs 
in  large  irregular  patches  with  ill-defined  borders.  The  distinction  from 
the  rash  of  scarlet  fever  is  not  likely  to  offer  any  difficulties,  except  in  cases 
where  the  blush  is  unusually  intense  and  persistent.  The  chief  points  of 
difference  are  the  following.  On  the  face  the  febrile  blush  is  often  well 
marked  and  reaches  to  the  margin  of  the  lips.  The  rash  of  scarlet  fever  is 
generally  faint  on  the  face  and  leaves  untouched  a  zone  of  skin  around  the 
mouth.  The  blush  of  fever  is  usually  faint  or  absent  in  the  groin  and  on 
the  inner  aspect  of  the  thighs,  parts  on  which  the  scarlatinal  eruption  is 
generally  well  marked.  The  blush  lies  beneath  the  surface  of  a  perfectly 
smooth  skin.  The  rash  of  scarlet  fever  is  punctiform  and  not  necessarily 
uniformly  diffused.  The  blush  is  less  persistent  than  the  rash,  and  more 
susceptible  to  external  influences. 

Labial  herpes  is  seen  in  many  kinds  of  fevers,  but  is  not  necessarily  an 
early  sign.  It  is  relatively  common  in  pneumonia,  not  rare  in  acute  tonsil- 
litis, febrile  gastric  disorders,  and  febricula,  and  may  occur  in  the  eruptive 
fevers.     Its  presence  practically  excludes  the  diagnosis  of  typhoid  fever. 

The  lips  dry  quickly  and  become  cracked.  Children  are  very  apt  to 
pick  and  cause  them  to  bleed  and  sometimes  to  become  swollen.  This 
picking  at  the  lips,  or  at  other  parts  of  the  body,  is  often  a'  sign  of  nervous 
prostration. 

The  tongue  does  not  present  with  any  constancy,  or  in  the  same  degree, 
the  \'arieties  of  aspect  which  characterize  it  in  certain  febrile  diseases  of 
adults,  and  is  therefore  of  little  value  in  helping  the  diagnosis.  An  excep- 
tion may  be  made  in  favor  of  scarlet  fever.  Slight  furring  on  the  dorsum 
with  redness  of  the  tip  and  edges  is  the  rule,  but  the  tongue  may  remain 
clean  and  dry  throughout.  A  dry  tongue  may  become  brown,  but  it  rarely 
cracks  to  any  great  extent,  even  in  typhoid  fever.  The  thick  creamy  fur 
of  rheumatic  fever  is  hardly  ever  seen.  Some  injection  of  the  fauces  is 
common  at  the  onset  of  an  acute  fever.  The  appearance  presented  differs 
in  degree  only  from  a  mild  scarlatinal  throat. 

The  digestive  functions  are  almost  invariably  impaired.  The  salivary 
and  pancreatic  secretions  are  much  diminished,  giving  rise  to  dryness  of 
mouth,  great  thirst,  distaste  for  food,  and  difficulty  in  assimilating  starchy 
foods.  The  secretion  of  bile  is  probably  also  lessened  :  the  stools  are  often 
pale  and  offensive.  There  is  usually  constipation,  but  this  is  a  rule  to 
which  there  are  many  exceptions.  Diarrhoea  is  rare  at  the  onset  of  fever, 
but  may  accompany  the  crisis. 

The  pulse  of  children  in  fever  does  not  exhibit  any  marked  peculiarities. 
Its  clinical  significance  is  relatively  small,  in  great  measure  owing  to  the 
difficulty  generally  experienced  in  making  a  satisfactory  examination,  on 


FEVEE.  431 

account  of  the  smalluess  of.  the  arteries  and  the  restlessness  or  intolerance 
of  the  little  patient.  In  infants  undue  pulsation  of  the  fontanel  will  suggest 
excited  vascular  action.  The  frequency  of  the  pulse  is  always  increased. 
It  is  often  full  and  bounding  in  the  earlier  stages,  but  tends  to  become 
smaller  and  weaker  as  exhaustion  increases,  and  in  the  later  stages,  when 
death  is  threatening,  is  often  running  or  thready  and  impossible  to  count. 

Increase  in  the  frequency  of  the  respiratory  act  is  a  constant  and  impor- 
tant concomitant  of  fever.  The  respirations  may  rise  to  forty  per  minute 
and  the  alfe  nasi  be  set  in  action,  even  in  the  absence  of  any  pulmonary  com- 
plication. More  than  this,  rhonchi  and  scattered  rales  may  be  heard  over  the 
lungs  during  the  exacerbations  of  a  simple  catarrhal  fever,  which  disappear 
entirely  when  the  temperature  remits.  This  accession  of  pulmonary  signs 
is  occasionally  very  marked  during  the  hot  stage  of  ague,  and  may  render 
the  diagnosis  from  pneumonia  or  broncho-pneumonia  somewhat  difficult. 
It  is  to  be  observed,  however,  that  whilst  catarrhal  fevers  may  be  accompa- 
nied by  very  definite  pulmonary  signs,  the  simple  bronchitis  of  children  is 
often  attended  by  high  temperatures,  even  though  no  pneumonia  is  present. 

The  disturbances  of  the  seusorium  vary  greatly  in  different  cases.  The 
reason  of  this  is  to  be  sought  partly  in  individual  differences  of  temperament 
and  resisting  power,  partly  in  the  nature  and  degree  of  the  intoxication. 
Many  a  case  of  simple  fever  runs  its  course  without  causing  any  appreciable 
impairment  of  health.  In  others,  cerebral  symptoms — vomiting,  drowsiness, 
headache,  etc; — predominate  to  such  an  extent  as  to  justify  the  recognition 
of  a  cerebral  type  of  simple  fever.  The  profound  and  rapid  prostration, 
with  or  without  coma  or  convulsions,  often  seen  in  the  malignant  forms  of 
the  eruptive  fevers  and  typhoid,  illustrates  strikingly  the  direct  effects  of 
the  fever-poison  on  the  nervous  system.  Restlessness,  irritability,  and  drow- 
siness are  common  symptoms.  Uneasy  sleep  and  sleeplessness  are  also  of 
frequent  occurrence,  and,  although  in  themselves  insignificant  symptoms, 
demand  close  attention  and  proper  treatment.  A  few  hours  of  peaceful 
sleep  will  often  do  more  to  restore  the  strength  of  a  fevered  child  than 
anything  else.  Children  under  five  do  not  generally  complain  of  headache. 
Altogether,  this  symptom  is  far  less  common  than  in  adults.  It  is  not  rare, 
however,  in  the  early  stages  of  typhoid,  and  may  occur  in  simple  continued 
fever.  The  occasional  occurrence  of  sickness  during  the  course  of  a  fever 
has  no  special  significance.  Severe  and  repeated  vomiting,  on  the  other 
hand,  is  a  grave  symptom,  requiring  prompt  treatment,  and  liable  to  do 
much  liarm  by  increasing  prostration. 

Delirium  is  relatively  uncommon  in  children,  and  the  key-note  to  this 
peculiarity  probably  lies  in  the  incomplete  state  of  their  mental  evolution. 
Talking  during  sleep,  however,  is  common  enough,  and  a  tendency  to  ram- 
ble in  their  talk,  when  awake,  is  not  rare.  If  prostration  is  very  great, 
a  condition  strictly  analogous  to  coma-vigil  may  be  present.  Deepening 
stupor,  sulisultus  tcndinum,  tendency  to  convulsion,  aud  picking  at  the 
l)ody  or  the  bedclothes  are  all  unfavorable  symptoms. 


432  FEVER. 

Hyperpyrexia  is  rare,  except  as  the  immediate  precursor  of  death,  when 
it  may  be  regarded  as  one  of  the  earliest  stages  in  the  process  of  dying. 
This  form  is  not  amenable  to  treatment.  Rheumatic  hyperpyrexia  is  very 
rare  indeed.  Several  cases  of  genuine  hyperpyrexia  have  occurred  during 
the  treatment  of  acute  renal  disease  by  a  variety  of  the  continuous  hot  ^yet 
pack  which  is  applied  in  the  following  manner.  "  A  blanket  is  soaked 
in  boiling  water  and  then  wrung  out.  The  patient  is  placed  in  this  just  as 
hot  as  can  comfortably  be  borne,  which  is  usually  at  a  temperature  of  130° 
F.,  and  completely  enveloped  in  it  as  far  as  the  neck.  A  mackintosh  is 
then  wrapped  round  this  so  as  to  exclude,  as  far  as  possible,  atmospheric 
influences,  and  finally  a  thick  blanket,  doubled,  is  laid  oyer  the  patient  thus 
enveloped.  The  pack  is  changed  hourly,  and  the  child  is  out  of  the  pack 
just  so  long  as  it  takes  to  remove  the  disused  one  and  replace  it  by  another.^' 
These  unfortunate  accidents  have  rendered  great  service,  not  only  in  draw- 
ing attention  to  the  dangers  of  this  mode  of  treatment,  but  also  because 
they  are  instances  of  hypei'pyrexia  artificially  induced  by  placing  the  human 
body  under  abnormal  conditions  which  are  accurately  known.  These  are, 
an  envelope  of  moist  heat  far  above  that  usually  encountered  by  the  body 
in  temperate  climates,  and  the  simultaneous  and  almost  complete  elimination 
of  the  most  important  cooling  agent,  the  skin.  There  may  be  profuse 
sweating,  but  this  is  of  little  ayail,  as,  under  the  existiug  conditions,  eyapo- 
I'ation  and  radiation  cannot  take  place  to  any  extent.  Under  such  condi- 
tions, assuming  that  regulation  remains  effective  and  thermogenesis  can  be 
held  in  sufficient  check,  there  need  be  no  hyperpyrexia,  in  spite  of  the 
almost  complete  closure  of  the  most  important  channels  of  heat-loss.  The 
temperature  may  rise  at  first,  owing  to  the  sudden  check  on  thermolysis, 
but  in  time  a  balance  between  production  and  loss  will  again  be  struck. 
This  is  precisely  Avhat  takes  place  in  some  cases.  The  temperature  rises 
two  or  three  degrees  and  gradually  falls  again.  But  once  allow  the  central 
mechanisms  inhibiting  thermogenesis  to  become  exhausted  or  temporarily 
paralyzed  by  over-stimulation,  heat-production  will  haye  unbridled  sway, 
and  the  result  will  be  hyperpyrexia.  These  clinical  experiments,  as  they 
may  fairly  be  termed,  are  in  reality  a  faithful  reproduction  of  the  conditions 
under  which  heat-stroke  sometimes  occurs  in  tropical  countries,  and  the 
sym^Dtoms  exhibited  in  the  two  conditions  are  almost  identical.  Of  these 
the  more  important  are  extreme  restlessness  or  delirium,  with  ashy  pallor 
or  liyidity  of  the  face  and  a  dry  tongue,  associated  with  ycry  rapid  shallow 
sniffing  breathing  and  extreme  rapidity  and  feebleness  of  pulse. 

The  changes  in  the  urine  do  not  call  for  any  lengthy  notice.  The  total 
quantity  is  reduced  and  the  specific  grayity  raised.  On  cooling,  the  urine 
generally  deposits  a  sediment  of  white  or  yellowish-white  lithates.  This 
amorphous  precipitate  of  mixed  urates  dissolyes  readily  on  heating.  At 
times,  especially  when  there  has  been  temporary  retention  of  urine,  hedgehog 
or  acicular  crystals  of  urate  of  soda  may  be  deposited  within  the  bladder, 
and  are  voided  with  the  first  portion  of  the  urine  subsequently  passed. 


FEVER.  433 

During  convalescence  it  is  common  to  find  a  cloud  of  white  phosphates  pre- 
cipitate by  heat,  which  dissolves  at  once  on  the  addition  of  a  drop  of  acetic 
acid.  At  this  period  the  urine  may  also  contain  uric-acid  and  oxalate-of- 
lime  crystals. 

The  occurrence  of  temporary  albuminuria  is  by  no  means  rare.  The 
quantity  of  albumen  present  is  always  small,  rarely  exceeding  a  large  trace, 
and  disappears  rapidly  with  convalescence.  The  occurrence  of  small  hyaline 
casts  has  no  special  significance,  but  the  presence  of  granular  or  cellular 
casts  points  to  some  structural  disease  of  the  kidneys. 

The  eifect  of  fever  on  the  body  is  generally  well  marked  in  children. 
Wasting  is  general,  muscles  and  cellular  tissues  chiefly,  but  probably  all 
tissues  in  varying  degree.  Emaciation  often  takes  place  with  startling 
rapidity.  A  fever  of  twenty-four  hours'  duration  ma}''  make  a  noticeable 
change,  especially  in  plump,  fat  children. 

Treatment. — In  dealing  with  fever,  two  lines  of  treatment  are  open 
to  us.  The  first  is  to  remove  or  destroy  the  fever-poison.  The  other — • 
our  only  resource  in  cases  where  the  poison  is  out  of  reach — is  to  place  our 
patient  under  the  most  favorable  conditions  and  treat  injurious  symptoms 
and  complications  as  they  arise. 

The  child  should  be  placed  in  an  airy,  well-ventilated  room  with  an 
equable  temperature,  between  60°  and  65°  F.  The  clothing  and  bed- 
covering  should  be  light,  but  adequate, — our  object  being  to  allow  radiation 
and  evaporation  free  play,  without  exposing  the  patient  to  the  variations  of 
the  external  temperature,  which  are  apt  to  produce  slight  shivers.  Linen 
clothing  is  to  be  preferred  to  flannel  during  the  active  stages  of  fever, 
except  when  there  is  much  sweating.  It  is  more  pleasant  to  wear,  is  not 
so  apt  to  irritate  the  skin,  and  can  be  more  easily  and  effectually  cleaned. 
During  convalescence  a  flannel  vest  may  be  worn  Avith  advantage.  Soiled 
body-  and  bed-linen  should  always  be  immediately  changed  and  removed 
from  the  sick-room. 

The  diet  should  be  bland  and  mostly  liquid,  and  the  food  is  best  given 
in  small  quantities  at  short  intervals.  During  fever  the  processes  of  diges- 
tion are  always  much  impaired,  and  we  should  be  careful  to  avoid  overload- 
ing the  stomach  in  our  anxiety  to  sustain  the  strength  of  the  patient.  Milk 
is  to  be  given  as  a  food,  and  not  as  a  drink.  Cold  water,  in  plenty,  or 
barley-water  flavored  with  lemon,  may  be  taken  to  slake  thirst.  If  pure 
milk  is  not  easily  digested,  it  may  be  diluted  with  plain  barley-water  or 
with  solution  of  gelatin  or  gum  acacia.  Beef  tea  and  mutton  broth  are 
generally  well  borne,  and  should  always  form  part  of  the  diet  of  children 
over  eighteen  months  old.  If  they  should  disagree,  chicken  broth  or  veal 
tea  Avill  be  available.  If  the  stomach  become  intolerant,  panereatized  milk 
or  beef  tea  may  be  tried  by  the  mouth,  or,  if  this  should  fixil,  in  the  form 
of  enemas  or  nutrient  suppositories. 

Constipation  should  be  relieved,  preferably  by  means  of  enemas  (soap- 
and-water  or  glycerin). 
Vol.  I.— 28 


434  FEVEE. 

Diuretic  and  diaphoretic  salines  may  be  given,  with  plenty  of  Avater. 
They  tend  to  promote  free  action  of  the  skin  and  kidneys,  and  facilitate  the 
removal  from  the  tissues  of  the  waste  products  of  fever. 

Fevers  due  to  some  disorder  of  digestion  generally  yield  at  once  to  a 
purge  or  an  emetic ;  and,  as  many  of  the  simple  fevers  of  children  are  of 
this  nature,  castor  oil  and  calomel  have  acquired  great  repute  in  their  treat- 
ment. The  pyrexia  which  accompanies  certain  specific  diseases  wdll  often 
yield  to  drugs  which  exert  a  specific  action  on  the  disease.  As  examples 
may  be  mentioned  quinine  and  salicylates  in  the  treatment  of  malaria  and 
acute  rheumatism.  Fevers  depending  on  purely  local  causes,  in  accessible 
situations,  are  also  readily  amenable  to  suitable  treatment.  Such  are  the 
putrid  fevers  of  foul  wounds,  of  acute  abscess,  ulcerative  stomatitis,  and 
others.  Admittedly  these  classes  of  fevers  represent  but  a  small  fraction  of 
the  whole  number  and  do  not  include  those  which  are  most  often  dangerous 
to  life.       . 

When  the  cause  of  the  fever  is  beyond  our  reach,  we  must  treat  symp- 
toms. Of  these,  pyrexia  is  not  only  one  of  the  most  important,  but  also 
the  one  that  we  are  best  able  to  cope  with.  It  is  well  to  bear  in  mind, 
however,  that  children  are  in  general  very  susceptible  to  the  action  of  anti- 
pyretics, and  that  unless  due  care  is  exercised  in  the  selection  of  suitable 
cases  and  appropriate  methods  this  form  of  treatment  will  often  disappoint 
expectation.  The  occurrence  of  collapse  constitutes  one  of  the  chief  risks 
in  the  employment  of  antipyretics.  To  guard  against  this  danger,  they 
should  always  be  used  tentatively  at  the  outset  and  their  effect  carefully 
watched.  Thus,  after  a  bath  or  a  dose  of  antifebrin  the  temperature  should 
be  taken  at  least  twice  within  an  hour,  in  the  mouth  or  the  rectum  accord- 
ing to  the  age  of  the  patient.  Any  symptoms  of  collapse  should  at  once  be 
met  by  the  exhibition  of  stimulants  and  warm  applications  to  the  surface. 
^Tien  cold  applications  cause  much  distress  to  the  patient,  they  are  of 
doubtful  benefit,  and  should  be  discontinued,  unless  the  reduction  of  the 
temperature  is  imperative,  as  in  hyperpyrexia.  In  certain  states  the  ex- 
ternal application  of  cold  is  contra-indicated.  It  rarely  does  good  in  the 
condition  described  above  as  the  possible  homologue  of  the  rigor  of  adults, 
in  which  the  extremities  are  cold  and  bluisli  and  the  trunk  burning  hot. 
In  such  a  case  cold  is  likely  to  aggravate  the  cyanosis  and  further  depress 
the  patient,  whereas  a  warm  bath  and  a  little  alcohol  will  often  quickly 
improve  the  general  condition.  In  some  cases  of  cerebral  disease  where 
the  employment  of  ice-bags  or  cold-water  coils  to  tlie  head  has  been  a 
source  of  discomfort  and  irritation,  much  benefit  has  attended  the  substitu- 
tion of  hot  fomentations. 

Although  it  is  obviously  impossible  to  lay  down  hard-and-fast  rules  for 
their  use,  antipyretics  may  legitimately  be  employed  (1)  in  cases  of  sus- 
tained high  temperature  above  103°  F.,  (2)  in  all  cases  of  hyperpyrexia, 
and  (3)  whenever  the  rise  of  temperature  is  accompanied  by  aggravation  of 
other  symptoms,  such  as  restlessness,  want  of  sleep,  drowsiness,  delirium, 


FEVER.  435 

or  rapidity  and  weakness  of  cardiac  action.  These  indications  are  more 
than  ever  imperative  when  the  patient's  strength  has  ah-eady  been  taxed  by 
prolonged  fever  and  in  children  of  weak  physique.  The  means  at  our  dis- 
posal are  (1)  drugs,  and  (2)  the  external  application  of  cold. 

The  drugs  on  which  most  reliance  can  be  placed  are  quinine,  in  full 
doses,  salicylates,  and  the  class  of  antipyretics  now  in  vogue, — viz.,  antipy- 
rin,  antifebrin,  and  phenacetine.  The  last-named  drugs  must  be  given  with 
due  caution.  In  full  doses  they  may  depress  the  heart  to  an  alarming 
degree ;  and  this  constitutes  a  serious  objection  to  their  use  when  there  is 
much  prostration. 

Antipyriu  has  now  been  extensively  used  for  some  time,  and  its  mode 
of  action  carefully  investigated.  It  increases  skin-radiation,  lessens  heat- 
production,  diminishes  nitrogenous  waste  by  checking  destructive  metabo- 
lism, and  frequently,  but  not  always,  increases  perspiration,  while  it  gen- 
erally slows  the  heart  and  slightly  increases  the  tension  of  the  radial  pulse. 
It  may  fairly  claim,  therefore,  to  be  a  true  antipyretic,  and  not  merely  a 
refrigerant.  It  has  met  with  marked  success  in  the  treatment  of  fever.  Its 
effect  on  the  temperature  is,  unfortunately,  very  transitoiy,  so  that  it  may 
be  necessary  to  repeat  the  dose  hourly  to  keep  the  pyrexia  under  control. 
At  times  it  causes  gastric  irritation  and  troublesome  vomiting,  and  occasion- 
ally diarrhoea.  This  tendency  may  be  obviated  to  some  extent  by  adding 
one  or  two  drops  of  tincture  of  opium ;  and  it  is  a  good  plan  to  give  a  little 
alcohol  at  the  same  time,  to  prevent  depression.  The  administration  of 
antipyrin  is  sometimes  followed  by  the  eruption  of  a  measles-like  papular 
erythema,  which  appears  first  on  the  arms  and  dependent  parts,  and  may 
spread  to  the  remainder  of  the  body.  This  rash  is  of  no  serious  import, 
and  quickly  disappears  on  discontinuing  the  drug.  In  rare  instances  the 
drug  has  caused  symptoms  of  acute  irritant  poisoning. 

Antifebrin  (acetanilide)  possesses  several  advantages  over  antipyrin,  and 
is  gradually  superseding  it  in  the  treatment  of  fever.  Its  mode  of  action 
is  probably  the  same.  As  an  antipyretic  it  is  more  rapid  and  powerful 
in  its  action,  and  its  effect  on  the  temperature  is  rather  more  permanent. 
Serious  collapse  is  liable  to  occur  when  it  is  given  incautiously,  and  it  may 
cause  rigors.  It  is  rarely  followed  by  sickness,  and  does  not  produce  a  rash. 
It  should  be  given  tentatively  at  first,  half  to  one  grain  for  a  cliild  of  two 
years  and  about  two  grains  for  a  child  of  five.  The  dose  required  will  vary 
according);  to  the  stao-e  and  nature  of  the  fever.  Full  doses  are  generally 
needed  in  the  early  stages  of  fever,  especially  in  scarlet  fever,  in  which  the 
drug  has  proved  of  considerable  value.  Tiie  pyrexia  of  typhoid  fever,  as 
a  rule,  yields  readily  to  all  antipyretics. 

Phenacetine,  so  far  as  we  know,  acts  in  the  same  manner  as  antifebrin, 
and  is  said  to  possess  tlie  same  advantages. 

One  other  drug  deserves  mention.  Aconite  is  of  conspicuous  value  in 
catarrhal  fevers  the  result  of  chill,  and  in  acute  tonsillitis.  If  given  in 
the  earliest  stages,  the  general  malaise,  sense  of  chilliness  or  burning  heat. 


436  FEVER. 

pains,  etc.,  rapidly  disappear  and  give  place  to  a  feeling  of  comfort.  The 
skin  becomes  moist  and  may  sweat  profusely,  and  the  pulse  is  lowered  in 
frequency.  The  drug  should  be  given  in  small  doses  at  frequent  intervals, 
half  to  one  drop  of  the  tincture  every  quarter  of  an  hour  for  a  child  of  five 
years,  until  the  desired  effect  is  obtained.  Much  care  is  required  in  its 
administration,  owing  to  its  powerful  depressant  action  on  the  heart. 

The  means  of  reducing  excessive  temperatures  by  the  external  applica- 
tion of  cold  include,  among  others,  sponging,  the  compress  or  ice-bag,  the 
wet  pack,  bathing,  and  affusion. 

The  mode  of  action  of  cold  is  not  exactly  known,  but  probably  differs 
considerably  from  that  of  the  drugs  just  considered.  It  is  highly  probable 
that  its  good  effects  are  attributable  to  some  stimulant  action  on  the  central 
nervous  system,  as  well  as  to  the  abstraction  of  heat  from  the  surface  and 
the  probable  diminution  of  heat-production.  Certain  it  is  that  this  mode 
of  treatment  is  far  more  effective  in  rousing  the  depressed  sensorium  and 
combating  prostration  than  the  antipyretic  drugs.  As  a  rule,  it  induces  a 
refreshing  sleep,  whereas  this  desirable  result  only  occasionally  follows  the 
administration  of  antipyrin  and  its  allies.  This  mode  of  treatment  is  always 
to  be  preferred  when  there  is  much  prostration.  In  a  general  way,  children 
do  not  stand  cold  well,  and  tepid  applications  should  always  be  given  a  trial 
before  using  cold. 

Sponging. — The  face,  trunk,  and  limbs  are  sponged  over  for  ten  or  fifteen 
minutes  with  tepid  water  (80°  F.),  or  with  cold  water  (50°  F.  or  lower). 
The  surface  is  then  rapidly  dried  and  the  covering  replaced,  A  sheet  and 
a  single  blanket  will  generally  suffice.  If  tepid  water  does  not  bring  about 
the  desired  effect,  a  graduated  bath  is  likely  to  answer  better  than  sponging 
with  cold  water. 

Compress. — This  consists  in  the  application  to  the  body  or  limbs  of 
cloths  wrung  out  in  cold  or  iced  water.  They  require  to  be  very  frequently 
changed,  and  should  be  discontinued  when  the  temperature  has  fallen  below 
100°  F.  Like  sponging,  compresses  demand  constant  attention  on  the 
part  of  the  nurse,  and  may  interfere  with  sleep.  They  are  chiefly  useful 
in  typhoid  fever  when  there  is  much  abdominal  distention  and  it  is  not 
advisable  to  disturb  the  patient. 

Bathing. — The  bath  is  the  most  powerful  antipyretic  agent  we  possess, 
and  almost  the  only  one  that  has  achieved  success  in  the  treatment  of  hyper- 
pyrexia. Its  chief  value  in  the  treatment  of  children,  however,  is  due  to 
its  combined  stimulating  and  sedative  effect  on  the  nervous  system.  To 
allay  restlessness  and  general  malaise,  a  warm  bath  (95°  F.)  will  often  ac- 
complish all  that  is  needed,  and  is  usually  followed  by  some  lowering  of 
temperature.  The  effect  of  a  bath  at  80°  F.  is  more  powerful  and  lasting, 
but  less  agreeable  to  the  patient.  When  reduction  of  temperature  is  the 
primary  object,  a  graduated  bath  is,  on  the  whole,  the  most  convenient 
plan.  The  child  is  placed  in  a  bath  at  90°  F.  which  is  rapidly  lowered  in 
temperature  by  the  addition  of  cold  or  iced  water.     The  bath  should  be  of 


FEVER.  437 

short  duration  and  given  in  the  presence  of  the  medical  attendant.  The 
rectal  temperature  should  be  taken  at  intervals  of  a  few  minutes,  and  the 
child  removed  from  the  bath  when  it  has  reached  100°  F.,  as  the  after-fall 
may  be  considerable.  It  is  often  advisable  to  give  a  small  dose  of  alcohol 
both  before  and  after  the  bath.  The  occurrence  of  shivering  or  of  blueness 
of  the  lips  and  extremities  is  an  indication  for  immediate  removal  from 
the  bath,  in  ordinary  cases.  In  the  treatment  of  hyperpyrexia,  ho^vever, 
every  consideration,  in  reason,  is  subordinate  to  the  paramount  necessity 
of  bringing  down  the  temperature. 

A  combination  of  the  warm  bath  with  cold  affusion  to  the  neck  and 
shoulders  is  occasionally  of  the  greatest  service  in  the  treatment  of  bron- 
chitis and  collapse  of  lung.  The  following  is  a  good  example  of  the  class 
of  case  in  question.  A  child  of  three  years,  who  had  been  suffering  from  a 
severe  attack  of  bronchitis  for  ten  days,  was  admitted  into  hospital  in  the 
following  condition.  Temperature,  103°  F.  Eyes  suffused,  face  puffed 
and  livid.  Respirations  over  sixty  per  minute,  short,  shallow,  and  ineffect- 
ual. Marked  inspiratory  recession  of  lower  ribs  and  interspaces  and  above 
clavicles.  On  auscultation,  loud  rhonchi  and  bronchitic  rales  all  over  lungs, 
with  weak  breathing  at  the  bases.  After  taking  a  teaspoonful  of  brandy  in 
hot  water,  the  child  was  placed  in  a  warm  bath  and  water  at  70°  F.  dashed 
over  the  neck  and  shoulders.  Each  affusion  caused  the  patient  to  take  a 
deep  inspiration,  and  the  relief  to  the  congested  pulmonary  circulation  was 
immediately  apparent.  The  face  soon  regained  a  more  normal  color  and 
expression,  the  breathing  became  deeper  and  slower  and  the  inspiratory 
recession  much  diminished.  A  second  bath  was  needed  a  few  hours  later, 
but  after  this  recovery  was  uninterrupted. 

Cold  Wet  Pack. — The  patient  is  wrapped  in  a  sheet  wrung  out  of  cold 
or  iced  water  and  covered  over  with  a  thick  blanket.  The  pack  should  not 
be  continued  longer  than  from  ten  to  fifteen  minutes. 

The  water-bed  or  water-pillow  may  be  utilized  to  reduce  the  temper- 
ature by  allowing  water  at  a  suitable  temperature  to  circulate  through  it ; 
but  it  cannot  be  recommended  as  a  convenient  or  satisfactory  method  of 
carrying  out  this  object. 

Ice-bags  or  iced-water-coils  are  applied  to  the  head  for  the  purpose  of 
allaying  meningeal  inflammation  and  reducing  temperature.  Their  utility 
in  the  latter  respect,  which  alone  concerns  us  here,  is  undoubted,  but,  as  a 
rule,  children  do  not  tolerate  them,  and  other  and  more  efficient  means  have 
been  mentioned. 

Some  of  the  indications  for  the  use  of  stimulants  have  been  incidentally 
mentioned.  In  them  we  possess  a  most  powerful  means  of  combating  pros- 
tration and  the  exhaustion  of  prolonged  fever.  Besides  the  general  con- 
dition and  aspect  of  the  patient,  the  state  of  the  tongue  and  that  of  the 
pulse  afford  the  safest  indications  for  their  employment.  When  they  cannot 
be  given  by  the  mouth,  alcohol  or  ether  may  be  administered  by  subcutaneous 
injection,  or  in  the  form  of  enema  with  a  sufficiency  of  water  or  beef  tea. 


438  FEVER. 


SIMPLE  OOISTTII^UED  FEYER. 

Synony  me . — Febricula. 

Definition. — A  fever  of  short  duration  which  is  not  characterized 
by  the  presence  of  any  definite  local  lesion  or  preceded  by  any  known 
invariable  antecedent.  It  is,  in  truth,  a  morbid  genus  without  essential 
attributes,  and  made  up,  in  large  part,  of  aberrant  varieties  of  other  species. 
An  initial  diagnosis  of  febricula  has  often  to  be  set  aside  in  favor  of  pneu- 
monia, typhoid,  tonsillitis,  or  some  other  acute  febrile  disease ;  and  the  con- 
verse happens  with  equal  frequency.  Such  facts  bear  strong  testimony  to 
the  indeterminate  character  of  this  affection. 

Simple  fevers  are  very  common  in  childhood,  and  their  early  recognition 
is  of  great  practical  importance.  They  may  be  roughly  grouped  under  the 
following  heads : 

1.  Abortive  or  incomplete  forms  of  the  specific  continued  fevers,  typhus, 
typhoid,  and  relapsing  fever.  Cases  of  irregular  type  may  occur  at  any 
time,  but  are  more  frequent  during  the  epidemic  prevalence  of  these  diseases. 

2.  Cases  of  scarlet  fever,  modified  variola,  and  more  rarely  measles  and 
erysipelas,  in  which  the  eruption  is  either  absent  or  unnoticed. 

3.  In  rare  instances,  anomalous  forms  of  intermittent  fever. 

4.  Fevers  due  to  the  effects  of  some  localized  inflammation,  in  which 
the  local  signs  are  transient,  ill  developed,  or  beyond  the  reach  of  observa- 
tion.   Cases  of  this  kind  occur  in  connection  with  lymphadenitis,  tonsillitis, 

-and  acute  catarrhal  affections  of  the  alimentary  and  respiratory  mucous 
membranes. 

5.  The  whole  group  of  fevers  caused  by  disorders  of  digestion,  attended 
by  the  absorption  of  pyrogenic  substances. 

6.  Fevers  depending  on  some  disturbance  or  exhaustion  of  the  nervous 
system  as  the  consequence  of  exposure  to  heat  or  of  some  peripheral  nerve- 
irritation. 

The  only  symptom  common  to  the  whole  class  is  pyrexia,  and  in  a  con- 
siderable number  of  the  cases  it  constitutes  the  whole  disease.  The  access 
is  generally  sudden,  but  may  be  gradual.  The  temperature  often  attains 
a  considerable  height,  104°  to  105°  F.  The  initial  rise  may  be  ushered 
in  by  any  one  of  the  symptoms  considered  in  an  earlier  part  of  the  article. 
Vomiting  is  common ;  convulsion,  on  the  whole,  is  rare.  Some  or  all  of 
the  clinical  symptoms  of  fever,  before  described,  may  be  present  in  varying 
degree.  The  febrile  blush  is  often  particularly  well  marked.  The  pulse 
and  respirations  are  always  increased  in  frequency.  Restlessness,  wake- 
fulness, and  slight  delirium  are  not  infrequent.  Constipation  is  the  rule, 
with  furred  tongue  and  disinclination  for  food.  Thirst  is  nearly  always 
excessive.  The  urine  is  usually  scanty  and  high-colored.  In  some  cases 
gastric  symptoms  preponderate,  the  tongue  being  thickly  coated,  vomiting 
frequent,  thirst  unquenchable,  and  the  bowels  difficult  to  move.     In  others 


FEVER.  439 

the  respiratory  organs  bear  the  brunt  of  the  attack ;  the  breathing  is  quick 
and  somewhat  labored,  the  alse  nasi  acting  strongly,  the  face  a  little  dusky, 
whilst  numerous  rales  and  rhonchi  are  audible  all  over  the  chest ;  mean- 
while, the  tongue  may  remain  almost  clean  and  digestion  be  but  little  im- 
paired. A  cerebral  type  has  already  been  referred  to,  in  which  headache, 
repeated  vomiting,  intolerance  of  light,  and  irritability  or  tendency  to 
delirium  are  prominent  symptoms.  The  temperature  generally  falls  by 
crisis  at  the  end  of  two  or  three,  it  may  be  five  or  six,  days,  and  con- 
valescence is  always  rapid.  The  diagnosis  rests  chiefly  on  the  exclusion 
of  other  acute  fevers. 

Typhoid  fever,  pneumonia,  tonsillitis,  scarlet  fever,  and  meningitis  are 
the  diseases  from  which  the  diagnosis  is  most  difficult  in  the  early  stages. 
The  occurrence  of  a  sharp  attack  of  fever  in  a  perfectly  healthy  child  is  in 
favor  of  febricula.  The  prognosis  is  always  favorable.  In  the  way  of 
treatment,  rest  in  bed  for  a  day  or  two,  with  liquid  diet,  is  all  that  is 
required  in  most  cases.  Cooling  drinks  and  diaphoretic  salines  are  agree- 
able to  the  patient,  and  harmless.  In  suitable  cases  a  purge  or  an  emetic  is 
the  best  treatment.  Antipyretic  treatment  is  not  called  for,  and  may  be 
injurious.  It  must,  however,  be  borne  in  mind  that  what  appears  to  be 
simple  fever  at  the  outset  may  prove  to  be  some  severe  or  highly  infectious 
disease.  And,  further,  it  would  seem  that  certain  forms  of  febricula  are 
infectious.  It  is  a  common  experience  to  find  all  the  children  in  a  house- 
hold sicken  one  after  another  with  a  fever  of  short  duration  accompanied 
sometimes  by  bronchial  catarrh  and  at  other  times  by  marked  gastric  dis- 
turbance. A  knowledge  of  these  facts  should  make  us  doubly  cautious  in 
dealing  with  cases  of  this  nature. 


THEEMIO  FEYER^ 

Synonymes. — Sunstroke,  Heat-stroke,  Insolation. 

This  condition  is  always  caused  by  exposure  to  excessive  heat  of  some 
kind.  A  moist  heat  is  more  likely  to  produce  it  than  a  hot  dry  air.  Hence 
cases  of  this  disease  are  more  often  met  with  in  damp,  low-lying  districts, 
and  near  the  sea-coast,  than  on  high  dry  table-lands.  Exposure  to  the  direct 
rays  of  the  sun  is  not  necessary  :  many  cases  have  been  reported  as  occur- 
ring towards  evening  or  during  the  night. 

Among  predisposing  causes,  bodily  fatigue  or  exhaustion  and  race  are 
the  principal.  In  hot  countries  Europeans  always  suffer  more  than  natives. 
Bodily  fatigue  is  less  likely  to  operate  as  a  predisposing  cause  in  children 
than  in  adults.     It  is  highly  probable  that  excessive  heat  is  a  factor  in  the 


'  See  remarlvs  on  thfrmif  fever  under  Yellow  Fever. 


440  FEVER. 

rise  of  tlie  death-rate  among  children  from  enteritis  during  the  hot  months. 
It  has  been  pointed  out  that  these  cases,  when  the  pyrexia  is  high  and  the 
cerebral  symptoms  marked,  are  often  relieved  by  the  application  of  cold, 
either  in  the  form  of  affusion  or  by  means  of  baths. 

The  symptoms  vary  within  wide  limits.  Mild  cases  of  thermic  fever 
may  be  indistinguishable  from  cases  of  simple  continued  fever.  In  severe 
sunstroke  or  heat-stroke  the  more  constant  symptoms  are  a  varying  degree 
of  coma,  with  or  without  delirium ;  rapid  sniffing  breathing,  or  labored 
respiration,  with  stertor ;  ashy  pallor  of  the  face  or  livid  suffusion ;  intense 
burning  heat  of  skin,  and  great  rapidity  of  pulse.  Great  restlessness,  sub-  ' 
sultus  tendinum,  and  partial  or  general  convulsions  are  of  frequent  occur- 
rence. A  peculiar  odor  of  the  skin  and  the  breath  has  also  been  described. 
The  urine  is  generally  retained,  but  the  contents  of  the  bowel  may  be 
evacuated  involuntarily. 

The  cause  of  the  rise  of  temperature  in  heat-stroke  has  already  been 
discussed  in  treating  of  hyperpyrexia,  and  need  not  be  recapitulated  here. 
In  the  case  of  sunstroke  the  paralysis  of  the  thermal  mechanisms  would 
seem  to  be  due  to  some  direct  effect  of  the  heat-rays  on  the  central  nervous 
system. 

After  death  putrefactive  changes  occur  rapidly.  The  most  obvious  post- 
mortem signs  are  those  of  general  venous  engorgement.  The  coagulability 
of  the  blood  is  often  impaired.  Petechise  or  small  extravasations  have  been 
found  in  various  parts  of  the  nervous  system. 

The  diagnosis  of  heat-stroke  is  not  'usually  attended  with  difficulty,  in 
well-marked  cases.  In  the  absence  of  any  definite  history  of  causation, 
the  distinction  from  meningitis  may  not  be  easy.  I  am  acquainted  with 
one  such  case. 

Mild  cases  of  thermic  fever  are  most  satisfactorily  treated  with  cold  or 
graduated  baths.  In  severe  cases  with  unequivocal  hyperpyrexia,  immediate 
treatment  is  of  paramount  importance.  The  temperature  must  be  reduced 
without  delay.  '  Cold  affusion,  cold  baths,  and  rubbing  the  surface  with  ice 
are  the  most  powerful  means  at  our  command.  The  thermometer,  in  the 
mouth  or  the  rectum,  is  the  only  safe  guide  as  to  the  effect  of  treatment. 
Great  care  must  be  used  to  avoid  and  prevent  collapse. 

In  cases  attended  with  coma,  if  the  lowering  of  the  temperature  is  not 
accompanied  by  a  return  to  consciousness,  the  prognosis  is  almost  hopeless. 
The  tendency  to  relapse  is  sometimes  very  marked.  In  all  cases  the  tem- 
perature should  be  closely  watched  after  the  fall,  and  antipyretic  measures 
adopted  on  the  first  indication  of  a  fresh  rise.  In  such  an  event,  cold 
packing,  quinine,  or  antifebrin  might  be  tried. 


ENTERIC  OR  TYPHOID  FEVER. 

By  J.  C.  WILSON,  M.D. 


Definition. — An  acute  infectious  disease  due  to  a  specific  cause.  It  is 
characterized  by  gastro-intestinal  catarrh,  febrile  movement  of  continued 
type,  varying  in  duration  from  ten  to  twenty  days,  marked  prostration, 
rapid  Avasting,  mild  nervous  symptoms,  and  a  scanty  eruption  of  isolated, 
slightly  elevated,  rose-colored  spots  disappearing  on  pressure  and  developed 
in  successive  crops.  After  death,  constant  lesions  of  the  solitary  and 
agminate  glands  of  the  ileum,  with  enlargement  of  the  mesenteric  glands 
and  of  the  spleen,  are  found.  Enteric  fever  in  infancy  and  childhood  does 
not  conform  closely  to  the  type  of  the  affection  in  adult  life. 

Synonymes. — Infantile  remittent  fever ;  Nervous  fever ;  Slow  nervous 
fever ;  Infantile  hectic  fever ;  Gastric  fever ;  Acute  mesenteric  fever ;  Entero- 
mesenteric  fever ;  Intestinal  fever ;  Pythogeuic  fever ;  Dothienenterie ;  Ty- 
phus abdominalis ;  Ileo-typhus. 

The  names  by  which  this  fever  has  been  described  at  various  periods 
and  by  different  authors  are  derived  from  its  supposed  relationship  to 
typhus,  its  mode  of  prevalence,  its  remittent  character,  its  long  dui'ation, 
its  supposed  nervous  origin,  the  occurrence  of  septic  or  putrid  symptoms, 
its  hectic  phenomena,  the  presence  of  symptoms  denoting  disturbances  of 
the  stomach  and  liver,  the  intestinal  symptoms,  the  morbid  anatomy,  and 
its  mode  of  origin. 

I  have  not  considered  it  necessary,  however,  to  enumerate  all  these  names, 
seeing  that  by  far  the  greater  part  of  them  have  for  obvious  reasons  fallen 
out  of  use.  The  term  "  abdominal  typhus"  and  its  equivalents  in  general 
use  in  Germany  and  elsewhere  upon  the  Continent  are  open  to  the  objection 
that  they  suggest  a  relationship  Avith  typhus  whicli  is  now  known  not  to 
exist.  They  are,  in  fact,  due  to  the  opinion  formerly  generally  entertained 
that  there  existed  between  the  two  affections  an  essential  pathological  rela- 
tionship,— that  they  were,  in  fact,  two  varieties  o.f  a  single  species  of  fever. 
This  opinion  is  n(^  longer  tenable.  "Typhoid,"  suggested  by  Louis  in 
1829,  is  open  to  the  same  objection,  since  the  labors  of  pathology  during 
the  past  half-century  have  shown  with  increasing  clearness  not  that  the 
fever  in  question  is  like  typhus,  but  that  it  is  unlike  it.  This  term  has, 
however,  the  sanction  of  very  general  acceptance  in  France  and  among 

441 


442  ENTERIC   OE    TYPHOID    FEVER. 

English-speaking  physicians.  The  strongest  objection  to  its  use  lies  in  its 
common  employment  as  an  adjective  to  designate  a  condition  or  group  of 
symptoms  that  may  appear  in  the  course  of  any  severe  acute  disease, — a  use 
that  has  given  rise  to  endless  confusion  of  thought  and  vagueness  of  de- 
scription. The  term  "enteric  fever"  proposed  by  the  late  Prof  George 
B.  Wood  possesses  the  advantage  of  designating  at  the  same  time  the  con- 
stant primary  lesion  and,  by  a  now  accepted  usage  of  the  word  fever  in 
combinations  of  this  kind,  the  infectious  nature  of  the  disease.  It  was 
adopted  in  the  "Nomenclature  of  Diseases"  in  1869.  The  term  "infantile 
remittent,"  though  no  longer  used,  has  an  historical  importance  as  embody- 
ing in  regard  to  the  pathology  of  this  disease  among  children  an  error  at 
one  time  universal. 

History. — The  scope  of  this  article  does  not  include  any  extended 
historical  sketch  of  the  growth  of  knowledge  concerning  the  disease  under 
consideration.  Those  interested  are  referred  to  my  work  upon  "  The  Con- 
tinued Fevers,"  ^  or  to  the  elaborate  classical  treatise  of  Dr.  Murchison.^  It 
is  probable  that  enteric  fever  has  come  down  to  us  from  a  remote  antiquity. 
It  has,  however,  been  separated  from  the  general  group  of  the  fevers  as  a 
substantive  disease  only  in  the  present  century.  The  fact  that  the  fevers 
were  not  clearly  differentiated  until  about  the  end  of  the  first  quarter  of 
the  present  century  lends  more  tlian  passing  interest  to  the  history  of  the 
labors  of  Bretonneau,  Louis,  Chomel,  and  others,  in  France;  of  Aber- 
crombie,  Hewett,  Bright,  and  Jenner,  in  England;  of  Hildenbrand,  in 
Germany;  and  finally  of  Gerhard,  Pennock,  Shattuck,  and  Bartlett,  in 
America.  It  was  chiefly  by  the  work  of  these  physicians  that  during 
the  first  half  of  the  present  century  enteric  fever,  the  great  fever  of  the 
present  historical  epoch,  was  distinctly  separated  from  all  other  forms  of 
fever  and  our  knowledge  of  its  pathology  placed  upon  a  sure  basis  of 
fact.  The  investigations  of  these  observers,  however,  were  directed  almost 
exclusively  to  the  disease  as  it  shows  itself  in  adult  life,  the  opinion  prior 
to  1840  being  universally  held  that  infancy  and  childhood  enjoyed  an  im- 
munity from  it.  To  Rilliet^  and  Taupin,"  who  published  at  about  the  same 
time  independent  descriptions  of  typhoid  fever  as  it  appears  in  childhood, 
is  due  the  credit  of  having  shown  that  this  view  was  erroneous,  and  that 
the  greater  number  of  the  cases  of  fever  amongchildren  previously  described 
as  "  infantile  remittent"  were  in  fact  instances  of  enteric  fever. 

Etiology. — Enteric  fever  is  due  to  the   entrance   into   a   susceptible 
organism  of  a  specific  infecting  principle. 

1.  Predisposing  Influences. — These  are,  on  the  one  hand,  all  conditions 
which  favor  the  development  and  accumulation  of  the  infecting  principle, 

1  The  Continued  Fevers,  by  J.  C.  Wilson,  M.D.,  1881. 

2  The  Continued  Fevers  of  Great  Britain,  by  Charles  Murchison,  M.D.,  LL.D.,  F.K.S., 
second  edition,  1873. 

»  De  la  Fievre  typhoide  chez  les  Enfants,  These,  1840. 

*  Journal  des  Connais.  med.-chir.,  Nov.-Dec.  1839,  Jan  v.  1840. 


ENTERIC   OR   TYPHOID    FEVER.  443 

aud,  ou  the  other  hand,  those  conditions  which  increase  the  susceptibility  of 
the  individual  to  the  cause  of  this  particular  fever  and  the  liability  of  his 
exposure  to  it.  The  etiological  considerations  relating  to  enteric  fever  are 
equally  applicable  to  childhood  and  to  adult  life. 

The  geographical  distribution  of  enteric  fever  is  wide.  This  disease 
has  been  observed  in  all  countries  aud  iii  every  climate.  It  is  endemic  in 
the  British  Isles,  in  almost  all  parts  of  Continental  Europe,  and  in  North 
America.  Hirsch^  has  reached  the  conclusion  that  its  general  prevalence 
in  Europe  and  America  dates  no  further  back  than  the  second  and  third 
decades  of  the  present  century, — that  is,  from  the  period  at  which  typhus 
[der  Petechialtyphus)  became  everywhere  less  common  and  in  many  regions 
disajjpeared  altogether.  In  America  it  prevails  as  the  common  fever  from 
Hudson's  Bay  to  the  Gulf  of  Mexico.  In  new  and  sparsely-settled  districts, 
where  the  land  is  being  gradually  brought  under  cultivation,  the  malarial 
fevers  occur ;  after  a  time,  as  populations  increase,  the  malarial  diseases  and 
enteric  fever  prevail  side  by  side ;  finally,  when  the  land  has  been  generally 
taken  up,  drained  and  tilled  for  some  generations,  aud  villages  and  cities 
abound,  the  malarial  diseases,  true  agues  and  remittents,  impress  communi- 
ties but  faintly  or  disappear  altogether,  while  enteric  fever  becomes  common 
and  asserts  itself  as  the  predominant  endemic  fever  in  proportion  to  the 
neglect  of  the  sanitary  measures  by  which  alone  it  can  be  kept  in  check  in 
populous  localities. 

Climate,  not  of  itself,  but  indirectly,  as  determining  the  mode  of  life 
in  communities,  has  a  manifest  influence  upon  the  extent  of  the  prevalence 
of  enteric  fever. 

Enteric  fever  is  by  no  means  confined  to  temperate  climates ;  it  is  far 
from  uncommon  in  tropical  and  subtropical  countries. 

The  season  of  the  year  is  a  predisposing  cause  of  great  im23ortance. 

Hirsch  found  that  519  epidemics  of  typhoid  fever  were  distributed 
among  the  seasons  as  follows :  in  the  spring,  29 ;  in  the  summer,  132  ;  in 
the  autumn,  168  ;  and  in  the  winter,  140.  Of  116  circumscribed  epidemics 
occurring  in  France  between  1841  and  1846  recorded  by  De  Claubrey,  20 
began  in  the  first  quarter  of  the  year,  21  in  the  second,  39  in  the  third, 
and  36  in  the  fourth.  The  number  of  cases  in  localities  where  the  disease 
is  endemic  is  usually  greatest  from  August  to  November,  decreasing  in 
December,  and  is  lowest  from  February  to  May,  again  increasing  in  June. 
This  fever  is  so  much  more  common  in  the  latter  part  of  the  year  tliat  it 
has  received  in  some  districts  of  the  United  States  the  popular  name  of 
"autumnal"  or  "  fall  fever." 

The  state  of  the  weather  as  regards  dryness  and  moisture  exerts  a  re- 
markable influence  upon  the  prevalence  of  enteric  fever.  Hot  and  dry 
summers  favor  the  development  of  the  disease,  cold  and  wet  summers  check 
it.     This  statement  is  supported  by  the  concurrent  testimony  of  observers 

'  Handbucli  der  historisch-geographischen  Pathologic,  Erluiigen,  1860. 


444  ENTERIC   OR   TYPHOID   FEVER. 

in  all  countries.  Dryness  of  the  atmosphere  alone  does  not,  however,  lead 
to  an  increase  of  enteric  fever.  In  cities  and  other  localities  possessed  of  a 
system  of  undergound  drainage,  warm  damp  weather  often  leads  to  an  out- 
break of  the  disease,  while  heavy  rainfalls  by  flushing  the  drains  reniove 
the  causes  to  which  its  origin  and  spread  are  chiefly  clue.  On  the  other 
hand,  outbreaks  of  enteric  fever  may  be  traced  to  the  influence  of  abundant 
rains  in  washino;  the  germs  of  the  disease  into  the  water  used  for  drinkino;- 
purposes,  particularly  where  the  water-supply  is  derived  in  part  from  tilled 
and  therefore  manured  fields. 

Pettenkofer  and  his  pupils  have  sought  to  establish  a  direct  relation 
between  the  prevalence  of  enteric  fever  and  the  height  of  the  deeper  springs 
of  water.  When  the  water  rises,  the  number  of  cases  of  enteric  fever 
decreases ;  when  the  water  sinks,  the  number  of  fever-cases  increases.  This 
relation  holds  true  for  Munich,  Berlin,  and  some  other  places.  It  has  not, 
however,  been  satisfactorily  explained.  The  observation  corresponds  with 
the  statement  above  made  that  enteric  fever  is  much  more  frequent  after  hot 
and  dry  sununers  than  after  cold  and  wet  ones.  These  observers  seek  to  ex- 
plain the  varying  prevalence  of  enteric  fever  in  connection  with  the  changes 
in  the  ground-water  by  the  assumption  that  the  ground-soil  is  the  chief  place 
of  development  for  the  schizomycetic  fungus.  When  the  water-level  sinks, 
the  layers  of  earth,  containing  moist  organic  substances  and  exposed  to  the 
air,  undergo  changes  which  lead  to  the  development  of  the  fever-poison ; 
when,  on  the  contrary,  the  water  rises,  these  layers  of  earth  are  again 
covered  and  the  development  of  the  germs  is  arrested. 

The  views  of  Pettenkofer  lack  confirmation  and  have  not  been  generally 
accepted. 

Age  is  of  great  importance  among  the  predisposing  causes  of  enteric 
fever.  This  affection  is  pre-eminently  a  disease  of  adolescence  and  early 
adult  life.  The  period  of  greatest  susceptibility  lies  between  the  ages  of 
fifteen  and  thirty,  and  the  liability  diminishes  progressively  both  above  and 
below  these  limits.  Cases  in  the  first  year  of  life  are  exceedingly  rare,  but 
from  this  period  through  infancy  and  childhood  the  liability  is  fully  estab- 
lished. In  1864,  Murchison  showed  at  the  London  Pathological  Society 
the  intestines  of  an  infant  six  months  old  Avho  had  been  attacked  at  the 
same  time  with  her  mother.  The  explanation  of  the  fact  that  the  propor- 
tion of  cases  occurring  in  infancy  is  smaller  than  that  of  childhood  and 
adolescence  is  to  be  sought  in  tlie  increased  exposure  to  the  infecting  principle 
at  the  later  periods. 

On  the  other  hand,  enteric  fever  is  not  common  in  advanced  life,  though 
well-authenticated  cases  in  persons  seventy,  eighty,  and  even  ninety  years 
of  age  have  been  reported.  The  infrequency  of  the  attack  in  the  later 
periods  of  life  is  doubtless  to  be  accounted  for  in  part  by  the  fact  that 
many  persons,  having  already  passed  through  the  disease,  enjoy  an  acquired 
immunity. 

Sex  in  childhood  exerts  no  influence  whatever  as  a  predisposing  cause. 


ENTERIC    OR   TYPHOID    FEVER.  445 

Statistics  that  have  been  from  time  to  time  adduced  to  show  that  the  dis- 
ease is  much  more  frequent  in  boys  than  in  girls  embody  the  fallacy  arising 
from  a  failure  to  appreciate  the  fact  that  beyond  the  age  of  infancy  girls 
are  much  less  exposed,  under  ordinary  circumstances,  to  the  infection  than 
boys.  The  latter  in  their  out-door  sports,  bathing,  swimming,  and  the  like, 
are  not  only  in  frequent  danger  of  inhaling  the  concentrated  emanations 
from  sewers  and  drains,  but  also  subject  to  the  liability  of  drinking  water 
directly  defiled  by  sewage. 

The  mode  of  life  is  also  without  influence.  Enteric  fever  is  as  common 
in  the  houses  of  the  affluent  as  in  the  most  crowded  and  destitute  localities. 

It  was  at  one  time  thought  that  some  sort  of  relationship  existed  be- 
tween enteric  fever  and  variola,  and  that  the  former  was  more  prevalent 
in  communities  protected  by  general  vaccination  than  those  less  fortunate 
in  this  respect.  This  opinion  is  now  known  to  be  devoid  of  foundation. 
The  suggestion  of  Harley  that  scarlatina  and  enteric  fever  are  different 
manifestations  of  the  same  poison,  but  that  enteric  fever  is  an  abdominal 
scarlatina,  is  likewise  untenable.  The  two  diseases  are  essentially  different 
in  their  causes,  course,  symptoms,  duration,  and  lesions. 

Habitual  exposure  to  the  poison  of  enteric  fever  in  small  amounts  ap- 
pears to  confer  an  immunity  from  the  disease.  Instances  are  recorded  where 
successive  visitors  at  the  same  house  at  intervals  of  months  or  even  years 
have  been  seized  shortly  after  their  arrival  with  enteric  fever  or  intestinal 
catarrh  from  which  the  ordinary  inhabitants  were  exempt.  Persons  changing 
their  residence  from  one  part  of  a  city  to  another  have  not  infrequently  been 
taken  with  enteric  fever,  and  persons  coming  from  the  country  into  cities 
very  frequently  become  the  subjects  of  the  disease.  The  French  observers 
strongly  insist  upon  recent  residence  as  a  predisposing  cause. 

2.  The  Exciting  Cause. — It  may  now  be  regarded  as  settled  that  the 
cause  of  typhoid  fever  is  a  specific,  organized,  pathogenic  germ. 

Numerous  observers — Eberth,  Klebs,  Koch — found  bacilli  in  Peyer's 
})atches,  the  mesenteric  glands,  and  the  spleen,  from  cases  of  this  disease. 
Eberth  gave  the  name  "  bacillus  typhosus"  to  an  organism  constantly  found 
in  the  affected  organs ;  but  a  species  described  by  Koch  and  extensively 
studied  by  Gaffky  ^  appears  to  be  the  only  one  constantly  present  in  this 
disease  which  is  not  known  to  occur  under  other  circumstances. 

The  last  observer  found  this  organism  in  the  mesenteric  glands,  liver, 
spleen,  and  kidneys  of  twenty-six  of  a  series  of  twenty-eight  cases  of  enteric 
fever  which  he  investigated.  Tiie  subjects  in  which  these  bacteria  were 
found  had  died  in  the  earlier  stages  of  the  disease.  Gaffky  was  unable  to 
determine  the  presence  of  the  typhoid  bacilli  in  the  blood  or  in  the  intes- 
tinal contents. 

Pfeifer,^  however,  claims  to  have  discovered  them  both  in  the  intestinal 


1  Mitth.  a.  d.  Kaiserl.  Gesund-Amt,  Bd.  ii.,  1884. 
'^  Deutsche  Medicin.  Wochenschr.,  1885,  No.  29. 


446 


ENTERIC  OR  TYPHOID  FEVER. 


contents  and  in  the  fascal  discharges.     Later  observers  have  found  them 
in  the  blood  and  in  the  albuminous  urine  of  typhoid  patients  during  life. 

The  bacilli  are  about  one-third  the  diameter  of  a  red  blood-corpuscle  in 
length,  and  about  three  times  as  long  as  broad  (2.5  : 0,8  p).     Their  ends  are 

blunt  and  rounded,  and  in  their 


interior  the  formation  of  spores 
can  sometimes  be  recognized. 
They  are  usually  found  lying 
in  little  clumps  in  tlie  organs. 
They  take  up  the  aniline  colors 
very  slowly  even  under  the  in- 
fluence of  heat.  The  bacillus 
typhosus  sometimes  occurs  in  the 
form  of  very  short  rods.  In 
cultures  it  develops  into  pseudo- 
filaments  which  are  motile  and 
probably  possess  flagella. 

Plate-cultures  on  gelatin  pre- 
sent a  peculiar  cloudy  appearance 
of  the  surface,  which  is  seen  to 
be  composed  of  minute,  super- 
ficial, grayish-white  colonies  with 
indented  borders.    Tube-cultures 
develop  in  the  course  of  a  few 
days  a  grayish-white  stripe  in  the  line  of  inoculation,  which  reaches  up  to 
the  colonies  extending  in  the  above-described  form  upon  the  surface  of  the 
culture-medium.     The  growth  does  not  liquefy  gelatin. 

The  form  of  growth  on  potatoes  is  characteristic.  After  forty-eight 
hours'  exposure  at  the  temperature  of  the  body,  the  surface  looks  moist  and 
glistening,  though  there  is  no  visible  growth.  Examination  of  the  film 
shows  it  to  be  made  up  of  long  threads  of  the  bacilli  containing  spores. 

The  formation  of  spores  occurs  in  about  four  days  at  a  temperature  be- 
tween 86°  and  108°  F.,  and  does  not  take  place  at  lower  temperatures. 

Inoculation  experiments  upon  animals  have  been  followed  by  unsatisfac- 
tory results.  Although  the  animals  have  sometimes  died,  the  characteristic 
lesions  of  typhoid  fever  have  not  been  produced, — a  fact  to  be  explained  by 
the  immunity  from  the  disease  possessed  by  the  species  of  animals  employed 
in  the  investigations.  FrankeP  and  Simonds  claim  to  have  produced  in 
rabbits  lesions  similar  to  those  occurring  in  man  by  the  injection  into  the 
blood  of  cultures  of  this  bacillus. 

This  micro-organism  which .  is  then  the  infecting  principle  of  enteric 
fever  is  invariably  derived  from  a  j^revious  case. 


'iSiii'/ti^Sli^ii^'^l^iSi^'"''!^^^^ 


Bacilli  of  Entekic  Fever  {Flugge).i    Section  of 
spleen,  X  800. 


1  General  Pathology,  Payne,  1888. 

2  Centralblutt  fur  Klin.  Medicin,  No.  44. 


ENTERIC    OR   TYPHOID    FEVER.  447 

The  doctrine,  so  ably  defended  by  Murchison  and  his  followers,  that  the 
specific  cause  of  this  disease  may  be  generated  de  novo  in  sewage  without 
the  presence  of  enteric  excreta,  is  no  longer  tenable.  There  is  no  proof 
whatever  that  enteric  fever  can,  in  the  absence  of  the  specific  pathogenic 
germ  above  described,  be  produced  by  the  products  of  decay  or  decompo- 
sition, by  tainted  food,  or  by  the  action  of  other  bacteria ;  nor  is  there  any 
reason  to  believe  that  typhoid  bacilli  can  be  developed  from  other  micro- 
organisms. 

When  introduced  into  the  human  body,  this  germ  is  capable,  under 
favorable  circumstances,  of  indefinitely  reproducing  itself.  It  is  eliminated 
with  the  fgecal  discharges.  It  retains  its  activity  when  it  has  found  its  way 
into  favorable  situations  for  an  indefinite  period  after  it  has  passed  out  of 
the  body,  the  requirements  to  this  end  being  decomposing  animal  matter, 
especially  fsecal  discharges  and  moisture ;  therefore  cesspools,  sewers,  drains, 
dung-heaps,  and  wet  manured  soils  favor  its  prolonged  existence.  It  is  capa- 
ble of  indefinite  multiplication  in  these  favorable  situations.  It  remains 
suspended  in  and  may  be  conveyed  by  water  and  milk.  These  fluids  become 
the  means  of  conveyance  for  the  enteric  fever  germ  to  the  interior  of  the 
organism.  It  is  probable  that  it  may  also,  under  certain  conditions,  float  in 
the  atmosphere  and  thus  occasionally  find  its  way  into  the  body  by  means 
of  the  inspired  air. 

This  germ  retains  its  power  of  growth  and  reproduction  within  wide 
ranges  of  temperature.  Prudden^  found  it  capable  of  growth  after  having 
been  frozen  in  ice  for  one  hundred  and  three  days  and  after  having  been 
heated  to  a  temperature  of  132.8°  F.  He  also  found  that  it  retained  its 
vitality  after  repeated  alternate  freezing  and  thawing.  The  investigations 
of  Seitz,  Wolfhiigel,  and  others  show  that  it  grows  abundantly  in  milk. 

The  fact  that  the  infecting  principle  of  enteric  fever  retains  its  vitality 
and  is  capable  of  multiplication  in  water  of  various  temperatures  has  been 
fully  established  by  the  great  number  of  carefully-studied  outbreaks  in  the 
past.  Among  others,  the  well-known  epidemic  of  North  Boston  in  1843, 
described  by  Dr.  Flint,^  the  epidemic  at  Lausen  in  the  canton  of  Basel, 
Switzerland,  in  1872,  and  the  extensive  outbreak  at  Plymouth,  Pennsyl- 
vania, in  1885,  have  attracted  especial  attention. 

It  remained,  however,  for  the  science  of  bacteriology  to  demonstrate  the 
presence  of  typhoid  bacilli  in  drinking-water  as  the  actual  visible  cause 
of  some  recent  outbreaks.  Arloing  and  Morat'^  found  this  germ  in  four  out 
of  six  specimens  of  drinking-water  taken  from  various  sources  of  supply 
at  a  school  in  Cluny  during  a  local  epidemic  of  enteric  fever,  comprising 
one  hundred  and  nineteen  cases,  with  twelve  deaths,  in  a  general  household 
of  two  hundred  and  thirty-five  persons. 

^  Medical  Record,  ix.,  1887. 

"  Treatise  on  the  Principles  and  Practice  of  Medicine,  Pliila.,  18G7. 
3  Annalcs  d'Hygiene  publiquo,  Nov.  1888. 


448  ENTERIC   OR    TYPHOID    FEVER. 

A  similar  result  followed  the  investigations  of  Rodet,  described  by 
Bondet/  in  regard  to  the  water-supply  of  Ville-sous-Charmoux,  the  scene 
of  a  limited  outbreak  of  the  disease  in  the  spring  of  1887. 

Finally,  Vaughan  and  Xo\y  ^  have  demonstrated  the  typhoid  bacillus,  by 
means  of  potato-cultures  and  by  physiological  experiment,  in  the  drinking- 
water  at  Iron  Mountain,  Michigan,  at  the  time  of  the  prevalence  of  a  severe 
epidemic. 

Our  knowledge  of  the  part  played  by  milk  as  a  means  of  transmission 
and  culture-medium  of  the  typhoid  bacillus  rests  upon  similar  facts. 

Ballard^  in  1871  called  attention  to  the  danger  of  infection  by  milk,  in 
a  valuable  report  concerning  a  local  epidemic  which  he  investigated,  with 
reference  to  its  cause,  as  health  officer  of  Islington.  This  outbreak  w'as 
apparently  due  to  the  use  of  water  defiled  by  direct  communication  with 
drains  and  probably  by  the  backing  up  of  the  contents  of  the  drains  into 
the  water-tank,  for  the  purpose  of  washing  the  milk-cans. 

Since  that  date  a  large  number  of  local  epidemics  have  been  traced  to 
infection  by  milk.  In  such  cases  the  probable  cause  is  not  a  disease  in  the 
cows,  but  an  admixture  of  defiled  water  with  the  milk,  either  intentionally, 
or  as  a  result  of  the  use  of  such  water  for  the  purpose  of  cleansing  milk-cans. 

Seitz*  and  Wolf  hiigel  and  RiedeP  found  that  the  typhoid  bacillus  grows 
abundantly  in  milk. 

Vaughan  and  Novy  obtained  a  poisonous  extract,  hereafter  to  be  men- 
tioned, both  from  milk  and  from  a  meat  preparation  which  had  been  inocu- 
lated with  water  containing  typhoid  bacillus. 

Philipowiez^  was  the  first  to  demonstrate  by  culture  the  existence  of 

'the  typhoid  bacillus  in  the  blood  of  patients.     He  obtained  blood  from  the 

spleen  by  capillary  puncture  under  antiseptic  precautions,  and  succeeded  in 

cultivating  the  bacillus  from  it.    His  observations  were  confirmed  by  Luca- 

tello,  Chantemesse  and  Widal,  and  other  observers. 

Neuhauss^  found  the  bacilli  in  the  blood  drawn  from  the  points  of 
eruption  in  nine  cases  out  of  fifteen,  and  succeeded  in  reproducing  them  by 
cultures. 

Efforts  to  obtain  cultures  from  the  blood  of  epistaxis  and  uterine  hemor- 
rhages during  the  course  of  the  fever  have  thus  far  failed. 

Wyssokowitsch^  injected  pure  cultures  of  the  typhoid  bacillus  into  the 

•     1  Lyon  Med.,  25  Dec,  1887. 

2  Experimental  Studies  on  the  Causation  of  Typhoid  Fever,  with  Special  Eeference  to 
the  Outbrealf  at  Iron  Mountain,  Mich.,  Medical  News,  January  28,  1888. 

3  On  a  Localized  Outbreak  of  Typhoid  Fever  in  Islington,  London,  1871. 
*  Archiv  fiir  Hygiene,  Bd.  vii. 

^  Arbeiten  aus  deni  Kaiserl.  Gesundheitsamte  zu  Berlin,  1886. 

^  Ueber  diagnostiche  Verwerlhung  der  Milzpunction  bei  Typhus  abdominalis,  Wien. 
Med.  Blatt,  1886. 

'  Nachweis  der  Typhusbacillen  am  Lebenden,  Berl.  Klin.  Wochcnschr.,  1886. 

8  Ueber  die  Schicksale  der  im  Blut  injicirten  Mikroorganismen  im  Korper  der  Warm- 
bliitter,  Zeitschr.  f.  Hvg.,  1886. 


ENTERIC    OR   TYPHOID    FEVER.  449 

veins  of  a  rabbit.  The  animal  in  eighteen  hours  was  killed,  and  investi- 
gations into  the  distribution  of  the  bacilli  were  made  by  plate-cultures 
upon  gelatin.  The  plates  inoculated  with  the  blood  of  the  heart  remained 
sterile ;  those  inoculated  with  the  blood  of  the  liver  produced  twelve  colo- 
nies ;  those  with  the  marrow  of  the  bone,  two  hundred  colonies ;  finally, 
the  inoculations  made  from  the  spleen  produced  two  hundred  and  forty-two 
colonies. 

These  experiments  indicate  that  the  typhoid  bacillus  does  not  remain  in 
the  blood,  but  tends  to  collect  in  particular  organs,  especially  the  liver,  the 
marrow,  and  the  spleen. 

The  researches  of  Chantemesse  and  Widal  and  Neuhauss  seem  to  estab- 
lish the  fact  that  the  microbe  in  question  is  able  to  pass  by  way  of  the 
placenta  from  the  blood  of  the  mother  to  that  of  the  foetus. 

The  period  of  incubation  varies  within  wide  limits.  Its  precise  deter- 
mination in  any  given  case  is  by  no  means  so  simple  a  matter  as  would  at 
first  sight  appear.  In  an  outbreak  which  occurred  at  Guildford,  England, 
in  1867,  the  contaminated  water  which  was  the  cause  of  the  infection  was 
supplied  on  a  single  day,  the  17th  of  August.  A  large  number  of  cases  came 
under  observation  on  the  3d  and  4th  of  September, — a  period  of  incubation 
apparently  covering  seventeen  or  eighteen  days.  The  possibility  that  the 
water  may  have  been  partaken  of  a  day  or  two  later  than  the  17th  of 
August  is  obvious,  and  the  fact  is  not  to  be  overlooked  that  there  are  few 
cases  which  come  under  observation  upon  the  first  appearance  of  the  dis- 
ease ;  so  that  in  this  case,  which  is  one  of  the  most  definite  upon  record, 
the  apparent  is  longer  than  the  actual  period  of  incubation,  and  longer  by 
a  number  of  days  not  possible  to  determine. 

On  the  other  hand,  there  are  facts  tending  to  show  that  this  period  may 
be  as  short  as  two  or  four  or  eight  days.  A  case  has  recently  occurred 
under  my  observation  in  the  wards  of  the  Philadelphia  Hospital  in  which 
the  first  rise  in  temperature  took  place  on  the  fourth  day  after  the  return  of 
the  patient  from  twenty-four  hours'  leave  of  absence  from  the  wards.  This 
patient  had  been  long  resident  in  the  hospital,  in  which  there  was  not,  at  that 
time,  nor  had  been  for  many  weeks  previously,  a  single  case  of  enteric  fever. 

That  enteric  fever  is  contagious  in  the  ordinary  sense  may  well  be 
doubted,  although  from  time  to  time  cases  arise  which  appear  to  be  expli- 
cable upon  no  other  hypothesis  than  that  of  direct  communication. 

The  o(!currence  of  house-epidemics  is  to  be  explained  by  infection  at 
the  same  time  or  in  quick  succession  of  a  number  of  individuals  from  the 
same  source ;  of  cases  developing  in  patients  occupying  beds  adjacent  to 
that  of  an  enteric  fever  case  in  the  wards  of  a  hospital,  by  the  conveyance 
of  infecting  material  contained  in  the  faecal  discharges  from  one  patient  to 
another  through  tlic  neglect  or  carelessness  of  the  attendants. 

In  the  Children's  Hospital  at  BaseP  there  were  treated  during  fifteen 

1  E.  Hagenbach-Burckhiirdt,  Jahrlnuli  Air  Kindcrhcilkumle,  N.  F.,  xxiv.,  1886. 
Vol.  I.— 29 


450  ENTERIC    OR   TYPHOID    FEVER. 

years  two  hundred  and  ninety-three  cases  of  enteric  fever  without  special 
separation  from  the  other  inmates  of  the  hospital ;  during  this  period  there 
occurred  eight  cases — namely,  2.46  per  cent. — of  house-infection,  viz. :  in 
the  year  1872,  three  cases;  in  the  year  1873,  one  case;  in  the  year  1875, 
one  case;  in  the  year  1878,  one  case;  and  in  the  year  1883,  two  cases.  In 
one  instance  a  child  suifering  from  hip-joint  disease  that  had  been  in  the 
wards  two  months,  no  case  of  enteric  fever  having  been  during  that  time  in 
the  hospital,  developed  the  disease  :  concerning  the  source  of  the  infection 
in  this  case,  no  theory  could  be  advanced.  In  four  other  instances  there 
was  at  the  time  of  the  house-infection  a  case  of  enteric  fever  in  the  same 
ward.  In  two  instances  there  were  at  the  time  of  the  development  of  the 
disease  cases  of  enteric  fever  in  the  hospital,  though  not  in  the  same  ward. 
Enteric  fever  developed  in  two  instances  of  patients  suifering  from  spondy- 
litis; twice  in  patients  suffering  from  chronic  inflammation  of  the  knee- 
joint;  once  in  hip-joint  disease  ;  once  in  a  case  of  nephritis ;  and  once  in  a 
case  of  multiple  osteitis.  It  is  worthy  of  note  that  patients  suffering  from 
diseases  of  the  bones  occupied  the  first  rank  among  the  victims  of  the 
typhoid  infection.  Of  the  eight  cases  developed  in  the  hospital,  a  single 
one — namely,  the  patient  suifering  from  nephritis — terminated  fatally.  The 
enteric  fever  cases  manifested  during  their  convalescence  a  special  liability 
to  other  infectious  disease,  among  which  diphtheria  occupied  the  first  rank. 
Of  the  two  hundred  and  ninety-three  cases  of  enteric  fever,  twenty-six,  or 
8.8  per  cent.,  died ;  among  these  twenty-six  fatal  cases  the  cause  of  death 
in  seven  was  diphtheria  or  scarlet  fever  developed  at  the  end  of  the  attack 
or  during  the  convalescence.  The  elimination  of  these  seven  cases  reduces 
the  enteric  fever  mortality  to  6.4  per  cent. 

Pathology. — The  bacilli  or  spores,  being  swallowed,  gain  entrance  to 
the  organism  by  means  of  the  intestine.  This  may  be  assumed  to  be  the 
case  even  in  those  instances  where  the  germs  reach  the  organism  by 
means  of  the  inspired  air,  as  it  is  probable  that  they  are  engaged  in  the 
mucus  of  the  mouth  and  then  swallowed.  If  not  destroyed  in  the  stom- 
ach, the  bacilli  retain  their  vitality,  pass  on  into  the  alkaline  contents  of 
the  intestine,  and  here  find  conditions  favorable  to  their  further  develop- 
ment. 

In  cases  examined  post  mortem  in  the  earliest  stages  of  the  disease,  the 
lesions  are  mainly  confined  to  the  lymphatic  tissues  of  the  intestine.  The 
bacilli  penetrate  into  the  solitary  follicles  and  Peyer's  patches  and  there 
multiply  and  form  colonies.  From  these  colonies  they  migrate  by  way  of 
the  lymphatic  vessels  to  the  mesenteric  ganglia,  and  by  way  of  the  radicles 
of  the  superior  mesenteric  vein  to  the  liver,  to  be  finally  distributed  by  the 
blood-current  to  the  spleen  and  other  organs. 

A  knowledge  of  the  causative  influence  of  the  typhoid  bacilli  in  the 
production  of  enteric  fever  and  of  the  mode  of  distribution  of  these  germs 
in  the  various  organs  fails  to  account  adequately  for  the  symptoms  of  the 
disease.    When,  however,  it  came  to  be  known  as  a  result  of  the  discoveries 


ENTERIC   OR    TYPHOID    FEVER.  451 

of  Hoifa/  Brieger,^  Vaiigiian,^  and  others  withiD  the  last  few  years,  that  in 
the  infectious  diseases  the  special  pathogenic  micro-organisms  produce  the 
definite  chemical  poisons  called  ptomaines,  the  relation  between  these  germs 
and  the  symptomatology  of  the  diseases  which  they  cause  became  obvious. 

In  1885,  Brieger  isolated  from  pure  cultures  of  the  typhoid  bacillus  a 
toxic  ptomaine.  This  substance  injected  into  guinea-pigs  produced  a  slight 
flow  of  saliva,  accelerated  respiration,  dilatation  of  the  pupils,  profuse  diar- 
rhoea, paralysis,  and  death  in  the  course  of  from  twenty-four  to  forty-eight 
hours.  Upon  post-mortem  examination,  the  heart  was  found  to  be  in 
systole,  the  lungs  deeply  congested,  and  the  intestines  contracted  and  pale. 

Brieger  considers  this  substance,  to  which  he  has  given  the  name 
"  typho-toxine,"  to  be  the  special  poison  of  enteric  fever. 

In  1887,  Yaughan  and  Xovy  obtained  from  pure  cultures  of  the  typhoid 
bacillus,  derived  from  the  drinking-water  which  had  been  the  supply  of  a 
large  number  of  persons  who  had  the  disease,  a  syrupy  extract,  which  in- 
jected under  the  skin  of  cats  caused  an  elevation  of  temperature  from  2°  to 
4.5°  F.  above  the  normal.  Similar  results  were  obtained  by  Sirotinin,^ 
Beumer,  and  Peiper®  by  inoculating  animals  with  sterilized  cultures  of  the 
germ.  These  observers  found  that  the  severity  of  the  symptoms  varied  in 
proportion  to  the  amount  of  the  culture  injected. 

In  view  of  these  facts,  Vaughan  and  Novy  have  suggested  a  new  defi- 
nition for  the  infectious  disease :  "  An  infectious  disease  arises  when  a 
specific  pathogenic  micro-organism,  having  gained  admittance  to  the  body, 
and  having  found  the  conditions  favorable,  grows  and  multiplies,  and  in  so 
doing  elaborates  a  chemical  poison  which  induces  its  characteristic  eifects." 

It  is  probable  that  certain  of  the  intestinal  symptoms  of  enteric  fever 
are  due  to  the  direct  action  of  the  typhoid  bacillus ;  but  the  constitutional 
symptoms,  including  the  fever,  must  be  explained  by  the  continuous  action 
of  a  chemical  poison  produced  by  the  growth  and  multiplication  of  these 
organisms  within  the  body ;  especially  is  this  true  of  the  nervous  and  vaso- 
motor phenomena,  the  feeble  circulation,  dicrotism,  relaxed  capillaries, 
flushed  face,  dilated  pupils,  and  delirium. 

Pathological  Anatomy. — Enteric  fever  diifers'  from  the  other  con- 
tinued fevers,  with  the  exception  of  cerebro-spinal  fever,  in  the  invariable 
presence  of  special  anatomical  lesions.  These  lesions  are  so  characteristic 
that  an  examination  of  the  body  after  death  will  in  all  cases  make  known 
the  nature  of  the  disease,  even  when  the  symptoms  have  been  or  were 
unknown. 

It  is  important,  however,  to  bear  in  mind  that  the  lesions  of  the  intes- 
tine and  of  the  mesenteric  glands  do  not  constitute  the  disease,  but  that  the 
chemical  poison  produced  by  its  specific  cause  is  taken  up  by  the  fluids  of 


^  Die  Natur  des  Milzbrandsgiftes,  Wiesbaden,  1886. 
2  L.  Brieger,  Ueber  Ptomaine,  Berlin,  1885-1886. 

*  Ptomaines  and  Leucomaines,  1888. 

*  Zeitschr.  fiir  Hygiene,  i.  *  Idem. 


452  EXTEEIC   OR   TYPHOID    FEVER. 

the  body  and  gives  rise  to  general  disturbances,  which  are  present  in  all 
fully-developed  cases,  and  which  manifest  themselves  at  a  very  early  period 
in  the  attack.  The  more  important  symptoms  of  enteric  fever  are  directly 
attributable  to  the  general  process,  and  not  to  the  special  lesions. 

The  anatomical  lesions,  therefore,  fall  naturally  into  two  groups. 

The  first  embraces  those  arising  from  the  local  action  of  the  typhoid 
bacilli  and  the  concentrated  ptomaine  which  they  produce,  and  includes 
changes  in  the  lymphatic  system  of  the  intestinal  canal. 

The  second  group  includes  lesions  which  are  not  the  direct  result  of  the 
local  action  of  the  bacilli,  but  are  due  to  constitutional  infection.  They 
consist  of  degenerative  changes  involving  the  tissues  of  the  various  organs, 
and  are  to  be  found  generally  manifested  throughout  the  body,  and  particu- 
larly in  the  liver,  the  kidneys,  the  voluntary  muscles,  the  heart,  the  salivary 
glands,  and  the  pancreas. 

The  marked  disturbances  in  the  function  of  the  nervous  system  indicate 
profound  nutritive  derangement,  the  nature  of  which  is  at  present  unknown. 

The  changes  of  the  second  group  are  not  peculiar  to  enteric  fever ;  they 
occur  in  other  acute  febrile  diseases,  and  must  be  ascribed  to  the  action  of 
the  various  special  toxic  principles  to  which  the  phenomena  of  such  diseases 
are  due.  These  anatomical  changes  attain  their  fullest  development  in 
enteric  fever,  however,  for  the  reason  that  in  this  disease  the  organism  is 
continuously  subjected  to  the  action  of  these  toxic  principles  for  a  prolonged 
period. 

As  the  following  description  is  intended  to  present  to  the  reader  not 
only  the  conditions  which  obtain  in  ordinary  cases,  but  also  those  which 
are  occasional  and  exceptional,  it  is  based  upon  the  well-recognized  lesions 
of  adult  life  taken  as  a  type.  This  course  is  necessary  for  the  reason  that 
while  the  anatomical  changes  in  childhood  are,  as  a  rule,  less  fully  devel- 
oped, this  is  a  rule  to  which  there  are  not  infrequent  important  exceptions. 

The  same  course  will  be  followed  in  the  description  of  the  clinical  phe- 
nomena of  the  disease. 

Cadaveric  rigidity  is  usually  marked  and  of  long  duration.  Emaciation 
is  often  extreme.  The  integuments  and  the  dependent  parts  of  the  body 
are  apt  to  be  more  or  less  discolored,  but  the  deep  livid  discoloration  of 
typhus  is  rare.  Except  where  death  has  taken  place  in  consequence  of  pul- 
monary complications,  the  face  is  seldom  livid.  The  characteristic  rash 
of  enteric  fever  is  not  often  observed  on  the  body,  even  in  those  cases  where 
the  spots  have  been  numerous  immediately  before  death.  Sudamina  and 
other  accidental  eruptions  persist. 

The  lesions  in  childhood  are,  as  a  rule,  less  extensive  and  conspicuous 
than  in  adults,  just  as  the  disease  itself  is  less  intense.  They  have  been  also 
less  thoroughly  studied,  by  reason  of  the  favorable  course  of  the  disease  in 
childhood  and  the  consequent  low  rate  of  mortality.  Exceptionally,  how- 
ever, the  local  changes  attain  their  full  development  in  childliood. 

The  Digestive  Tract. — The   pharyngeal   mucous   membrane  is  usually 


ENTERIC    OR    TYPHOID    FEVER.  453 

normal;  occasionally,  however,  it  exhibits  signs  of  recent  inflammation, 
and  sometimes  distinct  points  of  ulceration.  The  pharynx  may  also  be  the 
seat  of  diphtheritic  exudation.  Occasionally  the  oesophagus  shows  evidences 
of  ulcerative  processes  similar  to  those  met  with  in  the  pharynx.  These 
ulcers  are  massed  at  the  cardiac  extremity  of  the  oesophagus,  and  vary  from 
simple  excoriations  to  deep  lesions  implicating  the  muscular  coat.  The 
foreo-oino-  chano-es  are  not  found  when  death  occurs  earlier  than  the  third 
week  of  the  disease,  and  are  extremely  rare  in  childhood. 

Inflammation  of  the  mucous  membrane  of  the  stomach  is  common  in 
typhoid  as  in  other  acute  febrile  diseases. 

The  duodenum  usually  presents  no  anatomical  changes.  Sometimes  it 
exhibits  the  evidence  of  increased  vascularity,  with  slight  enlargement  of 
the  mucous  follicles.     Ulceration  does  not  occur. 

The  jejunum  and  the  upper  part  of  the  ileum  may  be  distended  with 
gas ;  the  lower  portion  of  the  ileum  is  usually  collapsed. 

The  tvmpany  which  belongs  to  the  disease  is  chiefly  due  to  the  presence 
of  gas  in  the  colon.  Invagination  of  the  intestine,  unaccompanied  by  the 
evidences  of  inflammation,  is  occasionally  met  with  at  one  or  more  points. 

The  constant  and  therefore  characteristic  lesion  is  an  affection  of  the 
solitary-  and  agminate  glands  in  the  lower  part  of  the  ileum.  The  lymphatic 
follicles  of  the  caecum  are  usually  involved,  and  not  infrequently  those  of 
the  colon  also. 

First  Stage. — The  earliest  change  observed  is  a  swelling  of  the  glands, 
wath  surrounding  hypergemia.  The  Peyer's  patches  project  above  the  surface 
of  the  surrounding  mucous  membrane  in  the  form  of  flattened,  oval  plaques 
with  a  reticulated  or  irregularly  mammillated  surface  and  elevated  margins. 
The  solitar}^  follicles,  which  are  not  constantly  implicated,  form  when 
affected  discrete,  shot-like  projections  varying  in  diameter  from  one-eighth 
to  one-fourth  of  an  inch.  These  changes  are  always  progressively  more 
advanced  in  the  lower  part  of  the  ileum,  reaching  their  full  development  in 
the  neighborhood  of  the  ileo-c?ecal  valve.  This  glandular  swelling  is  due 
to  extensive  hyperplasia  of  the  lymphatic  elements.  The  cellular  infiltra- 
tion extends  downward  into  the  sul)mucous  tissue,  but  at  the  borders  of 
the  patches  is  more  or  less  abruptly  limited.  It  attains  its  maximum  about 
the  end  of  the  first  week. 

It  is  probable,  for  reasons  to  be  hereafter  mentioned  in  connection  with 
the  discussion  of  the  subject  of  the  temperature-range,  that  the  glandular 
lesion  in  a  considerable  proportion  of  the  cases  in  childhood  at  this  time 
undergoes  resolution  without  ulceration. 

Second  Stage. — The  infiltrated  lymphatic  tissue  now  undergoes  necrosis. 
The  mass  changes  to  a  dirty-yellow  color  and  becomes  more  opaque,  and 
the  lymphatic  follicles,  with  the  epithelium  covering  them  and  some  of  the 
surrounding  tissue,  break  doM'n  at  scattered  points,  so  as  to  form  an  irregular 
or  ragged  ulcerated  surfiice,  or  oi  ina.s.^p  into  one  large  slough.  Tliis  slough, 
stained  a  deep  yellow  or  brown  by  the  intestinal  contents,  remains  for  a 


454  ENTERIC  OR  TYPHOID  FEVER. 

time  attached.  It  is  separated  by  an  abrupt  line  of  demarcation  from  the 
deeply-congested  surrounding  tissue.  It  is  then  gradually  cast  off,  either 
in  a  single  piece  or  in  fragments.  This  process  occupies  another  week,  so 
that  the  separation  of  the  slough  takes  place  at  the  end  of  the  second  or 
early  in  the  third  week.  In  the  greater  number  of  instances  of  enteric 
fever  in  childhood  the  sloughs  are  superficial  and  of  limited  extent,  and 
the  ensuing  ulceration  undergoes  prompt  cicatrization. 

Third  Stage. — The  ulcer  thus  formed,  as  a  rule  in  adults,  but  exception- 
ally in  childhood,  has  a  smooth  floor,  and  abrupt  and  to  a  certain  extent 
overhanging  edges.  The  bevelled  margins  seen  in  tubercular  ulcers  of  the 
intestine  do  not  occur. 

The.  ulcer  when  deep  involves  the  greater  part,  usually  the  whole, 
of  the  Peyer's  patch.  Its  base  is  usually  formed  by  the  muscular  coat, 
but  occasionally  this  is  also  destroyed,  so  that  the  peritoneum  alone  forms 
its  floor.  The  process  in  the  solitary  glands  is  the  same.  The  ulcerative 
process  may  involve  a  small  artery  and  give  rise,  upon  the  separation  of  the 
slough,  to  a  more  or  less  copious  or  even  fatal  hemorrhage.  Or  perforation 
of  the  wall  of  the  intestine  may  occur  from  an  implication  of  the  serous 
coat,  permitting,  unless  immediate  adhesions  by  plastic  lymph  to  neigh- 
boring parts  occur,  extravasation  of  the  intestinal  contents,  with  the  pro- 
duction of  purulent  peritonitis. 

The  process  above  described,  when  confined  to  the  agminate  glands,  pro- 
duces oval  lesions,  the  longer  axis  of  which  corresponds  to  the  direction  of 
the  bowel,  and  the  position  of  which  is  opposite  to  the  mesenteric  attach- 
ment ;  when  the  solitary  follicles  are  involved,  the  lesions  are  small,  circular, 
and  irregularly  scattered. 

The  hyperplasia  of  the  lymph-elements  is  due  to  the  growth  and  multi- 
plication of  the  typhoid  bacilli ;  their  necrosis  and  the  subsequent  ulceration, 
in  part  to  the  bacilli  themselves  and  in  part  to  the  irritating  efifects  of  the 
concentrated  ptomaine  produced  at  the  place  of  its  formation.^ 

Cases  have  occasionally  been  reported  in  which  irregular  ulceration  has 
extended  laterally  from  the  Peyer's  patch,  transversely  involving  a  consider- 
able extent  of  the  bowel.  This  form  of  ulceration  is,  as  a  rule,  superficial ;  ex- 
ceptionally, however,  it  is  deep  and  may  ultimately  give  rise  to  a  perforation 
of  the  intestine.  It  is  without  doubt  due  to  an  accidental  local  infection 
of  an  entirely  different  nature,  and  usually  much  prolongs  the  intestinal 
symptoms  and  constitutional  disturbances  of  the  period  of  convalescence. 

Cicatrization  in  adults  does  not  begin  until  after  the  third  Aveek,  and 
probably  occupies  a  period  of  two  or  three  weeks  before  it  is  completed. 
The  ulcers  heal  by  granulation  with  restoration  of  the  epithelium  ;  the  lym- 
phatic structures,  however,  are  permanently  destroyed.  The  resulting  scar 
is  thin,  transparent,  and  flexible,  and  does  not  lead  to  puckering  of  the 
tissue  of  the  bowel  nor  to  constriction. 


1  Vauglian  and  Novy,  op.  cit.,  pp.  93-107. 


ENTERIC  OR  TYPHOID  FEVER.  455 

The  mesenteric  vessels  connected  with  the  affected  portions  of  intestine 
are  distended  and  hypersemic. 

The  mesenteric  glands  undergo  changes  histologically  the  same  as  those 
which  take  place  in  the  lymphatic  structures  of  the  intestine.  In  the  early 
stages  of  the  disease  they  are  highly  vascular  and  enlarged,  as  a  result  of 
lymphatic  hyperplasia ;  later  they  become  pale  and  undergo  necrotic  changes. 
The  ordinary  termination  of  the  process,  however,  is  in  complete  resolution. 

If,  however,  the  softening  be  considerable,  resorption  does  not  always 
take  place,  but  the  softened  material  undergoes  cheesy  metamorphosis  and 
ultimately  becomes  calcareous.  Sometimes  the  softening  results  in  the  for- 
mation of  pseudo-abscesses,  which  may  burst  into  the  peritoneal  cavity  and 
give  rise  to  general  peritonitis.  The  other  lymphatic  glands,  particularly 
those  in  the  fissure  of  the  liver,  and  the  retro-peritoneal  and  bronchial 
glands,  are  occasionally  found  enlarged. 

Fagge^  expresses  a  strong  feeling  of  doubt  as  to  the  correctness  of  the 
generally-accepted  statement  that  caseation  or  the  deposition  of  calcareous 
salts  forms  part  of  the  ordinary  retrograde  process. 

The  lymphatic  follicles  at  the  root  of  the  tongue  and  in  the  tonsils 
undergo  changes  analogous  to  those  described,  giving  rise  to  enlargements, 
which  appear  early  in  the  course  of  the  disease  and  usually  disappear 
without  further  change,  although  in  some  cases  softening,  rupture,  and 
subsequent  ulceration  result. 

The  changes  in  the  spleen  are  analogous  to  those  which  take  place  in 
the  lymphatic  follicles  of  the  intestine  and  in  the  mesenteric  glands.  The 
organ  is  enlarged,  tense,  and  hypersemic.  In  the  early  periods  of  the 
disease  it  is  of  moderate  consistence ;  later  its  tissue  is  soft,  pulpy,  or  often 
diffluent.  On  section,  its  substance  is  of  a  brownish-red  color.  Hemor- 
rhagic infarcts  are  often  met  with.  The  enlarged  and  softened  spleen  in  the 
later  stages  of  enteric  fever  is  liable  to  be  ruptured  by  mechanical  force  in 
palpation,  and  in  some  instances  it  has  undergone  spontaneous  rupture. 
Enlargement  of  the  spleen  is  rarely  absent  in  the  young. 

The  second  group  of  anatomical  changes  comprises  parenchymatous 
degenerations  of  the  various  organs  of  the  body.  These  changes  are  to  be 
ascribed  in  part  to  the  action  of  the  toxic  infecting  principle,  and  in  part  to 
the  intensity  and  long  duration  of  the  febrile  movement.  Though  reaching 
their  higliest  development  in  fatal  cases  of  enteric  fever,  they  are  not  con- 
fined to  that  disease,  nor  are  they  characteristic  of  it. 

The  liver  is  occasionally  hyperaemic,  but,  as  a  rule,  it  is  normal  in 
appearance ;  exceptionally  it  is  pale.  Its  tissue  is  often  softened,  and  upon 
microscopical  examination  the  cells  are  found  to  be  granular  and  their 
nuclei  indistinct  or  no  longer  to  be  seen.  The  amount  of  bile  is  usually 
diminished,  and  in  the  later  periods  of  the  disease  it  is  thin  and  almost 
colorless. 

'  The  I'rinc'ipli-s  und  Practice  of  Medicin*.',  1880. 


456  ENTERIC  OR  TYPHOID  FEVER. 

The  kidneys  also  show  parenchymatous  degeneration.  The  epithelium 
becomes  granular,  the  contour  of  the  cells  indistinct,  and  the  nuclei  dis- 
appear. These  changes  aifect  first  the  cortex,  later  the  pyramids.  In  many 
cases  they  are  but  little  marked.  They  are  usually  associated  with  albu- 
minuria:  Liebermeister^  states,  however,  that  he  has  repeatedly  noted  the 
absence  of  albuminuria  throughout  the  whole  course  of  the  disease  where  at 
the  autopsy  advanced  degeneration  of  the  kidneys  was  discovered. 

Endocarditis  and  pericarditis  are  rare.  As  Strumpell  ^  has  pointed  out, 
the  slight  mitral  endocarditis  sometimes  found  at  the  autopsy  has  little 
clinical  significance.  On  the  other  hand,  the  myocardium  shares  in  the 
general  atrophy  which  accompanies  the  disease.  The  heart  becomes  re- 
laxed and  flabby.  In  addition  to  this  simple  atrophy,  the  myocardium 
undergoes  parenchymatous  or  fatty  degeneration.  This  change,  according 
to  Payne,^  consists  of  three  processes :  1,  interstitial  inflammation ;  2,  de- 
generation of  the  muscular  fibres ;  3,  regeneration  of  the  same. 

The  first  two  must  be  regarded  as  simultaneous  effects  of  the  typhoid 
poison  acting  on  different  tissues,  the  last  as  a  subsequent  process. 

1st.  The  interstitial  inflammation  shows  itself  in  the  form  of  a  small- 
celled  infiltration  in  the  connective  tissue  of  the  muscle.  Rindfleisch  called 
attention  to  the  fact  that  the  cells  are  somewhat  larger  than  ordinary  lymph- 
or  pus-corpuscles,  and  suggests  an  analogy  between  this  process  and  the 
lymphatic  hyperplasia  of  the  intestines  and  glands  above  described. 

2d.  Many  muscular  fibres  undergo  a  peculiar  form  of  degeneration. 
The  muscle-substance,  after  passing  through  a  stage  of  cloudy  swelling, 
loses  its  striation  and  becomes  translucent  or  vitreous.  This  change  is 
perhaps  less  frequent  in  the  heart  than  in  the  voluntary  muscles.  In  the 
former,  minute  granules  are  deposited  in  the  muscular  tissue. 

3d.  The  degenerative  fibres  are  slowly  absorbed,  but  in  the  mean  while 
there  are  always  seen  along  with  them  other  immature  or  newly-formed 
fibres,  indicating  a  regeneration  of  the  muscular  tissue.  This  new  formation 
apparently  takes  place  within  the  sarcolemma  from  the  persistent  nuclei. 

The  whole  of  the  destroyed  tissue  is,  not  always  restored,  so  that  a  gap 
partly  filled  by  fibrous  tissue  remains.  In  its  higher  degrees,  this  degenera- 
tion gives  rise  to  changes  in  the  muscular  tissue  of  the  heart  that  are  easily 
recognizable  by  the  unaided  eye. 

The  heart  is  soft  and  of  a  pale-yellow  or  yellowish-gray  color,  strongly 
in  contrast  with  the  bright-red  hue  of  the  voluntary  muscles.  Its  tissue  is 
easily  torn,  and  the  organ  thrown  upon  the  table  settles  down  into  a  form- 
less mass. 

Cardiac  thrombi  are  sometimes  present,  and  may  cause  embolism  of  the 
lungs,  spleen,  kidneys,  and  other  organs. 


1  Ziemssen,  Cyclopaedia  of  Medicine,  vol.  i. 
^  Practice  of  Medicine,  Amer.  ed.,  1887. 
3  Manual  of  General  Pathology-,  1888. 


ENTERIC    OR    TYPHOID    FEVER.  457 

Fatty  degeneration  of  the  minute  arteries  of  the  brain,  kidneys,  and 
other  organs  was  demonstrated  by  Hoifmann,  who  also  called  attention  to 
the  frequency  with  which  thickening  and  opacity  of  the  inner  coat  of  the 
larger  vessels,  and  particularly  of  the  pulmonary  arteries,  occur.  The  blood 
is  dark-colored,  and  there  are  numerous  small,  soft  coagula.  If  death  take 
place  in  the  latest  stage  of  the  disease  or  during  convalescence,  the  vessels 
are  frequently  nearly  empty,  the  blood  thin  and  watery,  and  the  tissues  j 
oedematous. 

Changes  in  the  voluntary  muscles,  similar  to  those  already  described  as 
occurring  in  the  muscular  tissue  of  the  heart,  are  of  very  frequent  occur- 
rence. They  were  originally  described  by  Zenker,^  who  distinguished  two 
forms :  first,  a  granular  degeneration  which  in  its  highest  degree  does  not 
differ  from  ordinary  fatty  degeneration ;  second,  a  waxy  or  fibrous  degen- 
eration by  which  the  muscle-substance  is  converted  into  a  glazy,  colorless 
mass.  The  former  is  more  frequent,  but  the  two  forms  are  often  associated, 
sometimes  one  and  sometimes  the  other  predominating.  The  swollen  and 
vitreous  fibres  break  up  into  polygonal  masses,  i:)robably  through  the  con- 
traction of  neighboring  fibres  which  are  not  affected.  Transverse  ruptures 
of  large  bundles  sometimes  occur,  producing  hemorrhage  or  pseudo-abscesses 
in  the  substance  of  the  muscular  masses. 

The  muscles  most  commonly  affected  are  the  recti  abdominis,  the  adduc- 
tors of  the  thigh,  the  pectoral  muscles,  the  diaphragm,  and  the  tongue.  All 
the  voluntary  muscles  may,  however,  be  affected  to  some  extent.  These 
changes  are  most  marked  usually  after  two,  three,  and  four  weeks.  They 
are  not  peculiar  to  enteric  fever,  but  occur  in  other  severe  febrile  diseases. 

The  salivary  glands  and  pancreas  are  frequently  found  to  have  under- 
gone parenchymatous  degeneration  analogous  to  that  which  occurs  in  the 
other  glandular  structures  of  the  body. 

The  organs  of  respiration  show  no  anatomical  changes  peculiar  to  enteric 
fever. 

The  epiglottis  is  congested,  sometimes  ulcerated  or  (Edematous,  or,  if 
diphtheria  complicates  the  case,  it  may  be  the  seat  of  diphtheritic  exudation. 

The  larynx  may  be  the  seat  of  more  or  less  extensive  ulceration. 

The  trachea  is  usually  normal  in  appearance,  or  somewhat  congested. 

In  the  bronchial  tubes  those  changes  are  met  -with  which  underlie  the 
various  forms  of  bronchial  catarrh  occurring  in  other  diseases. 

The  lungs  almost  constantly  present  changes  referable  to  the  enfeeble- 
raent  of  the  circulation  and  the  blunted  condition  of  the  nervous  system. 
Hypostasis  is  very  frequent;  it  is  limited  to  the  more  dependent  portions 
of  the  lungs.  More  or  less  extensive  lobular  pneumonia  of  the  nature  of 
the  so-called  inhalation  pneumonia  is  often  present.  Pulmonary  oedema  is 
common.     The  bronchitis  sometimes  takes  on  a  putrid  character,  and  the 

^  TJeber  die  Veranderungen  der  willkvirlichen  Muskeln  im  Typhus  abdominalis,  Leip- 
zig, 1864. 


458  ENTERIC  OR  TYPHOID  FEVER. 

lobular  infiltrations  may,  in  severe  cases,  be  transformed  into  genuine  gan- 
grene. Lobar  pneumonia  also  occurs,  not  only  as  a  complication,  but  in 
certain  instances  at  the  onset  of  the  disease,  under  circumstances  which 
render  it  probable  that  it  is  a  prominent  early  localization.  For  this  reason, 
the  term  pneumo-typhoid  has  been  applied  to  the  group  of  cases  thus  charac- 
terized. 

The  central  nervous  system  presents  in  most  instances  no  coarse  anatomi- 
cal changes  sufficient  to  account  for  the  symptoms  during  life.  JNIore  or  less 
extensive  adhesion  of  the  dura  mater  to  the  inner  surface  of  the  cranium 
is  occasionally  found,  even  in  the  early  periods  of  the  disease.  Increased 
vascularity  or  even  minute  hemorrhages  of  the  pia  mater,  and  injection  of 
the  vessels  of  the  brain-tissue  itself,  are  frequently  observed.  Later  in 
the  course  of  the  affection,  the  pia  mater  is  found  cedematous,  sometimes 
opaque ;  while  in  most  cases  there  is  moderate  distention  of  the  ventricles, 
with  oedema  of  the  brain-substance.  In  rare  cases,  large  cerebral  hemor- 
rhages and  purulent  meningitis  have  been  found. 

Symptomatology. — The  course  of  enteric  fever  in  childhood  is  not  only, 
as  a  rule,  much  lighter,  but  it  also  lacks  the  well-marked  sequence  of  phe- 
nomena which  characterize  the  evolution  of  the  sickness  in  the  later  periods 
of  life.  We  do  not  recognize  in  children  the  distinct  periods  into  which 
the  course  of  the  disease  in  adults  may  be  more  or  less  successfully  divided 
in  accordance  with  the  stage  of  development  and  the  successive  prominence 
of  special  symptoms,  ^oy  are  we  able,  as  a  general  rule,  to  divide  satisfac- 
torily the  febrile  movement  into  the  two  distinct  and  well-defined  stadia 
usually  seen  in  adults.  As  is  well  known,  the  first  stadium  corresponds  to 
the  disturbances  of  the  organism  due  to  special  infection ;  and  it  is  in  this 
period  that  pathologists  have  been  able  to  recognize  in  the  blood  and  tissues 
of  the  body  the  typhoid  bacillus.  The  fever  is  of  subcontinuous  type. 
The  second  stadium,  on  the  other  hand,  corresj^onds  to  that  period  of  the 
disease  intervening  between  the  formation  and  separation  of  the  intestinal 
sloughs  and  the  convalescence.  The  fever,  instead  of  being  subcontinuous, 
is  distinctly  remittent,  and  presents  the -characteristics  of  surgical  or  hectic 
fever,  being  without  doubt  due  to  an  infective  process  analogous  to  that 
which  occurs  in  those  conditions,  and  not  to  any  specific  action  of  the 
typhoid  infection. 

In  childhood,  this  second  stadium  is  imperfectly  developed,  short  in 
duration,  often  absent  altogether, — modifications  of  the  course  of  the  fever 
as  seen  in  adults  which  are  in  close  accord  with  the  fact  that  in  the  former 
period  of  life  the  intestinal  lesions  frequently  undergo  resolution  wholly 
without  ulceration,  or  more  commonly  present  some  superficial  sloughing 
and  ulceration,  and  only  exceptionally  reach  the  high  grade  of  development 
which  is  the  rule  in  adult  life. 

To  make  this  more  clear,  we  may  consider  a  corresponding  state  of 
affairs  as  regards  the  course  of  the  temperature  presented  by  cases  of  scarla- 
tina.    When  this  disease  runs  its  course  without  complications,  the  temper- 


Fahr. 
104° 


103° 


102° 


CHART   I. 

M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E. 


Cent. 


101° 


100° 


■of  Disease.        10        11        12        13        14        15        16        17        18        19        20        21        22        23 
M.  K.,  aged  eight  years.    Enteric  fever. 

J.  C.  Wilson,  M.D. 


CHART   III. 

M.  E.  M.  E.  M.'E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M. 


of        S  9         10        11        12        13        14        15        1(5        17        18        19        20       21        22        23        24 

G.  W.,  aged  nine  years.    Enteric  fever. 

'    ''  ■^  J.  C.  Wilson,  M.D. 


ENTERIC  OH  TYPHOID  FEVER.  459 

ature-curve  presents  a  single  stadinm,  and  terminates  in  the  course  of  eight 
or  ten  days,  usually  by  a  somewhat  prolonged  critical  defervescence.  When, 
on  the  other  hand,  it  is  complicated  by  secondary  infection  and  an  inflam- 
matory implication  of  the  parotid  gland,  the  middle  ear,  or  the  lymphatics 
of  the  neck,  the  febrile  movement  of  the  primary  infection  is  succeeded  by 
a  hectic  fever  and  suppuration,  and  a  second  febrile  stadium  shows  itself, 
which  may  indefinitely  prolong  the  sickness. 

In  typhus,  a  fever  Avithout  constant  or  distinct  local  lesions,  we  have 
a  single  febrile  stadium  due  to  the  specific  infection,  which  usually  termi- 
nates by  the  tenth  or  twelfth  day. 

A  consideration  of  the  foregoing  facts  enables  us  to  understand  at  the 
same  time  certain  of  the  inodifications  of  the  temperature-curve  of  enteric 
fever  as  seen  in  childhood  and  the  shorter  duration  of  the  disease. 

Another  usual  modification  of  the  temperature  in  childhood  consists  in 
the  greater  extent  of  the  morning  remissions  and  the  evening  exacerbations. 
This  finds  a  ready  explanation  in  the  labile  tendencies  of  the  temperature 
of  childhood  under  all  circumstances,  and  is  to  some  extent  a  trait  of  every 
febrile  disease  in  early  life. 

The  corresponding  instability  of  the  nutritive  processes  serves  to  explain 
the  rapid  wasting  of  children  suffering  from  enteric  fever,  and  has  been 
invoked  by  Kaulich,^  though  upon  insufficient  grounds,  to  explain  the  some- 
what rapid  evolution,  and  consequent  relatively  shorter  duration,  of  the 
disease. 

The  well-known  tendency  of  delirium  to  take  its  form  from  the  devel- 
opment and  mental  habit  of  the  individual  in  sickness  of  every  kind  will 
serve  to  explain  the  fact  that  in  childhood  apathy,  somnolence,  and  stupor 
are  much  more  common  than  active  or  even  Avanderins;  delirium.  Other 
physiological  conditions  peculiar  to  the  earlier  periods  of  life  and  capable 
of  analogous  modifications  of  pathological  processes  Avill  readily  suggest 
themselves  to  the  reader. 

It  is  convenient  to  sketch  first  in  a  general  way  the  clinical  course  of 
the  disease  and  afterwards  consider  in  detail  the  particular  symptoms. 

A  stage  of  prodromes  usually  precedes  the  onset  of  the  fever,  which  is 
so  insidiously  developed  that  it  is  impossible  to  designate  the  day  of  its 
commencement.  Patients  are  noticed  to  be  easily  fatigued  and  indisposed 
to  play ;  they  complain  of  feeling  badly,  and  of  headache,  especially  frontal 
headache,  which  is  usually  worse  toAvards  night.  They  often  complain  also 
of  pain  and  soreness  in  the  muscles.  Sleep  is  restless  and  broken.  The 
bowels  are,  as  a  rule,  constipated.  The  expression  is  dull,  tlic  appetite  poor, 
the  tongue  coated.  This  period  is  of  uncertain  but  brief  duration  ;  it  grad- 
ually merges  into  the  declared  disease.  Slight  irregular  cliills  or  repeated 
attacks  of  chilliness  may  mark  the  beginning  of  the  fever. 

Less  commonly  the  disease  is  preceded  by  an  attack  resembling  intermit- 


'  Jahrh.  fiir  Kintli'rluMlk.,  Bd.  xvii.,  1881. 


460  ENTERIC    OR    TYPHOID    FEVER. 

tent  fever.  Here  the  fever  speedily  assumes  the  remittent  type,  and  the 
characteristic  symptoms  of  enteric  fever  are  developed.  Such  cases  are 
most  frequently  encountered  in  malarial  districts.  In  other  instances  the 
disease  begins  abruptly  without  prodromes,  being  ushered  in  by  a  chill 
followed  by  high  fever. 

The  attack  is  to  be  regarded  as  beginning  with  the  first  chilliness  or  the 
first  rise  of  temperature.  The  fever  increases,  but  it  is  distinctly  remittent 
in  type,  the  exacerbations  occurring  in  the  afternoon  or  evening  and  the 
remissions  in  the  morning.  The  progressive  rise  in  temperature  often  lacks 
the  regularity  seen  in  adults,  nor  is  the  acme,  which  is  usually  reached  by 
the  evening  of  the  fifth  day,  as  a  rule  so  high. 

The  skin  becomes  dry  and  hot ;  not  infrequently,  however,  especially 
in  the  early  part  of  the  day,  it  is  moist  or  even  bathed  in  sweat.  The 
symptoms  of  the  prodromic  stage  are  intensified.  The  headache  becomes 
more  marked,  Epistaxis  sometimes  occurs :  it  is  usually  slight,  often  not 
exceeding  a  few  drops ;  at  other  times  it  may  be  considerable  in  amount. 
The  expression  is  dull  and  apathetic,  the  countenance  pale,  and  the  cheeks 
slightly  flushed.  Sleep  is  more  restless  than  before,  and  often  disturbed 
by  cries  and  jactitation.  In  the  ordinary  cases  as  seen  in  childhood,  pro- 
nounced delirium  is  uncommon :  when  present,  it  usually  occurs  between 
sleeping  and  waking  and  is  transient.  The  Hps  are  parched  and  dry  and 
speedily  become  fissured  and  scaly.  The  tongue  is  usually  moist,  red  at  the 
tip,  aud  covered  with  a  whitish-yellow  fiir,  which  is  sometimes  thin,  some- 
times thick  and  pasty.  Appetite  is  lost,  thirst  augmented.  Constipation  is 
much  more  frequently  present  in  childhood  than  in  adult  life ;  nevertheless 
diarrhoea  may  be  present  from  the  period  of  prodromes  until  convalescence. 

In  the  full  development  of  the  disease  there  is  usually  some  prominence 
of  the  abdomen,  which  is  very  exceptionally  distended  or  tense.  There  is 
often  tenderness  upon  pressure,  particularly  in  the  region  corresponding  to 
the  ileo-csecal  valve,  and  upon  paljjation  gurgling  is  produced.  In  the 
majority  of  cases  the  spleen  is  discovered  upon  physical  examination  to  be 
enlarged.  Cough,  usually  slight,  is  apt  to  be  present,  and  upon  auscultation 
a  few  scattered  coarse  mucous  rales  may  be  detected  posteriorly. 

The  eruption  appears  somewhere  between  the  fifth  and  tenth  days  of  the 
attack.  It  is  commonly  sparse,  scattered  over  the  abdomen  or  lower  part 
of  the  chest  and  upon  the  back.  It  may  be  absent  altogether;  when 
present,  it  is  characteristic  of  the  disease.  Its  peculiarities  will  be  hereafter 
described. 

The  urine,  which  during  the  course  of  the  disease  is  scanty  and  high- 
colored,  presenting  the  usual  cliaracteristics  of  fever-urine,  becomes  with 
the  defervescence  limpid  and  abundant. 

Towards  the  end  of  the  second  week  the  subcontinuous  fever  of  the 
acme  assumes  a  distinctly  remitteut  type,  aud  defervescence  takes  place 
by  rapid  lysis.  (See  Chart  I.)  Coiucideutly  with  this  change  general  im- 
provement takes  place.     Defen^escence  is,  as  a  rule,  completed  somewhere 


CH. 


Fakr. 


.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E. 


T  II. 


Cent, 


M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  M.  E.  ^^ 


30        31        32        33        31        35        36        37        38        39        40        il        42        43        44        45        46        47 


fever,  with  relapse.    (Kaulich.) 


J.  C.  Wilson,  M.D. 


ENTERIC   OR   TYPHOID    FEVER.  461 

between  the  tenth  and  twentieth  days,  and  the  child  enters  upon  convales- 
cence pallid,  feeble,  and  emaciated  out  of  proportion  to  the  symptoms  of 
his  sickness.  Thirst  diminishes ;  appetite  returns ;  the  mental  activity 
quickens,  and  the  restoration  to  health  is  more  rapid  than  in  adult  life. 

Such  is  the  clinical  picture  of  enteric  fever  as  commonly  seen  in  child- 
hood. Not  rarely  the  symptoms  are  much  milder  than  this  account  would 
indicate,  often  so  mild  that  it  is  difficult  to  restrain  the  patient  in  bed  or  to 
convince  his  attendants  of  the  actual  character  of  the  disorder.  On  the 
other  hand,  cases  are  encountered  marked  by  the  intensity  of  the  morbid 
processes  which  characterize  the  worst  cases  of  adult  life.  In  such  instances 
the  disease  may  be  prolonged  to  the  end  of  the  fourth  week  or  beyond  it, 
and  the  attack  may  terminate  in  death,  the  phenomena  under  these  circum- 
stances being  analogous  to  those  seen  in  adult  life, — subject  always  to  the 
special  modifications,  as  regards  the  fever,  the  nervous  symptoms,  and  the 
nutritive  derangements,  which  have  been  already  pointed  out. 

Relapses  occur  in  a  certain  proportion  of  the  cases  in  childhood  and 
infancy.  What  this  proportion  may  be  it  is  impossible  to  state  definitely. 
They  appear  to  be  much  less  common  than  in  adult  life. 

The  relapse  constitutes  a  true  second  attack  of  the  specific  fever.  It  is 
due  to  re-infection,  probably  from  some  source  within  the  organism"  itself, 
and  is  attended  by  the  characteristic  phenomena  of  the  disease.  It  is,  as  a 
rule,  however,  of  more  abrupt  onset  and  shorter  duration  than  the  primary 
attack.  It  is  commonly  separated  from  the  latter  by  an  interval  of  some 
days,  during  which  the  temperature-range  is  subnormal  or  normal.  (See 
Chart  II.) 

It  is  to  be  noted  that  during  this  period,  in  cases  in  which  relapse  occurs, 
the  spleen  remains  enlarged. 

The  relapse  is  not  invariably  thus  separated  from  the  primary  attack, 
but  may  occur  during  its  course.  It  is  then  termed  an  intercurrent  relapse; 
and  it  is  to  intercurrent  relapse  that  cases  of  unusual  prolongation,  in  the 
absence  of  complications,  are  to  be  ascribed.  Two  or  more  relapses  may 
occur. 

Relapses  not  infrequently  occur  after  primary  attacks  of  moderate 
severity ;  less  commonly  after  grave  cases.  The  opinion  at  one  time  held 
that  relapses  were  much  more  frequent  after  primary  attacks  treated  by 
strict  antipyretic  methods  than  after  those  treated  upon  the  expectant  plan 
does  not  seem  to  be  well  founded. 

An  attack  of  enteric  fever  appears  in  the  great  majority  of  instances  to 
confer  immunity  against  subsequent  attacks.  To  this  rule,  however,  there 
are  exceptions,  and  numerous  cases  are  recounted  in  which  a  second  or  even 
a  third  well-authenticated  attack  of  the  disease  has  occurred  in  the  same 
individual.  It  is  to  the  immunity  often  acquired  in  infancy  or  childhood 
that  the  insusceptibility  of  many  adults  to  the  disease  is  to  be  attributed. 
A  considerable  proportion  of  iudividuals  in  local  epidemics,  where  the  expo- 
sure to  the  infectious  principle  nuist  be  universal,  usually  escape  the  disease. 


462  ENTERIC    OR    TYPHOID    FEVER. 

Very  mild  cases  doubtless  frequently  escape  recognition.  The  little; 
patients,  tliough  far  from  well,  continue  to  play  about  with  their  com- 
panions. These  cases  do  not  correspond  to  the  "  walking  cases"  of  adult 
life.  The  intestinal  lesions  being  superficial,  the  attack  is  not  likely  to 
terminate  in  hemorrhage  from  the  bowels  or  in  perforation. 

ANALYSIS   OF   THE   PEINCIPAL   SYMPTOMS. 

The  Temjjeratiire. — The  typical  typhoid  temperature-range  of  Wunder- 
lich^  is  rarely  seen  in  childhood.  Nor  do  we  often  meet  with  charts  showing 
the  regular  progressive  zigzag  rise  of  the  first  five  days,  which  is  of  diag- 
nostic importance  in  adults. 

Owing  to  the  difficulties  of  diagnosis  at  the  beginning  of  the  attack, 
which  are  much  greater  in  childhood  than  in  adult  life,  and  to  the  insidious 
development  of  the  disease,  accurate  temperature-observations  of  the  earlier 
periods  are  not  often  taken.  Even  when  cases  develop  in  the  wards  of  hos- 
pitals or  in  the  families  of  well-to-do  people  and  thus  come  comparatively 
early  under  the  observ^ation  of  the  physician,  the  morbid  phenomena  are  not 
usually  such  as  to  lead  immediately  to  the  anticipation  of  a  serious  disease, 
nor  are  there  such  obvious  evidences  of  fever  as  to  suggest  the  systematic 
taking  and  recording  of  the  temperature. 

In  those  rare  instances  when  the  fever  begins  suddenly  with  a  chill 
followed  by  a  rise  in  temperature  of  several  degrees  and  sweating,  there 
remains  the  possibility  of  a  previous  insidiously-developing  febrile  move- 
ment which  has  been  overlooked.  In  these  cases  the  rise  in  temperature 
following  the  chill  is  abrupt,  often  reaching  103.5°  to  104°  F.  Much  more 
common  is  a  gradual  rise  in  temperature,  the  curve  taking  the  form  of  an 
irregular  zigzag  and  the  evening  exacerbation  exceeding  the  remission  of 
the  following  morning  by  about  one  degree  Fahrenheit,  so  that  the  fastigium 
is  reached  in  the  later  days  of  the  first  week.  Here  the  initial  chill  is  absent, 
but  there  is  often  a  slight  sense  of  chilliness  or  transient  shivering  during 
the  early  days  at  the  time  of  the  evening  exacerbation.  The  fastigium 
having  been  reached,  the  type  of  the  fever  becomes  subcontinuous,  the 
difference  between  the  evening  and  the  morning  temperature  being  about  a 
degree  to  a  degree  and  a  half. 

At  some  time  between  the  middle  of  the  second  and  the  end  of  the  third 
week,  or  exceptionally  even  later  than  this,  the  type  of  the  febrile  move- 
ment gradually  becomes  distinctly  remittent  or  even  intermittent,  the  remis- 
sions and  exacerbations  being  gradually  increased.  The  defervescence  thus 
assumes  the  form  of  a  rapid  or  gradual  lysis,  the  fever  terminating  when 
the  evening  temperature  falls  to  normal. 

In  a  considerable  proportion  of  the  cases  the  defervescence  takes  place 
by  a  rapid  lysis,  without  the  intervention  of  distinct  remissions  or  intermis- 
sions, the  fall  being  of  an  irregular  zigzag  not  unlike  that  which  marks  the 

1  On  the  Temperature  of  Diseases,  Sydenham  Society's  Transactions,  1881. 


~                    III                            ^ 

s 

s                                                

&i 

g      X 

Eli 

g    T 

^■"x::: ::  :::::::::  ::  ::i:"";:± 

fs                                     '«■-. 

^                                                                      "T" 

■^       '                                    '  -      4-                   _L        ^_ 

^:  __^ t X  -  ^ 

-.__x± i-is 

s                  1                                           •■      ■    ■            1        ^^'■■ 

-■  ±::::r:::i :::::::::::  ::::::"ri:^"" 

s                            ^ — -j — 

^"                                         Tn~" — ^-^ 

'^                                                          1         _j__ij— i-» —- 

-:___  ~ "I           s 

K                                                   1           1                                  "=1^^ 

^                            —1—                                               ^^         _L 

1> 

K^        ^              -T-                 -   |.    ,                                                                                    ^^-f-p 

Cj        "= Js 

g        S                                   .                                                                             -t-                          — > 

'^    s                                                             J^-''  1 

D  ^                      1                    °i^-       1 

s                             '                                  !    p-j 

K                           _j_                                   >Y^       1 

K                '""!Ti:""r~— 

^                      ""^~~T^ '       '                                   -4- 

s                                    X X--==="- 

t=:                           -«s=_l__^ 

(^                                                              1   1           " 

^                             ''~ 

S                                1     1                          i."T==r="' 

S                                          1      "~L!!Jrj — — ' 

'^                 ■     T^^^--LX_i      X                              X 

^                                   X-'  1  '  r^ 

^                    T~"""^— i-                ' 

^                              J-tX^-=^     I 

^-         -I?"~f~^--r-  T       1       1 

^                      ■~^"" 

'^  "T  1  1  f- L                1                       1 

S        1              i          1     i                _i-i-i-T==" 

K    X"7~"~p-~— L                                    '" 

S              1      1                1    JJZ-^  '     ?="T 

«:::_^$:::::tl::X:::::-^            +- 

^     ___X__,_  .    1     1           ,     M       ,.      __L__ 

ENTERIC    OR   TYPHOID    FEVER.  463 

access.  (See  Chart  III.)  Less  frequently — and  this  is  especially  the  case 
where  the  duration  of  the  fever  is  relatively  short — the  defervescence  takes 
place  with  considerable  rapidity,  in  itself  suggestive  of  crisis.  This  is  the 
well-known  mode  of  termination  in  the  abortive  cases  seen  in  adult  life. 

In  the  early  days  of  convalescence  the  morning  temperature,  and  at 
times  the  evening  temperature  also,  fall  to  subnormal  ranges.  (See  Chart 
IV.)  During  convalescence  the  temperature  is  exceedingly  unstable.  Tran- 
sient perturbations,  with  a  rise  of  three  or  four  degrees,  to  which  the  term 
recrudescence  of  fever  has  been  applied,  are  brought  about  by  slight  causes, 
among  which  are  errors  in  diet,  especially  the  eating  of  meat,  constipation, 
undue  muscular  effort,  and  mental  excitement. 

The  temperature-range  alike  during  the  fever  and  during  convalescence 
is  liable  to  modifications  in  consequence  of  complications.  Abundant  blood- 
loss  from  epistaxis  or  from  intestinal  hemorrhage  is  apt  to  be  followed  by 
a  considerable  fall  of  temperature.  This  fall  is  not  permanent  unless  it 
occur  during  the  defervescence. 

The  temperature  of  the  disease  in  childhood  reacts  promptly  and  de- 
cidedly to  antipyretic  treatment. 

Of  eighty  cases  in  which  Henoch  was  able  to  determine  accurately  the 
duration  of  the  fever,  in  seven  it  terminated  in  between  seven  and  nine 
days ;  in  four,  in  ten  days ;  in  eight,  in  eleven  days ;  in  one,  in  twelve  days ; 
in  seventeen,  in  between  thirteen  and  fifteen  days ;  in  five,  in  between  six- 
teen and  seventeen  days  ;  in  eleven,  in  between  eighteen  and  nineteen  days ; 
in  fifteen,  in  between  twenty  and  twenty-three  days ;  in  six,  in  between 
twenty-eight  and  thirty  days ;  in  one,  in  thirty-five  days ;  in  one,  in  forty- 
two  days ;  and  in  four,  in  between  forty-eight  and  forty-nine  days. 

The  occurrence  of  complications  or  of  intercurrent  relapses  in  the  cases 
of  unusually  long  duration  in  the  above  list  is  not  noted. 

The  heioi;ht  of  the  fever  in  the  fastiffium  is  variable.  In  manv  cases  it 
does  not  exceed  102.5°-103°  F. ;  exceptionally  it  reaches  104°  or  even  105°. 
The  average  diiference  between  the  morning  and  the  evening  temperature  is, 
as  a  rule,  about  a  degree  or  a  degree  and  a  half.  There  is  occasionally  ob- 
served a  slight  exacerbation  occurring  early  in  the  afternoon,  followed  by  a 
correspondingly  slight  remission.  The  maximum  temperature  is  reached  in 
the  evening. 

Where  two  temperature-observations  only  are  made  in  the  course  of 
twentv-four  hours,  the  most  convenient  time  is  between  seven  and  eiy:ht  in 
the  morning  and  between  seven  and  eight  in  the  evening.  In  grave  cases, 
and  M'hcro  the  temperature  is  either  very  liigh  or  shows  a  tendency  to 
sudden  t-lianges  of  considerable  extent,  observations  should  be  taken  much 
more  frequently.    A  temperature  of  inverse  type  has  been  occasionally  noted. 

IIv})erpyrexia,  tlie  temperature  roaclu'ng  105.8°  F.  and  rapidly  rising  to 
108°— 110°  F.,  does  not  occur  in  uncomplicated  enteric  fever  in  childliood. 

The  Circulatory  System. — In  mild  cases  the  action  of  the  heart  is  but 
little  disturbed.    In  those  of  moderate  severity  it  is  progressively  diminished 


464  ENTERIC    OR    TYPHOID    FEVER, 

until  the  impulse  and  the  first  sound  are  much  enfeebled.  These  changes 
are  less  marked,  as  a  rule,  in  infancy  and  childhood  than  in  cases  of  corre- 
sponding severity  in  adult  life. 

Pericarditis  is  rare,  and  must  be  looked  upon,  when  it  occurs,  as  a 
complication.  A  faint  systolic  apex-murmur  is  occasionally  met  with  in 
consequence  of  the  general  relaxation  of  the  wall  of  the  heart.  Actual 
endocarditis  of  a  mild  grade  is  probably  of  more  frequent  occurrence  than 
the  descriptions  of  the  text-books  would  indicate.  Certain  it  is  that  a 
slight  mitral  endocarditis  is  occasionally  encountered  u^Jon  post-mortem 
examination. 

The  degenerative  changes  in  the  muscle  of  the  heart  previously  described 
play  a  large  part  in  the  enfeeblement  of  the  circulation :  that  they  are  its 
sole  cause,  however,  is  doubtful.  It  is  probable  that  the  loss  of  cardiac 
force  is  largely  due  to  functional  disturbances  of  the  nervous  system. 

It  is  not  uncommon  to  find  later  in  life  in  those  who  have  suffered  from 
enteric  fever  evidences  of  impaired  integrity  of  the  myocardium.  There  is 
reason  to  beheve  that  in  a  considerable  proportion  of  the  cases  of  enteric 
fever  endarteritis  of  the  branches  of  the  coronary  vessels  leads  to  permanent 
degenerative  changes  in  limited  areas  of  the  heart-muscle. 

Sudden  death  in  the  absence  of  adequate  anatomical  lesions,  such  as 
occasionally  occurs  in  adult  life,  does  not  take  place  in  enteric  fever  in 
childhood. 

The  pulse  in  children  corresponds  in  a  general  way  to  the  height  of  the 
temperature.  The  exceptions  to  this  rule  are  very  frequent,  a  pulse  of  120, 
108,  or  even  96,  being  occasionally  met  with  where  the  temperature  ranges 
as  high  as  103°  or  104°  F. 

On  the  other  hand,  the  pulse  may  be  exceedingly  rapid,  reaching  a 
frequency  of  150  or  180,  in  cases  that  terminate  in  recovery. 

It  is  sometimes  irregular  both  in' rhythm  and  in  force.  Dicrotism  is 
much  more  rare  in  childhood  than  in  adult  life ;  but  we  must,  in  this  con- 
nection, again  insist  upon  the  fact  that  the  phenomena  of  enteric  fever  in  the 
later  years  of  childhood  closely  correspond  to  those  of  the  disease  in  adults. 

The  peculiarities  of  the  pulse  are  in  infancy,  by  reason  of  the  narrow- 
ness of  the  arteries,  difficult  to  recognize,  beyond  that  it  is  always  small 
and  compressible.     Extreme  irregularity  of  the  pulse  is  a  grave  symptom. 

During  convalescence  the  pulse  is  apt  to  be  more  rapid  than  in  health, 
and  to  show  marked  variations  in  frequency.  It  is,  on  the  other  hand,  not 
rarely  slower  than  normal. 

The  oedema  of  the  ankles  and  legs  often  seen  in  the  early  days  of  con- 
valescence must  be  ascribed  to  the  weakness  of  the  heart  and  imperfect 
circulation  of  the  blood. 

Collapse  is  rare  in  childhood.  It  occurs  only  in  the  graver  cases,  and 
may  result,  as  in  adult  life,  from  various  accidents,  among  which  are  intes- 
tinal hemorrhage,  the  shock  following  perforation,  or  even  sudden  copious 
diarrhoea  or  violent  vomiting. 


ENTERIC    OR    TYPHOID    FEVER.  465 

The  Respiratory  System. — The  frequency  of  the  respiration,  in  the  absence 
of  pulmonary  complications,  varies  with  the  intensity  of  the  febrile  move- 
ment. It  rises  with  the  pulse ;  but  in  cases  characterized  by  an  unusually 
slow  puke  there  is  no  corresponding  slowness  of  the  breathing. 

A  certain  amount  of  bronchial  catarrh  is  so  frequent  that  it  merits  con- 
sideration as  a  phenomenon  of  the  disease  rather  than  as  a  complication. 
Cough  is  much  more  common  in  children  than  in  adults,  although  the  cor- 
responding physical  signs  are  in  many  cases  not  present, — a  fact  to  be  ac- 
counted for  by  the  superficial  respiration  of  childhood  and  the  impaired 
muscular  tone  of  the  disease.  For  the  same  reason,  the  respirator}^  murmur 
is  ordinarily  much  enfeebled.  Upon  deep  inspiration,  such  as  accompanies 
crying  or  cough,  mucous  rales  are  distinctly  heard.  In  other  cases  dry  and 
moist  rales  are  to  be  heard  over  all  parts  of  the  chest. 

In  a  majority  of  the  cases  the  bronchitis  is  of  moderate  intensity,  es- 
pecially if  the  patient  early  receives  proper  care  and  treatment ;  in  severe 
cases,  however,  there  is  frequently  developed  broncho-pneumonia,  which 
manifests  itself  by  notable  enfeeblement  of  the  respiratory  murmur  of  the 
dependent  portions  of  the  lungs  and  by  impairment  of  resonance  upon  per- 
cussion. These  changes  are  apt  to  aifect  both  lungs,  although,  as  a  rule, 
the  signs  are  somewhat  more  pronounced  upon  one  side  than  upon  the  other. 
They  are  largely  due  to  the  condition  of  the  nervous  system.  The  patient 
expectorates  little,  is  apt  to  swallow  food  the  wrong  way,  and  lies  quietly 
upon  his  back. 

This  form  of  pneumonia,  which  is  the  outcome  of  a  severe  difiuse  bron- 
chitis and  has  been  described  as  a  "  deglutition"  or  "  inhalation"  pneumonia, 
was  formerly  described  under  the  name  of  hypostatic  pneumonia.  It  occurs 
during  the  acme  of  the  febrile  movement  or  early  in  the  defervescence, 
and  frequently  amounts  to  a  complication  which  much  prolongs  the  febrile 
process. 

Hypostatic  congestion  also  occurs  in  consequence  of  the  feeble  circula- 
tion ;  it  is  limited  to  the  posterior  parts  and  bases  of  the  lungs. 

Much  more  rare  is  a  true  lobar  or  fibrinous  pneumonia.  It  occasionally 
appears  as  early  as  the  second  or  even  during  the  first  week,  and  may 
attack  the  lower  as  well  as  the  upper  lobes.  In  cases  where  it  comes  on 
vcrv  early,  the  diagnosis  is  for  a  time  obscure.  It  mav  sometimes  occur 
during  convalescence.  It  remains  an  open  question  as  to  whether  or  not 
this  form  of  pneumonia,  occurring  in  the  early  period  of  the  disease,  is  due 
to  a  pulmonary  localization,  or  to  an  independent  coincident  infection.  The 
pulmonary  symptoms,  the  physical  signs,  and  the  post-mortem  appearances 
are  not  to  be  distinguished  from  those  of  lobar  pneumonia  occurring  as  an 
independent  affection. 

The  same  statement  is  true  of  pleurisy  with  fibrinous,  serous,  or  puru- 
lent exudation, — a  complication,  however,  which  is  rare.    Henoch  has  noted 
in  a  girl  aged  four  years  the  occurrence  of  gangrene  of  the  lung  in  pneu- 
monia occurring  as  a  complication  of  enteric  fever. 
Vol.  I.— 30 


466  ENTEEIC    OR   TYPHOID    FEVER. 

Catarrhal  laryngitis  with  hoarseness,  due  to  the  same  causes  that  produce 
the  bronchitis,  is  occasionally  encountered. 

An  extremely  infrequent  complication,  which  appears  to  be  much  more 
rare  in  this  country  than  in  Europe,  is  ulceration  of  the  vocal  cords  or  of 
the  posterior  wall  of  the  larynx. 

Perichondritis  of  the  arytenoid  cartilages  has  also  been  observed.  This 
is  a  complication  of  grave  import,  and  may  lead  to  rapid  development  of 
the  oedema  of  the  glottis,  Faucial  and  laryngeal  diphtheria  may  also  occur 
as  complications. 

Stenosis  of  the  larynx  may  occur  as  a  result  of  (1)  oedematous  laryn- 
gitis, (2)  ulcerative  laryngitis,  and  (3)  laryngeal  perichondritis.  In  ninety- 
four  cases  collected  from  various  sources  by  Keen  in  which  the  age  is 
regarded,  six  were  under  fifteen  years  of  age. 

Ulceration  of  the  nasal  cartilages,  resulting  sometimes  in  perforation  of 
the  septum,  sometimes  in  a  permanent  deformity  of  the  nose,  also  occurs. 

Epistaxis  is  much  less  common  in  children  than  in  adults,  and  is,  as  a 
rule,  not  severe.  Forchheimer^  noted  it  in  five  per  cent,  of  seventy  cases 
observed  during  a  recent  epidemic  in  Cincinnati.  In  the  early  j^eriod  of  the 
disease  it  usually  consists  simply  of  the  spontaneous  loss  of  a  few  drops 
of  blood  from  time  to  time ;  occasionally,  however,  profuse  epistaxis  occurs 
among  the  earlier  phenomena.  Later  in  the  course  of  the  attack,  trifling 
epistaxis  is  frequently  induced  by  the  patient  picking  at  the  nasal  orifices. 
Other  nasal  symptoms,  except  a  certain  amount  of  dryness  of  the  mucous 
membrane,  are  uncommon.  It  has  been  said  that  enteric  fever  never 
begins  with  coryza. 

The  Digestive  System. — The  symptoms  indicative  of  disturbances  of  the 
digestive  organs  are  much  the  same  in  childhood  and  in  adult  life.  Loss 
of  appetite  during  the  progress  of  the  fever  is  the  rule ;  a  desire  for  food, 
the  exception ;  upon  the  occurrence  of  convalescence  there  is  usually  marked 
hunger.  Thirst  is  a  prominent  symptom',  but  it  is  generally  of  moderate 
amount  and  readily  gratified. 

The  tongue  is  in  exceptional  cases  clean  and  moist  throughout  the 
attack ;  much  more  commonly  it  is  red  at  the  tip  and  edges  and  covered 
with  a  pasty,  yellowish-white  fur,  which  is  apt  to  separate  in  the  course 
of  the  disease,  leaving  the  tongue  smooth,  bright  red,  and  dryish.  It  is 
not  usual  to  find  in  childhood  the  hard,  dry,  and  brown  tongue  which  is 
common  in  the  later  stages  of  the  disease  in  adults.  Occasionallv  the 
appearance  of  the  tongue  differs  from  day  to  day.  Sordes  upon  the  teeth 
and  gums  are  not  common  in  childhood.  On  the  other  hand,  the  lips  are 
apt  to  become  cracked  and  fissured,  with  the  formation  of  superficial  crusts. 
Superficial  aphthous  ulcerations  likewise  occur  upon  the  tongue,  upon  the 
buccal  mucous  membrane,  and  at  the  corners  of  the  mouth. 

Vomiting,  sometimes  spontaneous,  sometimes  following  the  administra- 

1  Polyclinic,  March,  1888. 


ENTERIC    OR    TYPHOIi)    FEVER.  467 

tion  of  food  or  medicine,  occurs  much  more  frequently  in  children  than  in 
o;rown  persons.  It  is  more  common  in  the  first  week  of  the  attack,  but 
may  occur  from  time  to  time  throughout  the  whole  course  of  the  disease. 

It  is  much  more  apt  to  be  present  in  severe  than  in  mild  cases ;  but  this 
symptom  has  not  the  ominous  significance  in  childhood  that  it  has  in  adult 
life.  Repeated  vomiting  occurring  at  the  beginning  of  the  attack  tends  to 
increase  the  resemblance  between  enteric  fever  and  tubercular  meningitis, 
and  renders  the  diagnosis  for  the  time  being  obscure. 

The  condition  of  the  bowels  is  extremely  variable.  Constipation  is  at 
least  as  frequent  as  diarrhoea  in  the  beginning  of  the  attack.  In  a  consider- 
able proportion  of  the  cases  the  bowels  are  almost  normal  as  regards  the 
frequency  of  the  movements  and  the  consistence  of  the  dejections  throughout 
the  disease.  In  a  limited  number  of  cases  there  is  a  marked  tendency  to 
constipation ;  more  frequently  the  constipation  of  the  earlier  period  of  the 
disease  gives  way  to  a  more  or  less  frequent  diarrhoea  in  its  later  course. 
The  number  of  passages  may  varv'  from  one  to  ten,  or  even  to  fifteen  or 
twenty,  in  the  course  of  twenty-four  hours.  AVhen  the  movements  are 
infrequent,  the  dejections  are  often  formed  or  of  a  mushy  consistence,  being 
usually  of  a  lightish-yellow  color;  when  diarrhoea  is  present,  however, 
they  usually  present  the  well-known  appearance  of  thick  pea-soup  and 
divide  upon  standing  into  an  upper  cloudy,  quite  liquid  layer  and  a  lower 
layer  composed  of  greenish-yellow  masses.  They  have  generally  an  alka- 
line reaction,  and  are  found  upon  microscopical  examination  to  contain 
crystals  of  triple  phosphate.  The  discharges  from  the  bowels  are  sometimes 
of  a  rather  bright  greenish  color,  sometimes  of  the  color  descril^ed  as  cafe 
au  lait. 

The  frequency  of  the  diarrhoea  is  very  often  proportioned  to  the  general 
severity  of  the  case.  This  rule,  however,  is  not  absolute,  and  the  converse 
of  it  is  by  no  means  to  be  assumed,  since  veiy  severe  cases,  and  often  those 
in  which  there  are  advanced  intestinal  lesions,  run  their  course  without 
marked  diarrhoea.  Diarrhoea,  when  present,  is  apt  to  continue  until  defer- 
vescence is  completed,  and  to  be  succeeded  during  the  convalescence  by  con- 
stipation, which,  when  obstinate,  is  not  infrequently  a  cause  of  transient 
recrudescences  of  the  fever.  On  the  other  hand,  it  occasionally  happens 
during  convalescence  that  spontaneous  diarrhoea  occurs. 

Except  in  the  case  of  very  young  infants,  involuntary  evacuation  of 
the  bowels  or  bladder  in  the  bed  is  unusual.  Rillict  and  Barthez,  Henoch, 
and  others  have  noted  the  fact  that  quite  young  children  during  the  course 
of  the  disease,  even  when  a  certain  degree  of  apathy  and  somnolence  is 
present,  frequently  call  the  attention  of  the  attendant  at  such  times.  Later 
in  the  course  of  severe  cases  involuntar}-  discharges  are  apt  to  take  place. 

Upon  pressure,  the  belly  is  often  slightly  sensitive,  but  tenderness  is 
rarely  extreme ;  it  is  more  apt  to  be  present  in  cases  cliaracterized  by  con- 
stipation. It  is  more  difficult  to  determine  the  presence  or  absence  of  local 
tenderness  upon  pressure  in  the  ileo-csecal  region  in  children  than  in  adults. 


468  ENTERIC    OR    TYPHOID    FEVER. 

For  this  reason,  the  symptom  is  less  important.  This  is  also  true  of  borbo- 
rygmi,  a  symptom  by  no  means  rare  in  simple  diarrhoea.  The  abdomen 
is  usually  normal  in  contour  or  moderately  distended  ;  in  a  small  proportion 
of  the  cases  it  is  flat.     Marked  tympany  is  comparatively  rare  in  childhood. 

Abdominal  pain  is  often  wholly  absent.  Rather  sharp  attacks  of  colic, 
especially  just  before  an  action  of  the  bowels,  occasionally  occur.  Such 
attacks  are  also  apt  to  be  present  from  time  to  time  during  convalescence ; 
they  are  sometimes  severe  and  may  occasion  apprehension  lest  they  be  the 
beginning  of  actual  peritoneal  inflammation.  Rilliet  and  Barthez  have 
called  attention  to  these  abdominal  pains,  and  record  the  case  of  a  boy 
eleven  years  old  who  during  the  course  of  the  disease  was  attacked  with 
violent  pain  in  the  abdomen  of  thirty-six  hours'  duration,  accompanied  by 
vomiting. 

Intestinal  hemorrhage  occurs  as  the  result  of  the  implication  of  the  walls 
of  blood-vessels  in  the  ulcerative  process.  It  is  apt  to  show  itself,  there- 
fore, at  the  time  of  the  separation  of  the  sloughs, — namely,  comparatively, 
late  in  the  course  of  the  attack.  It  is  far  less  common  in  children  than  in 
adults, — a  fact  which  finds  its  obvious  explanation  in  the  relatively  slighter 
lesions  of  the  former  period  of  life.  The  blood  escapes  from  the  vessels 
into  the  intestine,  and  is  voided  with  the  stools.  It  varies  in  amount  from 
a  mere  trace  to  a  profuse  hemorrhage,  which  may  be  followed  by  lethal  col- 
lapse. When  the  amount  is  small,  it  is  usually  dark  in  color  and  the  later 
discharges  are  sometimes  tarry.  On  the  other  hand,  copious  intestinal  hem- 
orrhage is  apt  to  present  the  appearance  of  bright,  recently-drawn  arterial 
blopd.  Hemorrhage  from  the  bowels  is  in  all  cases  a  significant  symptom. 
Even  slight  hemorrhages  may  be  followed  after  some  hours  or  days  by 
dang-erous  or  fatal  loss  of  blood. 

Earle,  of  Chicago,  has  furnished  me  with  the  notes  of  an  unpublished 
case  of  fatal  intestinal  hemorrhage  in  a  child  twenty-t\vo  months  old.  Post- 
mortem examination  revealed  the  characteristic  lesions  of  enteric  fever. 

A  case  of  Henoch's  is  instructive.  Hemorrhage  occurred  in  a  girl  ten 
vears  old  in  the  course  of  a  relapse  which  took  place  in  the  third  week. 
There  was  first  an  insignificant  bleeding,  which  was  followed  upon  the  next 
day  by  very  copious  hemorrhages,  resulting  in  fatal  collapse. 

After  every  intestinal  hemorrhage  of  considerable  amount,  the  anaemia 
characteristic  of  the  period  of  the  disease  in  which  this  accident  is  liable  to 
occur  is  intensified,  and  the  signs  of  collapse  are  apt  to  appear.  The  fall  of 
temperature  amounts  usually  to  two  or  three  degrees  Fahrenheit,  and  may 
reach  normal  or  even  subnormal  ranges.  Hemorrhage,  even  when  large, 
does  not  necessarily  result  in  a  fatal  issue  of  the  case.  It  not  infrequently 
exerts  a  favorable  influence  upon  the  cerebral  symptoms,  and  occasionally 
is  followed  by  improved  intelligence,  permanent  reduction  of  fever,  and 
other  signs  of  beginning  convalescence. 

More  common,  but  still  extremely  rare  in  childhood,  is  perforation  of 
the  floor  of  an  ulcer  into  the  peritoneal  cavity.     This  accident  is  apt  to 


ENTERIC    OR    TYPHOID    FEVER.  4(39 

occur  late  in  the  course  of  the  attack.  Henoch  observed  it  in  a  boy  aged 
eleven  in  the  fifth  week  after  convalescence  had  been  apparently  established. 
The  solution  of  continuity  in  the  wall  of  the  gut  may  consist  of  a  simple, 
irregular,  longitudinal  rent  in  the  serous  coat,  or  may  present  the  appear- 
ance of  a  circular  or  oval  opening  three  or  four  lines  in  diameter.  The 
edges  of  such  perforations  are  usually  the  seat  of  a  deposit  of  plastic  lymph  : 
hence,  if  the  gut  at  the  point  of  perforation  come  immediately  into  contact 
with  the  serous  wall  of  a  neighboring  coil  of  intestine  or  some  other  viscus, 
adhesions  mav  take  place  and  extravasation  of  the  intestinal  contents  be 
prevented,  with  the  result  of  a  localized,  or  at  all  events  a  plastic,  peritonitis. 
If,  on  the  other  hand,  the  opening  communicate  without  such  adliesions 
directly  with  the  cavity  of  the  peritonemn,  extravasation  of  the  intestinal 
contents  is  sure  to  occur.  Slight  as  the  amount  may  be,  there  results  a 
purulent  or  even  an  ichorous  peritonitis,  with  the  well-known  symptoms  of 
a  fulminant  attack  of  this  form  of  serous  inflanmiation :  abdominal  pain, 
distention,  collapse,  eructations  and  vomiting,  a  small  and  frequent  pulse, 
rapid  fall  of  temperature,  followed  by  an  abrupt  rise  and  great  fluctuations, 
constitute  the  too  familiar  clinical  phenomena  of  this  accident. 

It  is  proper  to  state  that  statistics  of  various  authorities  present  a  wide 
range  of  variation  in  regard  to  the  frequency  of  perforation  in  children. 
Thus,  among  two  hundred  and  thirty-two  cases  according  to  Barthez  and 
Rilliet^  it  occurred  in  three  only,  while  among  seventy-three  persons  in 
whom  this  accident  occurred,  observed  by  Murchison,  fourteen  were  under 
fifteen  years  of  age. 

Peritonitis  may  occur  through  direct  extension  of  the  intestinal  ulcera- 
tion to  the  serous  membrane  without  actual  perforation.  Peritonitis  arising 
in  this  manner  may  be  either  local  or  general. 

I  have  reported  an  instance  of  this  kind.-  The  patient  was  a  puny 
girl,  twelve  years  of  age ;  her  defervescence  began  about  the  middle  of 
the  third  week.  On  the  seventeenth  day  the  morning  temperature  was 
normal,  and  on  the  twenty-first,  defervescence  was  complete.  On  the 
twenty-third  day  after  the  beginning  of  the  sickness,  the  patient  suddenly 
complained  of  severe  pain  in  the  abdomen  and  had  a  chill,  which  was 
followed  by  vomiting,  intense  nausea,  and  thirst ;  the  axillary  temperature 
was  104.5°  F. ;  the  belly  tense  and  tender ;  the  pulse  small,  hard,  and  140. 
Decubitus  was  dorsal  with  the  knees  drawn  up.  The  whole  abdomen  was 
exquisitely  tender  upon  palpation,  the  focus  of  tenderness  being  in  the 
right  iliac  fossa.  The  urine  contained  a  trace  of  albumin  and  a  few  hya- 
line casts.  Recover}'  took  place  in  tliree  weeks.  On  two  occasions  in  the 
course  of  the  following  month,  however,  a  larger  meal  than  usual  was 
followed  by  fever,  lasting  two  or  three  days,  and  by  tenderness  in  the  right 
iliac  fossa. 


'  Tmite  dcs  Maladies  dos  Enfans,  2e  cd.,  Paris,  1853. 
2  Philadelphia  Medical  Times,  Dec.  11,  1886. 


470  ENTERIC    OR    TYPHOID    FEVER. 

Strumpell  has  seen  as  a  result  of  the  peritoneal  bands  and  false  mem- 
branes thus  produced  complete  occlusion  of  the  intestine  :  the  age  of  the 
patient  is  not  stated. 

The  spleen  is  very  generally  enlarged :  in  this  respect  enteric  fever  does 
not  differ  from  many  of  the  other  acute  infectious  diseases.  The  enlarge- 
ment of  the  spleen  is,  however,  so  frequent  and  so  considerable  in  this 
disease  that  it  has  acquired  a  certain  sort  of  diagnostic  importance. 

The  difficulty  of  determining  with  satisfactory  precision  the  area  of 
splenic  dulness  in  enteric  fever  is  often  considerable  in  adult  life,  not  infre- 
quently impossible  in  childhood.  It  is  a  difficulty  sometimes  due  to  lesions 
of  the  left  lung  and  pleura,  sometimes  to  the  distention  of  the  colon  by  gas, 
and  very  often  to  the  restlessness  of  the  patient.  When  the  enlargement  is 
considerable,  it  may  often  be  readily  made  out  by  gentle  palpation,  especially 
at  the  moment  of  deep  inspiration.  It  is  sometimes  tender  upon  pressure. 
There  appears  to  be  no  relation  between  the  degree  of  splenic  enlargement 
and  the  severity  of  the  case.  The  area  of  splenic  dulness  usually  begins  at 
the  lower  border  of  the  seventh  rib  or  in  the  neighborhood  of  the  sixth  rib. 

In  a  proportion  of  the  cases  the  methods  of  physical  examination  fail 
to  reveal  splenic  enlargement.  The  splenic  tumor  may  occasionally  be 
made  out  as  early  as  the  third  or  fourth  day ;  in  most  instances,  however, 
not  until  the  sixth  or  even  the  ninth  day.  The  more  raj^id  the  rise  in 
fever,  the  earlier  does  the  spleen  enlarge.  The  enlargement  of  this  organ 
begins  to  subside  with  defervescence ;  exceptionally  the  spleen  remains 
enlarged  for  some  days  after  convalescence  is  established. 

In  cases  of  relapse  the  spleen  has  been  occasionally  found  enlarged 
during  the  interval  between  the  primary  attack  and  the  relapse. 

Pain  in  the  splenic  region  is  rare ;  it  may  result  from  laceration  of  the 
distended  capsule.  Softening  infarcts  may  prove  the  starting-point  of 
peritonitis. 

The  Nervous  System. — The  symptoms  of  disturbance  of  the  nervous 
system  are,  as  a  rule,  much  less  marked  in  infancy  and  childhood  than  in 
adult  life.  In  some  of  the  cases  decided  nervous  synipt(jms  are  lacking 
throughout  the  whole  course  of  the  disease ;  in  the  greater  number,  however, 
manifestations  of  disturbance  of  the  nervous  system  are  present.  Headache, 
increased  towards  evening,  frequently  occurs  during  the  period  of  pro- 
dromes and  the  first  week  of  the  disease ;  it  is  commonly  referred  to  the 
forehead  or  temples  ;  it  may  affect  the  whole  head ;  it  is  occasionally  neui'al- 
gic  in  character,  and  may  be  intense ;  it  almost  always  subsides  about  the 
end  of  the  first  week. 

The  cliild  is  usually  apathetic  and  indifferent,  even  in  cases  of  moderate 
severity ;  it  lies  with  its  eyes  half  closed,  lightly  somnolent,  sometimes  rest- 
less ;  when  spoken  to,  turning  away,  or  answering  in  monosyllables  with 
the  evidences  of  irritation,  often,  even  in  advanced  childliood,  refusing  to 
show  its  tongue,  or,  if  showing  it,  forgetting  for  a  few  moments  to  draw  it 
in  again,  unless  told  to  do  so.     There  is  dulness  of  hearing,  sometimes 


ENTERIC  OR  TYPHOID  FEVER.  471 

amounting  to  marked  deafness.  Dilatation  of  the  pupils  is  common. 
Sleep  is  restless  and  disturbed ;  not  infrequently  wakefulness  shows  itself 
as  a  distressing  symptom.     Dizziness  is  not  rare. 

Among  the  nervous  symptoms  must  be  mentioned  cutaneous  hyperses- 
thesia,  which  is  often  well  marked  and  extensive. 

Delirium  is  usually  mild ;  it  is  more  apt  to  occur  in  the  evening  or 
towards  night,  and  is  sometimes  associated  with  night-terrors.  The  com- 
mon form  in  childhood  is  the  so-called  wandering  delirium ;  it  is  apt  to  be 
transient  and  recurrent  rather  than  continuous.  The  severer  forms  of 
nervous  disturbance  are  infrequent,  and  present  themselves  only  in- grave 
cases.  In  infants  and  young  children,  nocturnal  delirium  is  sometimes 
accompanied  or  rej)laced  by  sudden,  sharp,  and  prolonged  outcries,  with 
excitement  not  easy  to  pacify.  In  older  children,  and  especially  at  the  age 
of  puberty,  the  manifestations  of  the  disturbance  of  the  nervous  system  are 
often  fully  developed,  so  that  we  encounter  active  delirium  accompanied  by 
efforts  to  leave  the  bed,  deep  stupor,  and  tremor  of  the  hands  and  tongue. 
Slight  twitching  of  the  muscles  of  the  face  and  of  the  tendons  of  the  wrists 
and  hands  also  occurs.  It  is  to  these  motor  disturbances  that  the  name 
subsultus  tendiuum  was  given  by  the  older  writers.  Plucking  at  the  bed- 
clothes is  not  common,  even  in  the  worst  cases  of  the  disease,  in  childhood. 

Grinding  with  the  jaws  occurs  as  an  ominous  symptom.  Persistent 
tremor  of  the  extremities  and  lower  jaw  is  apt  to  be  associated  with  increased 
tendon  reflexes  and  mechanical  excitability  of  the  muscles.  In  deep  coma 
the  muscles  become  lax,  the  movements  of  the  eyes  are  no  longer  co-ordi- 
nated, reflex  excitability  is  diminished,  involuntary  evacuation  of  the  bowels 
takes  place,  and  there  is  often  retention  of  urine. 

The  view  advocated  by  Griesinger  and  Liebermeister,  and  at  one  time 
universally  entertained,  that  the  nervous  symptoms  are  due  to  the  prolonged 
high  temperature,  is  no  longer  generally  accepted.  It  is  much  more  prob- 
able that  the  high  temperature  and  the  nervous  symptoms  have  a  common 
cause  in  the  toxic  principles  with  which  the  blood  is  charged  during  the 
■course  of  the  disease. 

A  number  of  nervous  aifections  develop  in  the  course  of  enteric  fever  or 
after  its  decline. 

As  has  been  already  pointed  out  in  speaking  of  the  anatomical  lesions 
of  the  disease,  actual  meningitis  is  exceedingly  rare,  notwithstanding  the 
comparative  frequency  of  symptoms  suggestive  of  its  presence.  In  recent 
years,  the  occurrence  of  cases  characterized  by  associated  convulsions,  paraly- 
sis, hypersesthesia,  and  opisthotonus,  with  the  discovery  upon  examination 
post  mortem  of  the  lesions  of  cerebro-spinal  meningitis,  has  placed  this 
affection  indisputably  among  tlie  complications  of  enteric  fever. 

As  regards  the  etiology  of  meningitis  as  a  complication  of  enteric  fever, 
two  views  may  be  advanced  :  first,  that  of  localization  of  the  typhoid  in- 
fection upon  the  meninges  ;  and,  second,  that  of  mixed  infection.  In  the 
present  state  of  knowledge,  this  question  cannot  be  decided,     I  believe  it 


472  ENTERIC   OR   TYPHOID    FEVER. 

more  in  accordance  with  the  natural  history  of  enteric  fever  and  cerebro- 
spinal fever  to  explain  their  association  on  the  principle  of  mixed  or  inde- 
pendent infection. 

Neuralgia  occasionally  occurs ;  it  is  sometimes  present  in  the  beginning 
of  the  attack,  but  is  much  more  apt  to  occur  during  convalescence.  Its 
most  common  seat  is  in  the  area  of  distribution  of  the  trigeminal  and  occip- 
ital nerves.  Pains  in  the  feet  and  ankles,  with  tenderness  upon  pressure 
and  disturbances  of  sensibility  and  in  some  instances  slight  localized  oedema, 
occasionally  occur  during  convalescence.  These  pains  are  due  to  a  subacute 
peripheral  neuritis. 

Among  the  rare  nervous  accidents  of  enteric  fever  in  children  are  para- 
plegia, hemiplegia,  paralysis  of  the  muscles  of  the  eye  and  of  the  larynx,'^ 
and  paralysis  of  single  muscles,  as,  for  example,  the  serratus  magnus,  or  of  a 
single  extremity.  These  accidents  usually  occur  during  convalescence.  Their 
tendency  is  to  recovery,  which  takes  place,  as  a  general  rule,  in  the  course 
of  some  weeks  or  months. 

Aphasia  is  much  more  common  in  children  than  in  adults.  It  is  very 
often  complete.  It  likewise  usually  appears  during  the  period  of  defer- 
vescence or  in  the  early  days  of  convalescence,  never  during  the  height 
of  the  fever.  It  usually  passes  away  gradually  in  the  course  of  ten  days  or 
two  weeks.  As  Gowers^  has  pointed  out,  although  there  is  almost  complete 
speechlessness,  there  is  no  disorder  of  speech  or  partial  loss  of  speech,  such 
as  occurs  in  cases  of  organic  disease  of  the  brain. 

Angel  Money  ^  states  that  in  cases  of  typhoid  fever  the  knee-jerk  is 
exaggerated  and  that  there  is  occasional  distinct  clonus  of  the  quadriceps 
extensor.  This  observer  found  that  the  muscular  irritability  was  greatly 
increased,  and  that  when  there  was  a  marked  degree  of  irritability  the 
ankle  clonus  was  usually  present  and  easily  elicited.  I  have  observed 
that  in  deeply  soporose  cases  the  tendon  reflexes  and  mechanical  irritability 
of  the  muscles  are  distinctly  diminished.  In  a  boy  nine  years  old  under 
my  charge  at  the  Philadelphia  Hospital,  the  knee-jerk,  absent  during  the 
height  of  the  fever,  only  slowly  reappeared  although  convalescence  was- 
almost  completed.  In  another  case,  that  of  an  adult,  in  the  same  institu- 
tion, there  was  complete  abolition  of  the  knee-jerk. 

The  electrical  reactions  are  found  by  Money  to  be  altered  both  quantita- 
tively and  qualitatively,  the  faradic  excitability  as  well  as  the  galvanic,  but 
the  faradic  excitability  is  rapidly  exhausted.  "  There  is  also  a  qualitative 
change  in  the  galvanic  reactions.  The  contraction  with  negative  break  occurs 
with  a  much  feebler  current  than  in  health,  and  the  contraction  from  positive 
may  occur  as  early  as  the  contraction  with  negative  make.  These  facts  show 
that  we  have  not  to  do  with  the  ordinary  reaction  of  degeneration." 


1  Landouzy,  Des  Paralysies  dans  les  Maladies  aigues,  1880. 

2  Diseases  of  the  Nervous  System,  Amer.  ed.,  1888. 
^  Lancet,  Nov.  7,  1885. 


ENTERIC   OR   TYPHOID    FEVER.  473 

The  cutaneous  reflexes,  as  the  plantar,  cremasteric,  epigastric,  abdominal, 
scapular,  and  gluteal  reflexes,  are  increased.  These  reflex  disturbances  come 
on  usually  in  the  second  week,  and  gradually  increase  till  defervescence, 
persisting  for  some  days  or  a  week  or  two  into  convalescence. 

General  convulsions  have  no  place  in  the  symptomatology  of  enteric  fever 
even  in  childhood.  When  present  in  the  early  stages  of  the  disease,  they  are 
either  the  manifestation  of  some  pre-existing  disorder  or  indicate  an  accidental 
irritation  of  the  intestinal  tract ;  in  the  later  stages  they  may  be  due  either 
to  a  developing  meningitis  or  to  nephritis  occurring  as  complications. 

The  Urine. — Systematic  examinations  of  the  urine  are  much  more  diffi- 
cult in  voung  children  than  in  adults.  Transitory  albuminuria  occurs  with 
sufficient  frequency  to  merit  consideration  as  a  symptom  rather  than  as  a 
complication.  The  amount  of  albumin  is  usually  slight,  and  casts  are  rarely 
present.  Bouchard  has  pointed  out  the  fact  that  the  bacillus  typhosus  is 
found  only  in  albuminous  urine.  Seitz  found  in  cultures  from  the  urinary 
deposit  in  seven  cases  the  bacillus  typhosus  present  in  two  only.  In  those 
two  cases  the  urine  was  albuminous  and  the  number  of  the  colonies  obtained 
was  proportionate  to  the  amount  of  albumin.  Enteric  fever  differs  from 
scarlatina  in  the  extremely  rare  occurrence  of  acute  nephritis  as  a  sequel. 
Retention  of  urine  is  much  less  common  in  childhood  than  in  adult 
life ;  nevertheless  it  occasionally  occurs ;  catheterization  is  then  necessary. 
Vesical  catarrh,  urethritis,  and  epididymitis  are  liable  to  result  from  want 
of  proper  precaution  in  the  disinfection  of  the  catheter.  Polyuria  has  been 
observed  in  the  course  of  the  disease  in  children. 

Menstruation  in  girls  at  puberty  is  apt  to  be  profuse  and  prolonged.  In 
a  girl  of  fourteen  years,  recently  under  observation,  menstruation  occurred 
for  the  first  time  during  the  attack  and  continued  for  a  fortnight.  This 
case  was  one  of  great  severity  and  terminated  fatally. 

The  Skin. — The  rose  spots  peculiar  to  the  disease  differ  in  no  respect 
from  the  eruption  as  seen  in  adults.  They  appear  as  scattered,  pale-red, 
slightly-elevated  (papulo-erythematous)  spots  of  an  oval  or  irregularly  cir- 
cular shape,  varying  in  diameter  from  one  and  one-half  to  three  lines. 
They  disappear  upon  pressure  or  when  the  skin  is  made  tense  by  traction. 
They  occur  in  crops  from  time  to  time  during  the  disease,  single  spots 
remaining  present  from  two  to  three  days.  They  are  at  first  distinctly 
marginate,  but  in  fading  their  color  blends  with  the  surrounding  skin,  and 
there  remains  a  faint  brownish-yellow  pigmentation,  which  only  gradually 
wholly  disappears.  They  are  to  be  looked  for  upon  the  abdomen,  the  lower 
part  of  the  chest  anteriorly,  and  posteriorly  between  the  shoulder-blades ; 
exceptionally  they  are  found  upon  the  anterior  and  inner  surface  of  the 
thighs.  In  three  instances  in  children  where  the  eru]ition  was  otherwise 
relatively  scanty  I  have  seen  it  upon  the  fiice.  In  a  small  proportion  of 
the  cases  the  spots  are  absent  during  the  whole  course  of  the  disease ;  as  a 
rule,  they  are  not  numerous ;  exceptionally  they  arc  abundant  and  are  dis- 
tributed to  some  extent  upon  the  extremities.     The  appearance  of  the  erup- 


474  ENTERIC    OE    TYPHOID    FEVEE. 

tion  is  usually  coincident  with  the  occurrence  of  the  splenic  enlargement. 
Where  the  fever  appears  suddenly  and  rapidly  increases  in  intensity  the 
eruption  may  sometimes  be  found  as  early  as  the  fourth  or  fifth  day.  In  a 
majority  of  cases  it  is  first  found  somewhere  between  the  seventh  and  tenth 
days,  and  rarely  not  until  the  end  of  the  second  week.  Upon  the  occurrence 
of  defervescence  no  more  crops  appear.  If  relapses  take  place,  the  eruption 
again  makes  its  appearance. 

Sudamina  occur  in  childhood  as  in  adult  life.  They  make  their  appear- 
ance abundantly  over  the  lower  part  of  the  abdomen,  coincidently  with  the 
free  sweating  w^hich  occurs  in  the  latter  period  of  the  febrile  movement. 

True  petechia  rarely  occur.     They  are  of  unfavorable  prognostic  import. 

Herpes  labialis  is  very  rare. 

Boils  may  occur,  and  abscesses  in  the  integuments,  the  muscles,  or  the 
intramuscular  connective  tissue  are  met  with  infrequently.  Suppuration  of 
the  lymphatic  glands  of  the  axilla  or  in  other  regions  may  also  occur.  In- 
flammation of  the  parotid  gland  is  exceptionally  met  with  in  childhood  as 
in  adult  life.  Superficial  bed-sores  may  occur  in  children  who  are  not  care- 
fully nursed.  Their  most  frequent  site  is  over  the  sacrum  and  trochanters  ; 
occasionally  they  form  at  the  elbows,  heels,  or  occiput.  The  hair  falls  out 
during  convalescence.  The  new  hair  is  often  lacking  in  lustre,  but  grad- 
ually acquires  its  normal  appearance.  The  nails,  both  of  the  hands  and  of 
the  feet,  show  transverse  markings  that  indicate  the  impaired  nutrition  of 
the  tissues  during  the  attack.  These  markings  extend  across  the  whole 
width  of  the  nail.  The  portion  of  the  nail  developed  during  the  attack  is 
duller  than  the  rest,  rough,  white,  and  more  or  less  thin.  Similar  changes 
occur  during  the  course  of  other  acute  febrile  diseases. 

A  diffuse,  faint,  er}i:hematous  rash  is  not  infrequently  observed  in  chil- 
dren, and  even  in  adults  with  white  delicate  skins,  chiring  the  first  week. 
It  is  usually  most  marked  over  the  abdomen  and  upon  the  flexor  surface  of 
the  limbs.  It  disappears  upon  pressure.  Its  usual  duration  does  not 
exceed  three  or  four  days,  although  jMurchison  states  that  it  occasionally 
persists  throughout  the  course  of  the  fever.  When  more  than  usually 
intense  and  associated  with  a  slight  erythematous  sore  throat,  it  may  lead  to 
an  error  in  diao;nosis  and  be  mistaken  for  scarlatina. 

Taches  bleudtres — spots  of  a  delicate  bluish  or  bluish-brown  tint,  irregu- 
larly rounded  form,  three  to  eight  lines  in  diameter,  not  raised  above  the 
surrounding  surface,  nor  affected  by  pressure — are  occasionally  met  with  in 
enteric  fever  and  some  other  diseases  in  adults.    They  do  not  occur  in  children. 

Facial  erj'sipelas  occasionally  occurs  at  the  end  of  the  attack  or  during 
convalescence  in  childhood  as  in  adults  ;  in  the  former  it  is,  however,  a 
much  less  serious  complication.  It  is  apt  to  terminate  critically  in  the  course 
of  four  or  five  days.  Gerent^  collected  sixty-four  instances  out  of  3910 
cases,  at  all  ages,  observed  by  various  clinicians. 

1  These  de  Paris,  1883. 


ENTERIC    OE    TYPHOID    FEVER.  475 

Suppurative  otitis  media,  geuerally  one-sided,  is  by  no  means  an  infre- 
quent complication.  It  is  usually  of  moderate  intensity,  and  if  properly 
cared  for  terminates  in  complete  recovery  during  the  period  of  convalescence 
from  the  fever. 

Lesions  of  the  Osseous  System. — Inflammatory  changes  in  the  bones  are 
relatively  common  in  infancy  and  adolescence.  The  process  implicates, 
according  to  Gelez,'  alike  the  substance  of  the  bones,  the  marrow,  and  the 
periosteum.  Keen,^  of  Philadelphia,  reported  in  1878  an  important  series 
of  cases  of  disease  of  the  bones  occurring  after  enteric  fever.  Of  forty-one 
cases  studied  by  Mercier,^  the  age  of  the  patient  was  below  twenty  years  in 
nineteen  cases ;  between  twenty  and  thirty  years  in  eleven  cases ;  between 
thirty  and  forty  years  in  six  cases ;  and  over  forty  years  in  five  cases. 

The  relative  frequency  with  which  the  divisions  of  the  skeleton  are 
implicated  is  indicated  by  the  following  table : 

Bones  of  the  head  . ' 22  cases. 

Trunk 7  cases. 

Superior  extremity 6  cases. 

Inferior  extremity 42  cases. 

The  symptoms  are  local.  There  is  pain,  at  first  vague,  speedily  becoming 
localized,  usually  severe,  lancinating,  aggravated  at  night  often  to  such  a 
degree  as  to  render  sleep  impossible.  The  pain  is  associated  with  great 
tenderness.  Localized  tumefaction  of  the  soft  parts,  with  or  without  red- 
ness, speedily  follows.  After  a  time  fluctuation  appears,  and  one  or  more 
fistulous  openings  are  formed,  which  discharge  a  small  quantity  of  pus. 
These  sinuses  frequently  close  spontaneously,  only  to  open  again.  The 
usual  termination  is  thus  in  suppuration  and  necrosis. 

Lesions  of  the  bones  are  more  common  during  the  convalescence  from 
prolonged  attacks.  They  are  due  to  disturbances  in  the  blood-supply ; 
traumatism  plays  only  a  secondary  part  in  their  causation. 

Early  surgical  intervention  is  imperatively  demanded. 

Spontaneous  dislocations  are  among  the  rare  accidents  of  enteric  fever 
in  childhood.  They  are  of  the  nature  of  "  distention-luxations,"  and  are 
probably  due  to  subacute  synovitis  with  gradual  serous  distention  of  the 
capsular  ligament.  They  have  been  fully  described  by  Keen,  who  collected 
forty-three  cases  at  all  ages,  in  which  spontaneous  dislocation  occurred 
twenty-seven  times  in  the  hip,  twice  in  the  shoulder,  and  once  in  the  knee. 
Fifteen  of  the  hip  cases  occurred  in  enteric  fever ;  a  number  of  these  were 
in  children  under  fifteen  years  of  age. 

In  a  boy  aged  eleven  years  and  eight  months,  the  subject  of  rickets  in 
infancy,  but  otherwise  licalthy  and  of  healthy  parentage,  Woronichin*  ob- 
served acute  hip-joint  disease  developed  in  the  early  convalescence  from 

1  These  de  Paris,  1884.  2  Toner  Lecture,  v.,  1877. 

'  Revue  Mensuelle  de  Med.  et  de  Chirurg.,  No.  3,  1879,  pp.  21  et  seq. 
*  Jahrbuch  fiir  Kinderheilkunde,  N.  F.,  xxiv.,  1884. 


476  ENTERIC    OR    TYPHOID    FEVEE. 

an  attack  of  enteric  fever  in  which  defervescence  was  complete  upon  the 
twenty-first  day. 

Henoch^  saw  in  a  boy  eleven  years  old  in  the  third  week  of  convales- 
cence from  enteric  fever  a  synovitis  of  the  left  wrist-joint,  and  encountered 
in  another  case  a  synovitis  of  the  right  knee-joint. 

Freundlich^  observed  among  two  hundred  and  twenty-eight  cases  of 
enteric  fever  acute  synovitis  of  different  joints  in  four  cases.  On  the  other 
hand,  Griesinger,  Barthez  and  Rilliet,  Steiner,  West,  and  others  make  no 
mention  of  diseases  of  the  joints  as  sequels  of  enteric  fever. 

Complications  and  Sequels. — In  the  foregoing  analysis  of  the  special 
symptoms  it  has  been,  necessary  to  allude  frequently  to  the  complications  of 
enteric  fever;  to  consider  the  complications  in  detail  would  necessitate  much 
unnecessar}'-  repetition  and  unduly  extend  the  limits  of  this  article.  A  few 
additional  remarks  are,  however,  necessary. 

It  is  obvious  that  no  hard-and-fast  line  can  be  drawn  between  the  com- 
plications of  an  acute  febrile  disease  and  the  mere  intensification  of  certain 
processes  with  corresponding  prominence  of  local  symptoms.  I  am  in  the 
habit  of  regarding  intestinal  hemorrhage,  perforation,  and  peritonitis  as 
complications.  To  the  same  category  it  seems  proper  to  refer  such  results 
of  parenchymatous  degeneration  as  atrophy  of  muscles,  abscess  of  muscles, 
parotitis,  and  nephritis.  The  category  to  which  hypostasis,  oedema,  throm- 
bosis, embolism,  and  infarction,  with  their  results,  should  be  referred  is  a 
matter  of  opinion.  Whether  these  processes  should  be  regarded  as  belong- 
ing to  the  primary  disease  or  as  complications  of  it  would  depend,  to  a  great 
extent,  upon  the  prominence  of  the  morbid  phenomena  to  which  they  give 
rise.  On  the  other  hand,  pneumonia,  erysipelas,  phlegmonous  abscesses, 
diphtheria,  and  other  septic  processes  are  obvious  complications,  concerning 
the  relation  of  which  to  the  original  disease  there  can  be  no  question. 

Enteric  fever  during  its  course  confers  no  immunity  from  the  ordinary 
diseases  of  childhood. 

Scarlatina  may  immediately  precede,  coexist  with,  or  follow  enteric  fever. 
Taupin,  Murchison,  and  others  have  recorded  instances  in  which  patients 
suifering  from  scarlet  fever  have  developed  enteric  fever,  or  in  which  the 
enteric  fever  has  merged  into  scarlatina,  and  other  instances  in  which  the 
eruptions  of  the  two  diseases  have  coexisted. 

Measles  may  also  develop  during  the  course  of  typhoid  fe\^r.  Instances 
of  this  association  of  the  two  diseases  have  been  reported  by  Ivesteven,^ 
Barthez  and  Rilliet,*  and  Ringer.^  Quite  recently,  Chrystie^  has  reported 
an  interesting  case  of  this  kind.  (See  Chart  Y .)  A  boy  in  his  twelfth  year 
was  doing  fairly  well  during  the  third  week  of  a  well-characterized  attack 
of  enteric  fever ;  on  the  sixteenth  day  of  his  attack  two  other  children  in 


1  Yorlesungen  iiber  Kinderkrankheiten,  1881. 

2  Deutsches  Archiv  fiir  Kliuische  Mcdicin,  Bd.  xxxiii.  Hft.  3  u.  4,  1883. 

3  Lancet,  vol.  i.,  1866.  *  Loc.  cit. 

5  Lancet,  June  30,  1888.  ^  University  Medical  Magazine. 


rv^"     "*  "" 

T 

S 

K 

% 

1 

1 

K  "7~ 

<• 

N 

1 

&; 

s 

T^ 

-I'                            4- 

S 

> 

1     T         j_ 

P^^ 

^-. 

T^^ 

S 

r^ 

E 

! 

<s, 

s 

j 

^•> 

•>i ^ 

fi 

1 

^.^-i  _■__  _z: 

S 

1      1 

L 

J_i:i>- 

K 

"*"n^- 

S 

"^ 

> 

H 

"ffzT 

L                      4-  - 

s 

^_^-- 

S 

K 

•■ 

s^^ 

g 

--  ;^5-- 

1 

w 

T-il 

s 

^^ 

H 

-S^<^ 

s 

-■-4-. 

L. 

H 

"^■>^ 

j 

s 

"^ 

P^ 

w 

<r 

S 

:>• 

H  1 

\~ 

r-r-.^ 

S 

J__      „ -.^Jp 

H 

''^'-•^ 

_^ 

S 



J_ICi=j-l 

1 

P-q 

"        T" 

4^^ 

±1 

g 

"■"■ 

^    1 

w 

]< 

,__^ 

s 

^^ 

'-r 

w 

1       *" 

T^--^ 

g 

"j^ 

w 

1 

'~""~— L^ 

S 

T__L 

"Ft 

H 

*'-^JI 

S 

i  i= 

*■        J 

H 

"'f^^^ 

IS 

"T5=i=" 

w 

'^--^ 

s 

il 

■"::>:>■ 

w 

•r= 

p±!__ 

s 

1   ~~77 

p4 

! 

1         "si^ 

s 

1        2> 

H 

Ll 

*T^rL.^^                        j 

s 

1 

1           -      - 

■>■            i 

w 

--------S^I---" 

S     ! 

\ 

___4:_  _Ji>  ___ 

f4     i 

1 

i           1 

-fi  1 

-:± 

1 

i  1 

J_       J_ 

^  j±  1 

o   a 


s    o. 


ENTERIC    OR    TYPHOID    FEVER.  477 

the  house  developed  measles ;  ou  the  twenty-third  day  the  enteric  fever 
patient  shoAved  the  symptoms  of  measles ;  five  days  later  his  respiration 
became  embarrassed,  and  he  died  in  convulsions  with  a  temperature  of 
106°  F.  A  number  of  instances  have  been  recorded  in  which  measles  has 
developed  during  the  convalescence  from  enteric  fever. 

Pertussis  has  likewise  been  observed  during  the  course  of  enteric  fever. 
Gillespie  ^  has  reported  a  case  of  this  kind. 

The  coexistence  of  diphtheria  and  enteric  fever  is  much  more  frequent. 

Tuberculous  infection  often  occurs  during  or  immediately  after  enteric 
fever  :  hence  pulmonary  phthisis  is  not  a  rare  sequel.  Tuberculous  menin- 
gitis and  tuberculous  ulceration  of  the  intestine  are  also  encountered  as 
sequels. 

I  have  reported  a  case  of  enteric  fever  in  a  precociously  developed  girl 
at  the  age  of  puberty  in  which  death  occurred  at  the  end  of  the  first  week 
from  intercurrent  fulminant  peritonitis  of  pelvic  origin.  At  the  autopsy 
the  lesions  of  botli  conditions  were  found.  The  peritonitis  resulted  from 
acute  double  septic  salpingitis.^ 

Crural  phlebitis,  which  was  noted  in  fully  one  per  cent,  of  the  cases  under 
Murchison's  care,  does  not  occur  in  childhood. 

Arterial  thrombosis  resulting  in  spontaneous  gangrene  is  among  the 
rarest  of  the  accidents  of  enteric  fever  in  childhood. 

Asch^  reported  a  case  of  abscess  of  the  liver  occurring  as  a  sequel  of 
enteric  fever  in  a  previously  healthy  boy  tAv^elve  years  of  age.  The  primary 
disease  ran  its  course  without  notable  complications.  On  the  twenty-first 
day  there  was  vomiting,  which  was  repeated  on  the  following  morning. 
On  the  twenty-seventh  day  there  was  a  violent  chill,  and  the  temperature 
rose  to  41.1°  C.  (106°  F.).  Two  days  later  the  patient  complained  of  pairi 
in  the  region  of  the  liver,  and  a  tense,  elastic  tumor  reaching  to  the  navel 
was  observed ;  there  was  no  fluctuation ;  jaundice  was  not  observed ;  the 
spleen  was  only  moderately  enlarged,  and  there  was  no  distention  of  the 
sujDcrficial  epigastric  veins.  The  type  of  the  fever  was  remittent ;  the 
patient  sank  rapidly,  suifered  from  profuse  sweating,  was  delirious,  and 
died  in  collapse  on  the  thirty-fifth  day.  Upon  post-mortem  examination, 
there  were  found  typhoid  ulceration  of  the  intestines  in  the  stage  of  cica- 
trization, and  a  liver-abscess,  the  result  of  a  pylephlebitis  due  to  suppura- 
tion of  the  mesenteric  glands.  On  the  upper  surface  of  the  right  lobe  of 
the  liver,  which  was  attached  to  the  diaphragm  by  recent  adhesions,  were 
eight  or  ten  small  abscesses.  A  larger  abscess  occupied  the  substance  of  the 
right  lobe.  In  this  case  there  was  no  repetition  of  the  chill  which  occurred 
on  the  twenty-seventh  day. 

Burder*  has  reported  the  case  of  a  boy  nine  years  old  in  which  the 

1  Edin.  Med.  Jour.,  May,  1870. 

2  Archives  of  Pediatrics,  July,  1887. 

3  Berlin.  Klin.  Wochenschrift,  1882,  51. 
*  Lancet,  1874,  ii.  552. 


478  ENTERIC   OR    TYPHOID    FEVER. 

liver  upon  post-mortem  examination  was  found  to  be  the  seat  of  a  number 
of  small  abscesses  and  there  was  superficial  ulceration  of  the  Peyer's 
patches. 

Diagnosis. — The  diagnosis  of  well-developed  cases  of  enteric  fever  in 
childhood  after  the  first  week  is  usually  unattended  with  difficulty.  During 
the  first  week,  however,  it  is  often  impossible  to  form  a  positive  diagnosis ; 
but  even  then  the  nature  of  the  disease  may  be  suspected  if  there  be  febrile 
movement  with  nocturnal  exacerbations  each  night  attaining  a  higher  tem- 
perature, and  especially  if  there  be  bleeding  at  the  nose,  diarrhoea,  either 
spontaneous  or  readily  produced  by  laxatives,  appreciable  enlargement  of 
the  spleen,  and  headache. 

The  direct  diagnosis  of  the  developed  disease  rests  upon  the  continuance 
of  the  febrile  movement  and  the  appearance  of  abdominal  symptoms, — 
namely,  diarrhcea,  abdominal  pain,  moderate  tympany,  and  enlarged  spleen. 
If,  in  addition  to  these  phenomena,  lenticular  rose  spots  appear,  the  diag- 
nosis becomes  certain. 

Plate  or  potato  cultures  of  blood  drawn  from  the  spleen,  of  the  sediment 
of  the  urine  when  albuminous,  or  of  the  faecal  discharges,  affiDrd  an  addi- 
tional means  of  diagnosis  in  obscure  cases. 

More  useful,  because  more  available,  as  a  means  of  diagnosis,  is  the 
occurrence  of  well-marked  typical  cases  in  adults  or  children  in  the  same 
house  or  locality.  It  is  not  easy  to  exaggerate  the  importance  of  the  light 
shed  upon  doubtful  cases  by  coincident  or  recently-preceding  house  and 
local  epidemics. 

The  diiferential  diagnosis  from  the  other  febrile  disorders  which  more 
or  less  closely  resemble  enteric  fever  is,  in  the  absence  of  the  characteristic 
eruption  and  the  abdominal  symptoms,  sometimes  attended  with  consider- 
able difficulty. 

The  diseases  with  which  enteric  fever  in  childhood  is  likely  to  be 
confounded  may  be  divided  into  two  groups :  first,  those  which  resemble 
it  in  the  first  Aveek  of  its  course ;  and,  secondly,  those  which  resemble  it 
in  its  more  advanced  stages.  To  the  first  group  belong  simple  continued 
fevers  and  the  exanthematous  diseases.  Diarrhoea  is  not,  however,  present 
in  these  diseases,  nor  is  their  onset  characterized  by  the  occurrence  of  marked 
prodromes.  Furthermore,  the  character  of  the  temperature-range  of  all  these 
affections  differs  greatly  from  that  of  enteric  fever,  being  marked  by  an 
abrupt  rise  Mdiich  lacks  the  distinct  morning  remissions  of  the  typhoid  and 
attains  its  maximum  with  greater  rapidity.  Moreover,  simple  continued 
fever  comes  to  an  end  in  less  time  than  is  required  for  the  full  development 
of  typhoid.  The  exanthemata  cannot  be  distinguished  from  enteric  fever 
with  absolute  certainty  in  their  pre-emptive  periods :  notwithstanding  this, 
the  presence  of  naso-pulmonary  catarrh  in  a  doubtful  case  would  lead  us 
to  suspect  measles,  or  a  sore  throat  would  lead  us  to  suspect  scarlet  fever, 
while  the  intensity  of  the  febrile  movement  and  the  lumbar  pains  in  small- 
pox serve  to  distinguish  it  in  its  early  stages  from  enteric  fever. 


EXTEEIC   OR   TYPHOID   FEVER.  479 

After  the  first  week,  enteric  fever  may  in  some  instances  be  confounded 
with  the  following  diseases :  remittent  fever,  small-pox,  influenza,  entero- 
colitis, peritonitis,  meningitis,  tuberculosis,  and  trichinosis. 

Remittent  Fever. — Enteric  and  remittent  fevers  not  infrequently  prevail 
together  in  malarious  countries,  and  physicians  practising  in  such  regions 
are  familiar  with  the  form  of  fever  frequently  designated  typho-malarial, 
which  is,  in  fact,  enteric  fever  modified  by  malarious  influences.  On  the 
other  hand,  severe  remittent  fever  not  infrequently  presents  clinical  re- 
semblances to  enteric  fever,  particularly  when  complicated  with  marked 
intestinal  symptoms.  Thus,  vomiting,  diarrhoea,  splenic  enlargement,  cere- 
bral symptoms,  and  the  condition  known  as  the  typhoid  state  may  occur  in 
both  diseases.  The  more  important  points  of  distinction  are  found  in  the 
eruption  and  the  subcontinuous  or  imperfectly  remittent  character  of  the 
temperature-range  in  the  second  week  of  enteric  fever  and  its  longer  course. 

In  a  considerable  number  of  the  cases  formal  rules  for  the  discrimina- 
tion of  the  two  diseases  are  unavailing ;  only  by  prolonged  study  of  the 
complexus  of  symptoms  presented  by  the  patient  does  the  diagnosis  become 
possible. 

Bacteriological  investigation  will,  however,  at  once  and  definitely  deter- 
mine the  presence  or  absence  of  any  form  of  malarial  disease.  The  concur- 
rent testimony  of  all  observers  who  have  carefully  studied  the  subject  serves 
to  establish  the  fact  that  in  malarial  diseases,  properly  so  called,  the  blood- 
parasites  described  by  Laverau,  Marchiafava  and  Celli,  Golgi,  Osier,  Coun- 
cilman, and  others,  are  invariably  present  in  one  or  another  of  their  forms  ; 
that  is,  as  (1)  amoeboid  bodies  in  the  red  corpuscles ;  (2)  pigmented  bodies 
in  the  red  corpuscles ;  (3)  larger  solid  bodies  in  the  interior  of  the  red  cor- 
puscles; (4)  free  pigmented  crescents,  which  crescents  may  sometimes  be 
seen  to  develop  in  the  interior  of  the  red  corpuscles ;  (5)  rosette  forms ; 
(G)  scattered  small  bodies,  the  result  of  segmentation  of  the  rosette  forms, 
— described  with  great  fulness  by  Golgi ;  (7)  flagellate  organisms,  round  or 
ovoid  or  pear-shaped,  with  finely  granular  protoplasm  containing  pigment 
with  flagella  variable  in  number,  one,  three,  or  four  being  observed  at 
different  times ;  (8)  small  round  pigmented  bodies  one- fourth  to  one-half 
the  size  of  the  red  corpuscles. 

The  alisonce  of  the  characteristic  rash  of  enteric  fever  loses  its  diagnostic 
value  in  doubtful  cases,  in  view  of  the  fact  that  in  a  small  proportion  of  the 
cases  the  eruption  does  not  appear  during  the  whole  course  of  the  disease. 

Variola. — Murcliison  states  that  he  has  frequently  known  a  cojDious 
eruption  of  lenticular  spots  to  be  mistaken  for  small-])ox.  This  is  an  error 
that  should  under  no  circumstances  occur.  The  eruptions  are  essentially 
unlike :  they  differ  in  date  of  appearance,  in  character,  and  in  evolution. 
The  rose  rash  of  typhoid  rarely  appears  earlier  than  the  sixth  or  seventli 
day  of  the  illness.  It  is  only  in  exceptional  cases  present  upon  the  face. 
It  disappears  on  pressure,  and  undergoes  little  or  no  change  from  the  time 
of  its  appearance  until  it  begins  to  fade ;  that  of  variola  appears  during 


480  EXTEEIC    OR   TYPHOID    FEVEK. 

or  after  tlie  third  febrile  exacerbation  of  the  initial  stage, — that  is,  upon 
the  third  day  of  the  disease ;  it  shows  itself  first  upon  the  face  and  hair}^ 
scalp  ;  from  the  beginning  it  is  hard,  shot-like,  and  acuminate ;  it  under- 
goes characteristic  and  unmistakable  changes  with  great  rapidity,  and  leaves 
a  more  or  less  persistent  conspicuous  scar. 

Influenza  occasionally  closely  resembles  enteric  fever.  The  following 
symptoms  are  common  to  both  affections :  fever,  attended  by  weakness, 
sleeplessness,  delu'ium,  sweating,  sometimes  diarrhoea;  pulmonary  catarrh, 
deafness,  epistaxis,  and  dry,  red  tongue  are  likewise  seen  in  both.  The 
differential  diagnosis  rests  chiefly  upon  the  occurrence  of  influenza  in  wide- 
spread epidemics,  the  short  duration  of  the  attack,  the  at\'pical  temperature- 
curve,  and  the  absence  of  the  eruption  and  the  abdominal  symptoms  that 
are  usually  associated  with  the  diarrhoea  of  enteric  fever. 

Enteritis  and  entero-colitis  may  be  confounded  with  enteric  fever.  These 
are,  however,  local  diseases,  the  fever  and  constitutional  disturbances  of 
which  are  symptomatic.  The  spleen  is  not  commonly  enlarged,  rose  spots 
are  absent,  the  abdominal  pain  is  more  conspicuous  and  severe  than  that  of 
enteric  fever,  and  the  whole  attack  is  usually  of  comparatively  short  duration. 

Peritonitis  due  to  other  causes  than  perforation  is  to  be  discriminated 
from  that  arising  in  the  course  of  enteric  fever  by  the  antecedent  history  of 
the  case.  If  the  patient,  however,  does  not  come  under  observation  until 
after  the  appearance  of  the  symptoms,  it  may  be  impossible  to  determine 
whether  they  are  due  to  perforation  or  not. 

Meningitis,  whether  secondary  or  occurring  in  the  form  of  epidemic  or 
sporadic  cerebro-spinal  fever,  presents  marked  points  of  difference  from 
enteric  fever,  yet  this  disease  has  in  some  instances  been  at  first  mistaken 
for  it.  The  differential  diagnosis  would  be  determined  by  the  abrupt  onset, 
the  acute  headache,  the  frequent  vomiting,  the  constipation,  the  irregular 
temperature-curve,  the  rapid  evolution,  and  the  herpetic  and  petechial  erup- 
tions of  meningitis. 

Acute  tuberculosis  presents  many  points  of  resemblance  to  enteric  fever. 

The  chief  points  of  difference  are  these :  in  enteric  fever  the  tempera- 
ture-range is  typical  or  more  or  less  conformed  to  a  definite  type,  whereas 
that  of  tuberculosis  is  extremely  irregular.  In  enteric  fever  diarrhoea  and 
some  degree  of  t}Tnpany  are  common ;  in  tuberculosis  diarrhoea  is  rare  and 
the  abdomen  is  apt  to  be  flat  and  often  scaphoid.  In  enteric  fever  epistaxis 
and  enlargement  of  the  spleen  occur ;  in  tuberculous  meningitis  these  symp- 
toms are  rare  or  absent  altogether.  The  headache  of  enteric  fever  is  dull, 
while  that  of  tuberculous  meningitis  is  acute  and  commonly  associated  with 
intolerance  of  light  and  sound.  In  enteric  fever  vomiting  is  much  less 
common  than  in  tuberculous  meningitis.  Convulsions,  especially  in  the  early 
part  of  the  disease,  are  likewise  rare,  and  the  headache  of  enteric  fev^er,  as 
was  pointed  out  by  Jenner,  disappears  upon  the  occurrence  of  delirium, 
whereas  in  tuberculous  meningitis  headache  and  delirium  may  alternate 
from  the  beginning. 


ENTEEIC   OE   TYPHOID    FEVEE.  481 

Trichinosis. — lu  trichinosis  there  is  pyrexia  with  vomiting  and  diar- 
rhoea. The  rose  spots  do  not  occur,  and  epistaxis  and  enlargement  of  the 
spleen  are  rare,  while,  on  the  other  hand,  the  severe  muscular  pains  and  ten- 
derness due  to  the  myositis  peculiar  to  the  disease,  and  the  local  and  general 
oedemas  which  are  almost  constant  symptoms  in  trichinosis,  are  absent  in 
enteric  fever. 

Prognosis. — The  death-rate  among  children  in  the  first  year  is  high, 
especially  among  the  new-born.  Taking  all  the  cases  together,  the  mortality 
in  childhood  is  decidedly  lower  than  in  adults,  probably  not  exceeding  one 
per  cent.  The  published  statistics  relating  to  mortality  are  without  value, . 
except  as  showing  these  general  facts.  Enteric  fever,  like  all  the  acute 
infectious  diseases,  shows  an  extremely  variable  intensity  in  children,  the 
severe  cases,  however,  being  the  exception  rather  than  the  rule. 

Among  the  conditions  which  tend  to  make  the  prognosis  unfavorable 
are  (1)  the  previous  poor  health  of  the  patient,  hereditary  syphilis,  local  or 
pulmonary  tuberculosis,  chronic  catarrhal  bronchitis,  previous  unwholesome 
sanitary  surroundings,  improper  food,  or  other  causes  tending  to  impair  the 
powers  of  resistance  of  the  organism ;  (2)  the  intensity  of  the  infection  as 
manifested  by  the  rapid  development  of  severe  symptoms,  intense  pyrexia, 
failure  of  heart-power,  ataxic  phenomena,  and  the  occurrence  of  multiple  cases 
in  the  same  house  or  in  the  immediate  locality  ;  (3)  intestinal  symptoms  of 
a  high  grade,  as  copious  diarrhoea,  meteorism,  abdominal  pain,  and  the  like. 
It  is  to  be  added  that  prolonged  and  intractable  vomiting  has  an  ominous 
prognostic  import.  Finally,  (4)  complications,  as  intestinal  hemorrhage, 
perforation,  local  or  general  peritonitis,  ulcerative  endocarditis,  meningitis, 
nephritis,  diphtheria,  croupous  pneumonia,  pleural  effusions,  and  the  acute 
exanthemata,  arising  as  intercurrent  or  consecutive  affections,  render  the 
prognosis  extremely  grave. 

Treatment. — This  division  of  the  subject  embraces  the  following  topics, 
each  of  which  demands  separate  consideration :  1,  prophylaxis ;  2,  general 
management  of  the  patient,  and  dietetics  ;  3,  special  forms  of  treatment,  and 
the  treatment  of  symptoms,  complications,  and  sequels ;  4,  the  management 
of  the  patient  during  convalescence. 

Prophylaxis. — A  knowledge  of  the  cause  of  enteric  fever  and  of  the 
ways  by  which  the  disease  is  propagated  warrants  the  confident  belief  that 
it  may  not  only  be  greatly  restricted  in.  its  prevalence,  but  may  even  be 
ultimately  got  rid  of  altogether. 

An  efficient  prophylaxis  is  theoretically  within  reach ;  its  practical 
results  in  localities  in  which  the  disease  is  endemic  depend  upon  the  energy 
and  steadfastness  with  which  measures  for  the  destruction  of  the  infecting 
principle  and  the  prevention  of  its  spread  are  carried  out.  What  these 
measures  are  is  to  be  directly  deduced  from  the  statements  made  regarding 
the  causation  of  enteric  fever  in  a  previous  section  of  this  article.  They 
l)elong  to  the  subject  of  public  hygiene,  and  are  of  sufficient  importance  to 
demand  the  closest  attention  of  all  local  and  general  sanitary  organizations ; 
Vol.  I.— 31 


482  ENTERIC  OR  TYPHOID  FEVER. 

they  are,  nevertheless,  largely  within  the  personal  control  of  the  physi- 
cians of  every  community.  It  is  the  highest  duty  of  the  doctor  to  see  to  it 
that  no  new  case  of  disease  arise  by  direct  or  indirect  contagion  from  any 
patient  under  his  care.  In  enteric  fever  we  have  to  do  with  a  disease  in 
which  this  is  wholly  possible.  Xot  only  may  the  spread  of  the  typhoid 
bacilli  be  prevented,  but  they  may  be  absolutely  destroyed.  The  efficiency 
of  the  measures  of  prophylaxis  adopted  in  any  given  case  will  be  propor- 
tionate to  the  belief  in  the  material  nature  of  the  cause  of  the  disease  and 
in  the  possibility  of  at  once  and  definitely  destroying  that  cause  by  disin- 
fection. 

The  danger  that  a  house-epidemic  of  enteric  fever  may  arise  from  a 
single  case  suffered  to  become  a  focus  of  infection  is  to  be  constantly  borne 
in  mind.  It  is  not  house-epidemics  alone  that  are  to  be  prevented,  but  also 
the  spread  of  the  disease  to  distant  points  in  consequence  of  the  pollution 
of  running  streams  or  other  sources  of  water-distribution,  or  in  cities  by 
way  of  continuous  sewer-systems  that  may  convey  the  poison  to  compara- 
tively remote  localities. 

The  one  efficient  measure  of  prophylaxis  that  includes  all  others  is  the 
proper  treatment  of  the  dejections.  The  fsecal  discharges  of  every  case, 
and  the  urine  when  albuminous,  must  be  promptly  and  thoroughly  disin- 
fected. This  is  to  be  accomplished  by  the  action  of  powerful  chemical 
agents.  Chloride  of  lime  of  the  best  quality  dissolved  in  pure  water  in  the 
proportion  of  six  ounces  to  the  gallon  may  be  used  for  this  purpose.  One 
quart  of  the  solution  is  to  be  poured  over  each  discharge,  thoroughly  mixed 
with  it,,  and  the  vessel  allowed  to  stand  for  an  hour  or  more  before  being 
emptied  into  the  privy-vault  or  water-closet.  If  the  discharge  be  very 
copious,  it  is  advisable  to  use  even  a  larger  amount.  For  the  disinfection 
of  solid  fffical  matter  the  above  solution  should  be  of  double  the  strength. 
The  matter  to  be  disinfected  must  be  exposed  to  the  action  of  the  solution 
for  four  hours,  and  solid  masses  are  to  be  broken  up  by  agitation  of  the 
vessel.  Solution  of  carbolic  acid  1  to  20  or  of  sulphate  of  copper  1  to  25 
may  also  be  used  for  this  purpose,  but  the  best  of  all  is  a  solution  of  corro- 
sive sublimate  of  the  strength  of  1  to  500.  This  fluid  should  be  colored 
red  by  the  addition  of  potassium  permanganate  and  kept  in  a  glass  bottle 
or  earthen  crock,  for  the  reason  that  the  corrosive  sublimate  is  decomposed 
with  the  precipitation  of  mercury  by  contact  with  copper,  lead,  or  tin.  No 
stool  from  a  case  of  enteric  fever  should  be  thrown  into  a  closet  without 
having  been  previously  disinfected  as  above.  Great  care  must  be  taken  to 
prevent  the  contact  of  the  discharges  with  the  wood-work  of  the  seat.  The 
closet  is  to  be  fully  flushed  several  times  a  day,  and  in  the  intervals  of  its 
use  a  quantity  of  carbolic-acid  solution  or  chloride-of-lime  solution  should 
be  allowed  to  remain  in  the  hopper. 

A  privy-vault  requiring  disinfection  may  be  treated  with  two  or  three 
pounds  of  corrosive  sublimate  dissolved  in  a  large  quantity  of  water  and 
slowly  poured  into  the  vault.     During  an  epidemic,  chloride  of  lime  should 


ENTERIC   OE   TYPHOID   FEVER.  483 

be  freely  sprinkled  over  the  surface  of  the  contents  of  the  vault  every 
day. 

Prolonged  boiling  will  destroy  the  vitality  of  all  known  disease-germs. 
There  is,  therefore,  no  better  way  of  disinfecting  clothing  that  can  be 
washed  than  to  subject  it  to  the  ordinary  operations  of  the  laundry. 
Clothing  may  also  be  disinfected  by  immersion  for  two  hours  in  a  solution 
of  corrosive  sublimate  of  1  to  1000,  or  of  sulphate  of  copper  of  1  to  100,  or 
of  carbolic  acid  of  1  to  50,  or  of  chloride  of  lime  of  1  to  100.  The  bleach- 
ing properties  of  chloride  of  lime  must  not  be  overlooked.  Clothing  should 
not  be  allowed  to  accumulate  in  the  sick-room,  but  should  go  to  the  laundry 
as  promptly  as  can  be  arranged.  It  should  at  once  be  freely  sprinkled  with 
one  of  the  above  solutions  by  the  nurse. 

Search  must  in  all  instances  be  made  for  the  original  cause  of  infection, 
and  measures  taken  to  correct  faulty  arrangements  which  lead  to  the  pollu- 
tion of  the  drinking-water  or  of  the  air.  During  the  prevalence  of  enteric 
fever  in  local  or  general  epidemics  all  drinking-water  and  milk  should  be 
subjected  to  boiling ;  especially  is  it  important  at  such  times  that  the  milk 
supplied  to  children  should  be  sterilized  by  means  of  the  Soxhlet  apparatus.^ 

2.  The  General  Management  of  the  Patient,  and  Dietetics. — The  success- 
ful treatment  of  enteric  fever  in  childhood  is  largely  dependent  on  the  atten- 
tion which  is  given  to  the  general  management  and  nursing  of  the  patient. 

In  the  first  place,  it  is  important  to  see  that  he  is  not  exposed  to  the 
further  action  of  the  poison.  If  the  original  source  of  the  infection  be 
found  upon  inspection  to  be  connected  with  faulty  sanitary  arrangements  in 
the  house  or  in  the  neighborhood,  it  may  be  necessar}^  to  remove  the  patient 
to  more  favorable  surroundings.  In  hospitals,  enteric  fever  patients  are 
usually  treated  side  by  side  with  the  patients  suffering  from  other  diseases. 
This  practice  is  unattended  with  the  danger  of  the  communication  of  tlie 
disease,  if  proper  jjrecautionary  measures  are  taken  with  reference  to  the 
disinfection  and  removal  of  the  dejections  and  to  the  cleanliness  of  the 
patient's  person  and  bedding. 

In  private  practice  among  the  well-to-do  classes  children  commonly 
come  under  observation  during  the  prodromic  period  or  early  in  the  first 
stage  of  the  disease.  If  the  fever  have  already  declared  itself,  the  use  of 
the  thermometer  will  put  the  physician  upon  his  guard  as  to  the  nature  of 
the  sickness.  If  in  cases  seen  during  the  period  of  prodromes  the  symptoms 
are  such  as  to  excite  a  suspicion  as  to  the  nature  of  the  disease,  the  patient 
sliould  be  ordered  to  bed.  Should  the  malady  prove  to  be  in  fact  a  simple 
ailment,  nothing  is  thus  lost;  if,  on  the  other  liand,  the  symptoms  sub- 
sequently prove  to  have  been  those  of  the  foi-ming  stage  of  enteric  fever, 
early  rest  in  bed  cannot  fail  to  influence  favorably  the  subsequent  course  of 
the  attack. 

The  strict  rules  in  regard  to  absolute  rest  in  bed,  and  to  the  use  of  the 

1  Miinchen.  Med.  Wochenschr.,  Nrs.  lo  u.  IG,  1886. 


484  ENTEEIC   OE   TYPHOID   FEVEE. 

bed-pan  and  urinal,  which  must  be  enforced  in  adults,  cannot  ■svell  be  carried 
out  in  the  case  of  young  children. 

The  room  should  be  large  and  well  ventilated ;  the  temperature  should 
be  maintained  at  Q6°  to  70°  F.  It  is  desirable  that  the  apartment  should  be 
heated  by  an  open  fireplace  rather  than  by  furnace-heat.  Thorough  venti- 
lation must  in  all  cases  be  secured  both  day  and  night,  and,  whilst  direct 
draughts  are  to  be  avoided,  it  must  be  impressed  upon  the  attendants  that 
fever  patients  are  not  likely  to  take  cold. 

The  bed-covering  should  be  light.  The  body  should  be  sponged  twice 
a  day  with  water  containing  Labarraque's  solution,  aromatic  vinegar,  or 
alcohol  in  small  quantities. 

Among  the  minor  duties  of  the  nurse,  which  are  not,  however,  of  in- 
ferior importance,  are  the  frequent  changing  of  the  position  of  the  patient's 
body,  moistening  his  mouth,  cleansing  his  tongue,  the  prevention  of  the 
accumulation  of  sordes,  and  the  most  scrupulous  care  of  his  person  in  other 
respects.  If  the  evacuation  of  the  urine  and  faeces  in  bed  cannot  be  pre- 
vented, the  discharges  and  soiled  clothing  are  to  be  changed  without  loss  of 
time  and  immediately  disinfected.  In  severe  cases  it  is  sometimes  conve- 
nient to  use  two  beds,  the  patient  being  occasionally  lifted  from  one  to  the 
other. 

Fluid  is  to  be  administered  freely.  The  best  drink  is  pure  water, 
either  of  the  temperature  of  the  room  or  iced.  Wine-and- water,  milk-and- 
water  or  milk-and-seltzer,  koumys,  kefir,  matzoon,  thin  barley-water,  or 
water  commingled  with  jelly,  may  be  occasionally  given  instead  of  simple 
water.  It  frequently  happens  that  patients  fail  to  obtain  the  necessary 
amount  of  drink  unless  it  is  proffered  them,  even  when  apparently  fully 
conscious.  It  is  important,  therefore,  that  fluid  be  offered  at  short  inter- 
vals ;  it  is  often  taken  with  eagerness,  though  not  asked  for.  The  amount 
at  each  time  must  be  moderate. 

The  diet  must  be  rigidly  restricted.  The  directions  of  the  physician  as 
'  to  its  kind,  its  quantity,  and  the  intervals  at  which  it  is  to  be  given  must  be 
definite  and  explicit.  A  record  of  the  amounts  given,  as  well  as  of  the. 
inters^als  of  the  administration  of  food,  is  to  be  kept  by  the  attendant  and 
submitted  at  each  visit.  Neither  general  directions  nor  general  reports  are 
sufficient.  The  diet  throughout  should  be  nutritious,  easily  digestible,  and 
liquid.  If  overfed,  the  patient  suffers  from  indigestion  and  an  aggravation 
of  the  intestinal  symptoms ;  if  underfed,  the  derangement  of  nutrition  will 
be  increased  and  the  convalescence  prolonged.  It  is  desirable  to  give  the 
maximum  amount  of  proper  food  that  can  be  assimilated,  and  not  to  exceed 
this  amount.  How  much  this  may  be,  can  be  determined  only  by  careful 
study  of  individual  cases.  During  the  early  stages  of  the  disease,  or  indeed 
up  to  the  middle  of  the  second  week,  not  only  is  it  desirable  that  the  diet 
of  the  patient  should  be  verv'^  digestible,  but  it  is  also  important  that  it 
should  be  of  only  moderate  amount.  After  the  middle  of  the  second 
week,  as  much  food  is  to  be  given  as  can  be  properly  digested.     Milk  and 


ENTERIC   OR   TYPHOID   FEVER.  485 

milk  foods,  broths,  soups,  and  meat  juices  constitute  the  diet.  Once  or 
twice  a  day  in  older  children  a  little  coffee,  largely  diluted  with  milk,  may 
be  administered.  If  the  patient  craves  it,  a  small  quantity  of  thickened 
gruel  or  arrow-root  or  bread-and-milk  may  be  given  once  a  day.  Some 
patients  do  better  with  an  occasional  meal  of  such  semi-solid  food ;  it  is, 
however,  to  be  said  that,  as  a  general  rule,  starchy  foods  are  objectionable. 

The  details  of  dietetics  must  in  every  case  be  determined  in  accordance 
with  the  age  of  the  child  and  the  previous  character  of  the  diet  in  very 
young  children.  To  milk,  unless  otherwise  diluted,  lime-water  must  be 
added  in  proper  ^proportions,  in  order  to  prevent  the  formation  of  firm 
curds  in  the  stomach.  To  this  end,  it  is  also  desirable  that  the  milk  should 
be  administered  slowly.  If  the  milk  thus  treated  be  not  well  digested,  it 
should  be  peptonized  or  sterilized. 

Alcoholic  stimulants  form  no  necessary  part  of  the  routine  treatment  of 
enteric  fever  in  children.  In  the  early  stages  of  the  disease,  their  use,  except 
to  meet  special  indications,  is  probably  in  most  cases  injurious  rather  than 
beneficial.  In  the  later  stages  the  indications  which  call  for  their  adminis- 
tration are  twofold  :  first,  great  general  prostration,  as  manifested  by  weak- 
ness of  the  heart's  action ;  secondly,  prominence  of  nervous  symptoms  :  thus, 
a  feeble  or  scarcely-perceptible  cardiac  impulse  and  a  correspondingly  faint 
or  almost  inaudible  systolic  sound  call  for  their  administration ;  while  such 
evidences  of  nervous  prostration  as  marked  delirium,  stupor,  tremor,  sub- 
sultus  tendinum,  and  the  like  are  best  combated  by  the  administration  of 
stimulants.  Alcohol  is  also  indicated  where  the  symptoms  which  attend 
extensive  and  deep  intestinal  ulceration,  such  as  frequent  diarrhoea,  tympany, 
and  great  tenderness,  are  marked.  It  is  impossible  to  lay  down  any  general 
rule  as  to  the  amount.  The  quantity  should  be  only  as  much  as  is  necessary 
to  modify  the  symptoms  for  which  it  has  been  prescribed.  The  character 
of  the  systolic  heart-sound,  the  pulse,  and  the  nervous  symptoms  are  our 
best  guides  as  to  the  amount  and  the  frequency  of  its  administration.  If 
the  urine  is  albuminous,  alcohol  is  to  be  given  with  the  utmost  caution,  and 
its  effects  upon  the  amount  and  character  of  the  secretions  must  be  carefully 
investigated  at  short  intervals.  To  sum  up,  alcoholic  stimulants  are  to  be 
given  according  to  the  special  indications  of  each  individual  case :  they  are 
not  required  at  all  in  many  cases,  are  useful  in  a  few,  indispensable  in  some. 
Alcohol  may  be  administered  in  the  form  of  milk  punch,  wine  whey,  port 
or  Tokay  wine,  or  champagne. 

3.  Special  Forms  of  Treatment,  and  the  Treatment  of  Particular  Sjpn/i- 
toms  and  Complications. — The  management  of  enteric  fever  in  childhood 
may  be  conducted  in  accordance  with  (a)  the  expectant,  [b)  the  expectant 
symptomatic,  or  (c)  the  specific  or  etiological  plan.  The  maxim  that  the 
patient  rather  than  the  disease  is  to  be  treated  is  spe(;ially  ajiplicable  to  this 
disease.  The  prejionderance  of  cases  of  mild  form,  the  inherent  tendency 
to  recovery,  the  exceptional  occurrence  of  grave  cases,  and  the  peculiar 
difficulties  which  they  present  from  the  stand-point  of  therapeutics  render 


486  ENTERIC   OR   TYPHOID   FEVER. 

it  difficult  to  formulate  rules  of  treatment  that  will  be  applicable  to  all  cases 
of  the  disease. 

(a)  The  expectant  plan. — Many  of  the  milder  cases  do  Veil  without  any 
medication  whatever.  Rest  in  bed,  careful  nursing,  and  a  well-regulated 
dietary  constitute  all  that  is  necessary  for  the  proper  management  of  the 
case.  With  moderate  fever,  absent  or  insignificant  chest-symptoms,  a  good 
heart,  and  little  or  no  evidence  of  serious  intestinal  lesions,  there  is  no  need 
for  the  administration  of  drugs.  In  such  cases  there  is  often  a  slight  ten- 
dency to  constipation.  At  most,  then,  we  may  commence  our  treatment 
advantageously  with  a  purgative  dose  of  calomel,  which  may  be  from  time 
to  time  repeated  until  the  end  of  the  first  or  the  middle  of  the  second  week 
of  the  attack.  After  this  time  constipation  is  best  relieved  by  enemata  of 
lukewarm  water  to  which  has  been  added  a  little  salt,  or  of  soapsuds,  or, 
still  better,  by  the  administration  of  a  ninety-per-cent.  glycerin  suppository. 
Tliese  measures  to  secure  action  of  the  bowels  do  not  require  repetition 
oftener  than  once  in  three  days. 

(b)  The  expectant  symptomatic  or  so-called  rational  plan. — This  is  the 
method  in  general  use  atid  available  for  cases  of  average  severity  and  for 
those  presenting  complications.  This  plan,  like  the  expectant  plan,  makes 
no  attempt  to  shorten  the  duration  of  the  attack  or  to  modify  its  course  as 
determined  by  the  intensity  of  the  infection  and  the  reaction  of  the  organism 
to  that  infection.  In  the  absence  of  serious  symptoms  or  complications,  it 
is  practically  the  same  as  the  expectant  plan. 

An  effort  is  made,  however,  by  the  administration  of  quinine  in  small 
so-called  tonic  doses,  the  mineral  acids,  turpentine,  nitrate  of  silver,  or  other 
medicinal  agents  from  the  beginning,  to  modify  favorably  the  nervous  sys- 
tem, the  digestive  apparatus,  or  the  mucous  surfaces,  as  the  case  may  be, 
with  a  view  of  controlling  the  severity  of  the  symptoms  of  the  disease  and 
diminishing  the  danger  of  the  occurrence  of  complications.  Whether  or 
not  these  effects  are,  as  a  rule,  actually  accomplished,  it  is  not  easy  to  deter- 
mine. The  extreme  variation  in  the  intensity  of  the  attack  in  different 
cases  must  put  us  on  our  guard  against'  ascribing  to  therapeutic  measures 
results  which  ought  rather  to  be  attributed  to  the  natural  history  of  the 
disease  in  any  particular  case  or  series  of  cases. 

Under  this  plan  of  treatment,  reasonable  efforts  are  made  to  combat  the 
more  serious  symptoms  of  the  disease  and  the  complications  from  the  time 
of  their  appearance,  as  well  as  to  anticipate  their  development ;  and  it  is 
here  that  we  may  most  advantageously  discuss  the  management  of  the 
various  symptoms  and  complications. 

The  headache  of  the  early  days  of  tlie  attack  generally  requires  no 
special  treatment :  it  subsides  spontaneously  between  the  end  of  the  first 
and  the  middle  of  the  second  week.  Absolute  quiet,  exclusion  of  light, 
local  applications,  sometimes  cold,  sometimes  warm,  constitute,  as  a  rule,  all 
that  is  necessary  to  control  it.  Small  doses  of  antipyrin,  gr.  i-iii  according  to 
the  age  of  the  child,  or  of  acetanilide,  gr.  |— i,  or  of  phenacetin,  gr.  ^-ii,  may 


ENTERIC   OR   TYPHOID    FEVER.  487 

be  administered  for  the  relief  of  obstinate  and  distressing  headache.  If 
necessary,  these  doses  must  be  repeated  once  or  twice  at  intervals  of  an  hour 
or  an  hour  and  a  half;  but  the  repetition  will  rarely  be  required.  My  prefer- 
ence is  for  antipyriu,  both  for  the  relief  of  headache  and  other  nervous 
symptoms  and  for  the  reduction  of  the  temperature  when  necessary.  It  is 
easier  of  administration  than  the  others,  and  may  be  given  by  enema  or  sub- 
cutaneouslv  when  required.  It  does  not  diminish  the  ability  of  the  blood- 
corpuscles  to  carry  oxygen,  and  thus  produce  cyanosis,  as  does  acetanilide. 
The  theoretical  danger  that  these  small  doses  are  likely  temporarily  to 
depress  the  action  of  the  heart  may  be  combated  by  the  simultaneous 
administration  of  small  amounts  of  alcohol. 

Sleeplessness  is  sometimes  an  important  symptom  in  the  early  stages  of 
the  disease.  Like  the  headache,  it  usually  diminishes  some  time  during  the 
course  of  the  second  week ;  on  the  other  hand,  it  is  occasionally  persistent 
and  exhausting.  During  the  primary  fever  sodium  Ijromide,  gr.  ii-x,  and 
chloral,  gr.  J-ii,  yield  most  satisfactory  results.  These  drugs  may  be  used 
either  in  combination  or  separately.  Chloral  alone  in  moderate  doses  is 
usually  adequate  to  overcome  sleeplessness,  and  its  administration  has  not 
in  my  experience  been  followed  by  cardiac  depression  or  other  unfavorable 
results.  Sulphonal,  gr.  v-x,  will  also  prove  useful  in  the  control  of  this 
symptom  ;  finely  triturated,  it  may  be  administered  in  milk.  If  other  hyp- 
notics fail,  opium  w^ill  sometimes  secure  sleep.  This  drug  and  its  prepara- 
tions must,  however,  be  regarded  as  objectionable  during  the  early  stages  of 
the  disease,  on  account  of  its  unfavorable  influence  upon  digestion  and  the 
secretions,  an  influence  not  wholly  obviated  by  the  hypodermic  use  of 
morphia.  In  the  later  period  of  the  disease — that  is,  during  the  secondary 
fever — opium  becomes  at  once  the  most  efficient  and  safest  means  of  con- 
trolling prolonged  sleeplessness  and  excitability.  In  the  later  stages  of  the 
disease,  chloral  is,  by  reason  of  its  depressing  influences  upon  the  circula- 
tion, even  more  objectionable  than  is  opium  in  the  earlier  stages. 

Somnolence,  stupor,  and  delirium  are  to  be  treated  by  stimulants  and 
the  abstraction  of  heat.  Among  the  stimulants,  alcoliol  stands  first  and 
almost  alone  ;  spirits  of  chloroform  and  camphor  are  of  use  in  emergencies  ; 
ether  may  be  administered  subcutaneously,  or  a  five-per-cent.  solution  of 
camplior  in  ether.  Ammonium  carbonate  is  of  inferior  value ;  it  is,  how- 
ever, frequently  used  in  the  treatment  of  pulmonary  complications.  Pure 
Siberian  musk  is  a  powerful  stimulant  in  conditions  of  nervous  depression. 
Its  high  cost  and  the  difficulty  of  obtaining  it  stand  in  the  way  of  its 
general  use. 

If  delirium  be  marked,  or  coma  tlircaten,  great  benefit  is  often  derived 
from  local  applications  of  cold  to  the  head,  by  means  eitlier  of  the  cold 
douche  or  of  an  ice-cap,  the  hair  having  been  previously  cut  short.  These 
applications  must  be  transient  and  not  too  frequently  repeated,  otherwise 
they  may  produce  depression  or  collapse.  At  the  same  time,  warm  applica- 
tions to  the  feet  and  legs  and  sinapisms  to  the  praecordia  or  epigastrium  are 


488  EXTEEIC    OPw    TYPHOID    FEVEE. 

called  for.  The  tepid  or  warm  batli  is  often  followed  by  good  results ;  cold 
baths  are  to  be  avoided. 

Tremor  indicates  extreme  prostration.  Sir  William  Jenner  has  called 
attention  to  the  fact  that  tremor,  out  of  all  proportion  to  the  other  signs  of 
nervous  prostration,  is  to  be  looked  upon  as  a  sign  of  deep  ulceration  of 
the  intestine.  A  small  deep  slough,  the  separation  of  which  is  especially 
liable  to  give  rise  to  intestinal  hemorrhage  or  perforation,  Mill  often  occasion 
great  tremor.  Tremor  of  this  kind  is  to  be  treated  with  full  doses  of 
alcohol  and  opium,  not  only  for  their  general  eifect  upon  the  nervous  system, 
but  also  with  a  view  to  their  local  effects  in  limiting  sloughing  and  ulcera- 
tion. 

The  nervous  accidents,  and  complications  of  enteric  fever  in  childhood 
do  not,  as  a  rule,  call  for  special  treatment  when  they  appear  during  the 
course  of  the  disease;  upon  the  subsidence  of  the  fever,  however,  they  are 
to  be  treated  in  accordance  with  general  rules. 

The  fact  that  the  nervous  phenomena  directly  due  to  the  typhoid  infec- 
tion often  closely  simulate  meningitis  renders  the  recognition  of  actual 
meningeal  inflammation  occurring  as  a  complication  difficult.  It  is  apt  to 
make  its  appearance  late  in  the  course  of  the  fever  or  during  convalescence. 
When  recognized,  it  calls  for  prompt  measures  of  treatment.  Opium  in 
full  doses,  caution  being  had  in  regard  to  the  age  of  the  patient,  the  bro- 
mides, cold  applications  to  the  head,  external  warmth  to  the  trunk  and 
extremities,  even  the  abstracting  of  blood  by  leeches  applied  behind  the 
ears  or  to  the  septum  narium,  may  be  indicated. 

Dryness  of  the  tongue  and  accumulation  of  sordes  upon  the  teeth  are  to 
be  obviated  by  the  frequent  administration  of  water  or  of  pieces  of  ice 
allowed  to  dissolve  in  the  mouth.  The  mouth  should  be  frequently  rinsed 
or  washed  with  pure  water  or  water  containing  small  amounts  of  claret, 
tincture  of  myrrh,  or  listerine.  Saturated  solution  of  boric  acid  may 
occasionally  be  used.  Fissures  about  the  nostrils  and  upon  the  lips  may 
be  touched  with  an  ointment  containing  tw^enty  grains  of  boric  acid  to  the 
ounce. 

Constipation  when  slight  requires  no  treatment  beyond  an  occasional 
administration  of  small  doses  of  calomel  or  castor  oil  or  the  juice  of  an 
orange.  Constipation  may,  however,  be  due  to  the  torpidity  of  the  large 
intestine,  the  faecal  matter  accumulating  and  the  stools  being  hard  and  dry. 
These  conditions  may  set  up  a  sort  of  secondary  diarrhoea,  due  to  irritation 
of  the  lower  bowel,  attended  with  a  feeling  of  local  distress  and  tenesmus 
unusual  in  enteric  fever,  and  are  promptly  relieved  by  the  removal  of  the 
cause.  Prolonged  constipation  is  by  no  means  to  be  taken  as  indicating 
moderate  intestinal  lesions ;  on  the  contrary,  deep  ulceration  of  a  single 
Peyer's  patch  is  not  only  occasionally  associated  with  constipation,  but  by 
its  paralyzing  influence  upon  the  intestine  it  may  give  rise  to  constipation. 
Aperients  administered  by  the  mouth  are  therefore  after  the  middle  of  the 
second  week  to  be  shunned,  lest  by  inducing  active  peristalsis  they  forcibly 


ENTERIC    OR    TYPHOID    FEVER.  489 

detach  a  deep  slough,  or  otherwise  mechanically  give  rise  to  perforation, 
Avhere  the  slough  extends  to  or  implicates  the  serous  coat  of  the  intestine. 
Large  enemata  are  also  attended  with  danger,  arising  from  their  liability  to 
set  up  energetic  peristaltic  movements  which  may  extend  to  the  lower  part 
of  the  ileum.  The  systematic  administration  of  laxative  doses  of  calomel 
(vide  supra)  every  second  day  during  the  first  week  may  be  depended  upon 
to  obviate  to  a  great  extent  excessive  intestinal  disturbances,  whether  of  the 
nature  of  constipation  or  of  diarrhoea. 

Diarrhcea,  so  lono-  as  the  stools  are  of  moderate  amount  and  do  not 
exceed  in  number  three  or  four  in  the  course  of  twenty-four  hours,  does  not 
call  for  sj)ecial  treatment :  if,  however,  the  passages  are  copious  or  frequent, 
it  becomes  necessary  to  control  them.  When  diarrhoea  is  due  to  errors  in 
diet,  such  as  the  use  of  improper  food  or  excessive  amounts  of  food,  particu- 
larly milk  and  the  strong  animal  broths,  it  usually  abates  upon  the  substi- 
tution of  a  more  suitable  dietary.  Diarrhoea  may  also  arise  in  consequence 
of  the  patient's  drinking  excessive  amounts  of  fluid,  which  pass  through 
the  bowel  without  being  absorbed  and  stimulate  the  secretions  of  the 
intestinal  mucous  membrane.  In  the  absence  of  these  causes,  it  is  to  be 
attributed  to  catarrhal  inflammation  of  the  intestine.-  It  is  then  best 
treated  by  disinfectant  and  soothing  remedies, — bismuth  subcarbonate  or 
subnitrate  in  large  doses,  gr.  v— xx,  every  four  or  six  hours.  To  this  may  be 
added,  if  necessary,  opium  in  doses  proportionate  to  the  age  of  the  patient, 
gr.  Yk^~At>  o^*  Dover's  powder,  gr.  yj-l,  or  the  deodorized  tincture 
of  opium,  gtt.  ^ii.  Equally  satisfactor}'  is  the  combination  of  minute 
doses  of  calomel,  gr.  2^"  iV>  ^^'^^^  Dover's  powder  in  the  doses  above  indi- 
cated. Opium  may  be  advantageously  administered  in  enemata  of  starch- 
water  or  in  suppositories  of  cacao-butter,  and  when  thus  given  may  be  com- 
bined with  an  equal  quantity  of  the  tincture  or  extract  of  cannabis  indica. 
Formerly  astringents,  such  as  alum,  plumbic  acetate,  silver  nitrate,  tannin, 
catechu,  and  kino,  were  recommended  for  the  control  of  diarrhoea ;  more 
recently,  bismuth  salicylate,  naphthalin,  salol,  thymol,  and  resorcin  have 
been  employed  for  the  same  pui-pose.  All  of  these  remedies  are  difficult 
of  administration,  and  most  of  them  impracticable  in  the  therapeutics  of 
childhood. 

It  is  more  satisfactory  at  the  bedside  to  use  one  or  two  efficient  remedies 
than  to  resort  to  a  number  of  uncertain  drugs.  In  bismuth  freely  given, 
or  in  opium  in  repeated  small  doses,  either  l)y  the  mouth  or  Ijy  enemata,  or 
in  these  two  remedies  combined,  will  be  found  in  almost  all  cases  an  efficient 
medication  against  excessive  diarrhoea  in  enteric  fever.  If  the  stools  be 
fetid  or  highly  ammoniacal,  small  doses  of  animal  charcoal  in  the  form  of 
an  impalpable  powder  may  be  administered  in  the  broth.  Creasote  and 
carbolic  acid  may  also  be  of  service. 

Tympany  may  be  due  to  sloughing  or  ulceration  of  the  intestine  suffi- 
ciently deep  to  cause  paralysis,  or  to  general  prostration  leading  to  deficient 
contraction  alike  of  the  intestinal  walls  and  of  the  abdominal  muscles,  or 


490  ENTERIC  OR  TYPHOID  FEVER. 

to  the  alteration  in  the  character  of  the  digestive  fluids,  which  no  longer 
possess  the  antiseptic  properties  of  health  and  therefore  permit  a  speedy 
decomposition  of  the  intestinal  contents.  Flatus  accumulates  in  part  in  the 
small  intestine,  chiefly  in  the  colon  :  it  varies  from  an  amount  scarcely 
greater  than  that  of  health  to  great  abdominal  distention,  interfering  with 
the  play  of  the  diaphragm,  and,  by  the  outward  pressure  of  the  accumulated 
gas  within  the  gut,  adding  to  the  danger  of  perforation.  Indications  for 
the  treatment  of  this  symptom  are  twofold :  the  first  have  reference  to  the 
loss  of  nerve-energy,  and  call  for  an  increased  stimulation ;  the  second,  to 
the  nature  of  the  food  and  the  arrest  of  the  gas-generating  decomposition 
of  the  intestinal  contents.  Thus,  alcohol  is  to  be  given,  or,  if  already  em- 
ployed, the  amount  is  to  be  increased.  Turpentine,  camphor,  and  minute 
doses  of  opium  may  be  added  to  the  treatment,  and  pepsin  may  be  adminis- 
tered with  the  food.  The  application  of  compresses  wrung  out  of  cold 
water  or  of  turpentine  stupes  is  useful,  as  is  also  very  gentle  massage  of  the 
abdomen.  Enemata  of  iced  water  or  cold  enemata  containing  turpentine 
are  sometimes  followed  by  good  results.  The  careful  introduction  of  a  long 
rubber  catheter  will  sometimes  relieve  the  distended  lower  bowel.  The 
puncture  of  the  distended  gut  with  a  hypodermic  needle  is  a  hazardous 
procedure.  Jacobi^  states  that  he  has  seen  faeces  entering  the  abdominal 
cavity  through  the  openings  thus  made  and  fatal  peritonitis  result.  In 
cases  systematically  treated  by  laxative  doses  of  calomel  during  the  early 
days  of  the  disease,  troublesome  tympany  is  not  apt  to  occur. 

Intestinal  hemorrhage,  if  it  be  slight,  does  not  call  for  other  measure  of 
treatment  than  absolute  rest,  restriction  or  complete  withholding  of  food  for 
a  time,  land  moderate  doses  of  opium,  either  by  the  mouth  or  by  supposi- 
tory. Drink  must  be  given  in  small  quantities,  repeated  at  short  intervals, 
or  lumps  of  ice  may  be  held  in  the  mouth  and  swallowed.  The  action  of 
the  bowels  is  to  be  as  far  as  possible  controlled.  If  the  blood-loss  be  pro- 
fuse, danger  to  life  becomes  imminent,  and  more  active  measures  are  to  be 
employed.  An  ice-bag  or  bladder  filled  with  broken  ice  mixed  with  bran 
is  to  be  applied  to  the  abdomen.  Opium  is  to  be  cautiously  administered 
until  drowsiness  is  produced.  Fluid  extract  of  ergot  may  be  adminis- 
tered by  the  mouth ;  but,  if  this  is  not  practicable,  ergotin  may  be  injected 
hypodermically  at  intervals  of  a  half-hour  or  an  hour;  if  properly  ad- 
ministered, there  is  little  danger  of  the  production  of  abscesses.  Gallic 
acid,  turpentine,  alum,  and  lead  are  recommended.  Small  enemata  of  iced 
water  may  be  administered,  and  repeated  at  short  intervals.  It  is  not  to 
be  hoped  that  any  direct  effect  upon  the  intestinal  lesions  will  follow  the 
use  of  tlie  astringent  preparations  of  iron  either  by  the  mouth  or  by  the 
rectum.  The  pillows  should  be  removed,  and  the  foot  of  the  bed  elevated 
by  blocks. 

Upon  the  occurrence  of  large  intestinal  hemorrhage,  an  area  of  local 

1  "Therapeutics  of  Infancy  and  Childhood,''  Archives  of  Pediatrics,  December,  1888. 


ENTERIC    OR   TYPHOID    FEVER.  491 

dulness  may  sometimes  be  detected  upon  careful  percussion  in  a  region  of 
the  abdomen  previously  tympanitic. 

Peritonitis,  whether  due  to  perforation  of  the  intestine  or  to  other 
causes,  calls  for  the  free  administration  of  opium.  For  a  time,  at  least,  no 
nourishment  except  concentrated  meat  juices,  a  spoonful  at  a  time,  or  braudy- 
and-water  in  not  larger  amounts,  is  to  be  administered.  The  abdomen 
may  be  smeared  with  a  mixture  of  equal  parts  of  sweet  oil,  laudanum,  and 
turpentine,  and  covered  with  a  large,  finely-spread  flaxseed  poultice,  or  ice- 
poultices  may  be  applied.  If  opium  be  not  well  borne  by  the  stomach, 
morphine  is  to  be  administered  hypodermically.  Should  the  patient's  life  be 
prolonged,  it  is  of  the  utmost  importance  that  the  bowels  be  confined  as 
long  as  it  is  possible  to  keep  them  so.  As  a  general  rule,  an  action  will 
occur  at  the  end  of  several  days,  even  under  the  continued  use  of  opium ; 
if  not,  at  the  end  of  a  week  small  lukewarm  enemata  or  a  glycerin  supposi- 
tory may  be  employed.  Palpation  of  the  abdomen  is  to  be  practised  with 
great  caution,  on  account  of  the  danger  of  exciting  peritonitis,  of  causing 
perforation,  or  of  rupturing  the  spleen.  Peritonitis  due  to  perforation  is 
almost  invariably  followed  by  death.  Should  this  accident  occur,  as  it  not 
infrequently  does,  at  the  close  of  defervescence  or  during  convalescence  at 
a  period  when  the  appetite  is  returning,  the  nutrition  improving,  and  the 
strength  of  the  patient  returning,  the  propriety  of  laparotomy  should  be 
seriously  considered.  Perforations  are  usually  single  :  thus,  of  Murchison's 
cases  there  was  only  one  perforation  in  twenty-eight  instances,  two  in  five, 
and  three  in  four. 

The  suprapubic  region  must  be  examined  by  percussion  as  a  matter  of 
routine,  and  whenever  necessary  the  catheter  is  to  be  employed. 

Frequent  exploration  of  the  chest  by  the  methods  of  physical  diagnosis 
is  necessary.  Complications  capable  of  determining  a  fatal  result  may  often 
be  arrested  by  the  prompt  detection  and  treatment  of  pulmonary  lesions  at- 
tended by  insignificant  subjective  symptoms.  Hypostatic  congestion  is  to  be 
prevented  by  guarding  against  the  heart-failure  to  which  it  is  chiefly  due. 
Among  the  evidences  of  debility  of  the  heart  are  extreme  pallor,  cyanosis 
of  the  lips,  ears,  and  finger-tips,  mottling  of  the  surface,  coldness  of  the 
extremities,  frequent  or  irregular  pulse,  and  enfeeblement  of  the  first  sound. 
The  patient's  position  is  to  be  changed  from  time  to  time  from  the  dorsal  to 
the  lateral  decubitus.  Strophanthus,  convallaria,  sparteine  sulphate,  and 
caffeine  may  be  administered  under  such  circumstances,  according  to  the 
special  indications  of  the  case.  Alcohol  is  pre-eminently  useful :  for 
prompt  action,  it  should  be  administered  in  the  form  of  champagne. 
Digitalis  must  be  used  with  caution  and  closely  watched.  The  occasional 
application  of  turpentine  stupes  to  the  chest  is  of  great  advantage. 

Bronchitis,  if  of  moderate  degree,  requires  no  special  treatment ;  if 
severe,  it  nmst  be  managed  in  accordance  with  general  principles. 

Bed-sores  do  not  occur  in  childhood,  except  as  the  result  of  inefficient 
nursing.    They  are  to  be  prevented  by  frequent  change  of  position,  removal 


492  ENTERIC    OR   TYPHOID    FEVER. 

of  pressure  by  means  of  cold-water  bags  or  air-cushions,  scrupulous  cleanli- 
ness, and  attention  to  the  bed.  If  erosions  by  any  chance  appear,  they  are 
to  be  treated  in  accordance  with  general  surgical  principles. 

The  fever  when  of  moderate  degree,  the  evening  temperature  not  ex- 
ceeding 103.5°-104°  F.,  requires  no  special  treatment.  This  is  especially 
the  case  if  the  morning  remissions  are  considerable.  A  higher  temperature 
than  this  demands  antipyretic  treatment. 

Antipyretics  may  be  divided  into  two  groups,  internal  and  external. 

The  internal  antipyretics  available  for  this  purpose  are  antipyrin,  aceta- 
nilide,  phenacetin,  sodium  salicylate,  and  quinine.  Of  this  group,  phenacetin 
and  quinine  are  difficult  of  administration,  and  the  use  of  sodium  salicylate 
is  attended  with  the  danger  of  deranging  the  stomach.  Antipyrin  may  be 
administered  by  the  mouth,  by  the  rectum,  or  hypodermically,  in  doses 
varying  from  grs.  iiss-v.  These  doses  may  be  repeated  once  or  twice  at 
intervals  of  one  or  two  hours,  the  effect  being  carefully  watched.  The  dose 
of  acetanilide  is  from  gr.  ^iiss  :  it  cannot  be  administered  hypodermically 
nor  in  enemata,  owing  to  its  imperfect  solubility.  The  administration  of 
small  doses  of  quinine  or  tepid  baths  in  connection  with  these  antipyretics  is 
often  followed  by  marked  reduction  of  temperature  without  other  unfavor- 
able effects.  After  some  hours  the  temperature  tends  to  rise  again,  and  the 
administration  of  the  drugs  may  be  repeated  after  it  reaches  its  maximum ; 
but  the  antipyretic  course  should  not  be  resumed  at  intervals  shorter  than 
twenty-four  or  forty-eight  hours. 

External  antipyretic  treatment  consists  in  the  systematic  application  of 
cold  water  or  ice,  and  includes  (a)  cold  sponging,  (6)  cold  compresses,  (c)  the 
application  of  ic6,  (d)  the  cold  pack,  (e)  the  cold  or  gradually-cooled  bath, 
(/)  cold  affusion,  and  (r/)  iced-water  enemata.  The  therapeutic  action  of 
external  antipyretics,  whether  in  the  form  of  baths  or  of  other  cold-water 
applications,  is  greater  in  children  than  in  adults  in  proportion  as  the  extent 
of  surface  to  which  the  application  may  be  made  is  relatively  greater  as 
compared  with  the  volume  to  be  cooled.  The  effect  of  cold  applications  is 
more  rapid  and  greater,  circulation  is  more  easily  disturbed,  and  the  reaction 
is  more  tardy.  The  routine  employment  of  external  antipyretics  is  neither 
desirable  nor  safe  in  enteric  fever  in  childhood,  and  the  extreme  method  of 
Brand  is  inadmissible. 

(a)  Cold  Sponging. — The  water  may  be  of  the  temperature  of  the  room, 
or  slightly  cooled  with  ice.  A  little  alcohol  or  vinegar  may  be  added,  or 
Labarraque's  solution.  A  sponge  or  wash-cloth  may  be  used,  and  more  or 
less  moderate  friction  according  to  the  sensation  of  the  patient.  In  all  use 
of  water,  great  care-  must  be  taken  to  protect  the  bed.  Every  part  of  the 
body  is  in  turn  bared,  washed,  dried,  and  again  covered.  Spongings  may 
be  repeated  at  intervals  of  tAvo  or  three  hours.  In  the  hands  of  a  skilful 
nurse  they  not  only  add  greatly  to  the  comfort  of  tlie  patient,  but  also  exert 
a  favorable  influence  upon  the  nervous  system  and  upon  the  circulation 
of  the  blood,  by  causing  it  to  flow  more  freely  in  the  vessels  directly  under 


ENTERIC   OR   TYPHOID    FEVER.  493 

the  skin.  They  lower  the  temperature  only  slightly,  unless  the  water  be 
very  cold  and  the  spongings  frequently  repeated. 

(6)  Cold  Compresses. — For  this  purpose  three  or  four  thicknesses  of 
old  table-linen  or  towelling  which  is  porous  enough  to  hold  a  good  deal 
of  water  are  most  useful.  The  compress  is  wrung  out  of  water  of  the 
required  temperature  and  reapplied  as  it  becomes  warm.  Or  two  com- 
presses may  be  used  alternately,  each  being  cooled  in  turn  by  placing  it  on 
a  block  of  ice  in  a  basin  or  pan  at  the  bedside.  Cold  compresses  are  often 
used  for  the  head,  and  are  commonly  very  acceptable  to  patients.  They  are 
without  appreciable  eifect  upon  the  general  temperature.  Very  large  cold 
compresses,  extending  over  the  entire  thorax  and  abdomen,  and  frequently 
renewed,  exert  a  decided  effect  upon  the  internal  fever.  The  compresses 
are  sometimes  allowed  to  remain  continuously  in  position,  a  small  quantity 
of  cold  water  being  from  time  to  time  added  to  replace  that  lost  by  evap- 
oration. 

Leiter's  coils,  which  may  be  fitted  to  the  head,  or  applied  over  the  heart 
or  to  other  regions  of  the  body,  in  such  a  manner  as  to  reduce  local  temper- 
ature by  means  of  cold  water  flowing  through  them  from  a  reservoir  over 
the  bed,  exert  an  influence  analogous  to  but  not  exactly  the  same  as  that 
of  the  cold  compress. 

(c)  The  Application  of  Ice. — Ice  is  commonly  applied  by  means  of  a 
bladder  or  gum  ice-bag.  It  must  be  cracked  into  pieces  the  size  of  a  walnut 
and  introduced  into  the  bag  with  a  little  water,  the  bag  being  about  half  or 
two-thirds  full.  The  air  is  then  squeezed  out  and  the  stopper  adjusted.  If 
the  bag  be  filled,  or  air  enough  be  left  in  it  to  distend  it,  it  will  not  conform 
itself  to  the  part  to  which  it  is  applied.  A  much  more  effectual  method  of 
applying  ice  to  the  abdomen  or  over  the  heart  is  by  spreading  out  a  thick 
layer  of  finely-cracked  ice  between  the  folds  of  a  coarse  towel,  wdiich  is  then 
placed  directly  over  the  skin.  This  method  requires  constant  watching,  and 
is  almost  sure  to  wet  the  bedding.     It  is  not  available  for  prolonged  use. 

(d)  The  Cold  Pack. — A  blanket  is  spread  evenly  over  a  couch  or  bed ; 
over  this  blanket  is  laid  a  coarse  sheet  wrung  lightly  out  of  water  of  the 
prescribed  temperature  and  folded  once.  The  patient  is  lifted  upon  the  bed 
thus  prepared  and  quickly  wrapped  in  the  wet  sheet  by  the  attendant  in 
such  a  manner  tliat  it  lies  as  smoothly  as  possible  over  every  part  of  the 
body  except  the  head.  If  the  extremities  feel  cold  before  the  packing,  they 
must  be  warmed  by  friction  or  else  not  included  in  the  packing. 

So  soon  as  the  damp  linen  is  everywhere  in  contact  with  the  body,  the 
attendant  folds  the  blanket  over  the  patient  in  the  same  way,  first  drawing 
over  and  tucking  one  side  smoothly  under,  and  then  the  other,  seeing  that 
the  chin  is  free,  and  that  the  blanket  is  folded  evenly,  but  Avitliout  tension 
at  the  neck.  Finally,  the  long  end  is  drawn  down  and  folded  smoothly 
under  the  feet. 

Three  or  even  four  thicknesses  of  wet  sheets  spread  upon  the  blanket 
are  necessary  to  reduce  the  temperature  effectively. 


494  ENTEEIC   OR   TYPHOID   FEVER. 

The  reduction  of  temperature  from  a  single  pack  is  usually  transient, 
and  repeated  packings,  even  to  the  number  of  five  or  six,  are  often  adminis- 
tered, the  rise  of  temperature  being  slower  after  each.  When  the  tempera- 
ture does  not  rise  above  normal,  or  when  shivering  takes  place,  the  packing 
must  not  again  be  renewed.  When  repeated  packings  are  necessary,  two 
couches  are  used  side  by  side,  and  the  patient  is  lifted  directly  from  one 
pack  on  to  the  other.  The  same  effect  is  produced,  but  less  completely,  by 
unfolding  the  blanket  and  sprinkling  the  sheet  afresh  with  cold  water. 

The  patient  is  allowed  to  remain  in  the  last  pack  from  half  an  hour  to 
an  hour :  at  the  expiration  of  this  time  the  skin  generally  becomes  pleas- 
antly warm,  and  in  many  cases  outbreaks  of  perspiration  take  place. 

During  the  packing  the  pulse  is  felt  at  the  carotid  or  temporal  artery 
and  the  temperature  taken  in  the  mouth. 

(e)  The  Cold  or  Gradually-Cooled  Bath. — The  gradually-cooled  bath 
is  generally  employed.  The  quantity  of  water  used  should  be  sufficient 
wholly  to  immerse  the  body  of  the  patient.  The  tub  must  stand  at  the 
bedside.  During  the  bath  the  skin  should  be  gently  rubbed.  The  temper- 
ature of  the  water  should  be  about  100°  F.,  or  even  higher  than  this,  at 
the  first  bath.  As  the  patient  becomes  accustomed  to  the  bath,  it  is  grad- 
ually cooled  by  the  addition  of  cold  water  to  80°  F.,  or  lower.  Under  no 
circumstances  should  it  be  cooled  below  75°  F.  The  average  duration  of 
the  bath  is  five  minutes.  But  if  shivering  or  great  uneasiness  occur,  the 
patient  is  at  once  lifted  into  bed,  placed  upon  a  sheet  previously  made 
ready,  and  wiped  dry,  with  brisk  rubbing  of  the  extremities  and  back. 
The  moist  sheet  is  then  removed.  The  patient  is  covered  up,  and  some  hot 
soup  or  wine  or  bramdy-and-water  administered.  The  temperature  is  not 
always  immediately  reduced,  but,  as  measured  in  the  rectum,  usually  falls 
within  an  hour  from  one  and  a  half  to  four  or  five  degrees.  In  the  course 
of  some  hours  it  rises  again,  and  the  bath  is  then  repeated.  If  cold  baths 
are  not  well  borne,  good  results  in  lowering  the  temperature  often  follow 
prolonged  lukewarm  baths.  Sometimes  it  becomes  necessary  to  repeat  the 
bath  once  or  twice  in  the  course  of  twenty-four  hours.  A  patient  who  is 
quietly  sleeping,  even  if  his  temperature  be  high,  should  not  be  roused  and 
immediately  placed  in  the  bath. 

When  young  children  are  treated  by  this  method,  the  temperature  of  the 
bath  at  the  beginning  should  be  warm,  and  a  blanket  spread  over  the  tub, 
in  which  the  little  patient  is  gradually  lowered  into  the  water. 

Not  only  is  the  temperature  lowered  by  this  means,  but  also  a  very 
favorable  influence  is  exerted  upon  the  state  of  the  nervous  system.  The 
intellect  clears  up,  the  dulness  diminishes. 

(/)  Cold  Affusion. — While  the  patient  is  in  the  tub,  cold  water — 60° 
F. — is  thrown  by  means  of  a  sponge  over  his  head,  face,  neck,  shoulders, 
and  chest.  This  is  repeated  once  or  twice  just  before  he  is  removed  from 
the  bath.  It  is  done  rather  for  the  sake  of  its  good  effects  upon  the  nervous 
system  in  cases  of  great  stupor  and  other  evidences  of  serious  nervous  de- 


ENTERIC  OR  TYPHOID  FEVER.  495 

mngement  than  mfirely  as  a  means  of  reducing  high  temperature.  Cold 
affusions  may  be  practised  in  bed,  the  patient  being  suitably  protected  by 
water-proof  sheets. 

((/)  Iced- Water  Enemata. — Rectal  injections  of  iced  water  are  some- 
times followed  by  a  fall  of  temperature.  They  are,  when  carefully  admin- 
istered, rather  grateful  than  otherwise  to  patients.  The  quantity  of  water 
employed  should  not  in  enteric  fever  exceed  three  or  four  fluidounces. 

The  patient's  head  and  face  must  always  be  well  bathed  with  cold  water 
just  before  and  during  applications  of  cold  to  the  general  surface  of  the 
bodv.  The  occurrence  of  chill  or  rigor  may  be^  delayed  by  more  or  less 
vigorous  rubbing  or  chafing  of  the  body. 

The  reduction  of  temperature  by  one  or  two  degrees  and  marked  tran- 
quillizing influence  often  follow  the  administration  of  a  tepid  bath — 85°- 
95°  F. — of  a  duration  of  from  five  to  ten  minutes. 

The  contra-indicatious  to  the  use  of  external  antipyretics  are  marked 
general  debility,  feebleness  of  the  heart's  action,  coolness  of  the  surface  and 
extremities,  and  intestinal  hemorrhage. 

Chest-complications,  even  when  severe,  do  not  of  themselves  necessarily 
contra-indicate  the  cautious  employment  of  antipyretic  treatment  when  the 
temperature  becomes  dangerously  high. 

Other  complications  and  sequels  are  to  be  treated  in  accordance  with 
general  therapeutic  indications. 

(c)  The  Specific  or  Etiological  Plan. — The  assumption  that  enteric  fever 
can  be  artificially  aborted  has  been  made  upon  insufficient  evidence.  Un- 
doubted cases  of  spontaneous  abortion  of  the  disease  are  occasionally  ob- 
served. The  alleged  termination  of  enteric  fever  in  the  course  of  a  few  days 
as  a  result  of  some  special  form  of  treatment  demands  the  incontrovertible 
evidence  of  a  large  series  of  cases  to  establish  its  correctness. 

The  systematic  use  of  calomel  in  the  early  days  of  the  attack,  and  the 
administration  of  antiseptic  remedies  subsequently,  must  be  regarded  as 
coming  under  this  general  plan.  The  use  of  carbolic  acid,  either  alone,  or 
in  combination  with  iodine,  as  suggested  by  Bartholow,  during  the  whole 
course  of  the  attack,  has  in  my  experience  appeared  to  be  followed  by  ex- 
cellent results  in  children  as  in  adults.  Clinical  researches  in  the  direction 
of  a  plan  of  treatment  having  for  its  object  some  degree  of  influence  upon 
the  fluids  of  the  body  such  as  shall  diminish  their  availability  as  culture- 
media  for  infectious  germs  are  not  only  justifiable,  but  in  the  present  state 
of  knowledge  are  imperatively  demanded  by  the  known  facts  in  regard  to 
the  causation  not  only  of  enteric  fever  but  also  of  the  other  infectious 
diseases.  It  cannot  be  said  that  investigations  of  this  kind  have  thus  far 
yielded  definite  results. 

4.  The  Management  of  the  Patient  dunng  Convalescence. — During  the 
early  days  of  convalescence  the  temperature  remains  labile,  and  abrujit 
recrudescences  of  the  fever  arc  a})t  to  arise  from  slight  causes.  It  is  there- 
fore important  that  the  patient  be  cared  for  assiduously  for  some  time  after 


496  ENTERIC    OR    TYPHOID    FEVER. 

convalescence  is  complete.  For  at  least  a  week,  morning  and  evening  tem- 
perature observations  should  be  taken,  and  during  this  time  the  diet  is  to  be 
restricted  to  milk,  eggs,  custards,  animal  broths  or  jellies,  and  the  lighter 
farinaceous  foods.  At  the  end  of  a  week,  wholesome,  easily-digested  solid 
food,  including  meat,  may  be  resumed  ;  but  the  cifect  of  such  changes  of  diet 
upon  the  temperature  and  general  condition  of  the  patient  is  to  be  carefully 
watched. 

If  diarrhoea  persist,  it  is  to  be  treated  by  bismuth  and  small  doses  of 
opium,  either  alone  or  in  connection  with  the  mineral  acids.  If  there  be  a 
tendency  to  constipation,  simple  enemata  or  ninety-per-cent.  glycerin  sup- 
positories may  be  employed  for  its  relief.  Laxative  medicines,  with  the 
exception  of  castor  oil  in  small  doses,  are  inadmissible. 

Milk  punch,  egg-nog,  and  wine,  once  or  twice  a  day,  may  be  of  service 
during  convalescence ;  but  it  is  important  wholly  to  dispense  with  alcohol  as 
early  as  possible.  Quinine,  iron,  and  cod-liver  oil  may  be  administered  if 
the  convalescence  be  tardy  and  aneemia  persist. 


TYPHUS  FEVER. 

By  ALEXANDEE  COLLIE,  M.D. 


Definition. — An  acute  infectious  disease,  characterized  by  an  eruption 
on  the  skin  of  ill-defined  brownish-red  spots  (Collie  "  On  Fevers,"  etc.). 

Synonymes. — Typhus  (French) ;  Fleckfieber,  Flecktyphus,  Typhus- 
exanthematismus  (German) ;  Typhus  (Eng.)  ;  Petechial  Fever  (general  term). 

Definition  of  Children. — Ten  and  under. 

History. — On  this  point  there  is  very  little  to  be  said.  The  disease  is 
not  mentioned  by  any  physician  of  ancient  times ;  but  it  has  been  asserted 
that  the  great  plague  of  Athens  was  typhus,  an  opinion  which  could  not 
have  been  held  by  any  one  familiar  with  typhus  and  with  Thucydides.  It 
was  first  clearly  described  by  Fracastorius  in  the  fifteenth  century ;  but 
from  this  time  fonvard  it  was  confounded  with  other  diseases  until,  about 
1846,  Jenner  showed  it  to  be  quite  distinct  from  enteric  fever  and  conse- 
quently from  everything  else.  The  last  great  epidemic  of  typhus  was  that 
which  affected  the  French  troops  during  the  Crimean  War. 

Etiology. — Typhus  does  not  arise  primarily  among  children,  but  when 
it  appears  among  adults,  children  of  all  ages  take  it.  Its  cause  is  unknown. 
It  has  been  confidently  asserted  that  it  arises  from  destitution,  overcrowding, 
and  insanitary  conditions ;  but  of  this  there  is  no  more  evidence  than  that 
small-pox  or  any  other  infectious  disease  so  arises.  Destitution,  however, 
leads  to  overcrowding,  and  this  increases  the  probability  of  the  existence  of 
a  case  from  which  it  may  spread. 

Small-pox  appeared  among  the  soldiers  in  the  Franco-German  War. 
No  one,  however,  supposes  that  it  originated  from  the  aggregation  of 
individual  soldiers,  but  rather  that  it  was  carried  by  some  individual  soldier 
from  his  home  and  that  from  him  it  spread.  So  with  typhus  :  overcrowding 
and  general  unsanitary  conditions  do  not  originate  it,  but  they  supply  the 
condition  for  its  spread ;  and  the  proof  of  this  is  obvious ;  for  overcrowd- 
ing and  general  unsanitary  conditions  are  permanent,  whereas  typhus  is 
occasional.  It  is  essentially  a  disease  of  temjierate  climates.  It  has  not 
been  met  witli  in  the  tropics  nor  in  the  tropical  parts  of  America.  It  has 
from  time  to  time  appeared  in  most  parts  of  Europe,  in  the  United  States, 
in  Canada,  in  Australia,  and  in  New  Zealand ;  but  it  is  most  common  in 
Ireland  and  among  the  Irish  inhabitants  of  Great  Britain. 

Vol.  I.— 32  497 


498  TYPHUS    FEVER. 

It  may  occur  at  any  season  of  the  year,  but  it  is  more  common  in  winter 
than  in  summer.  One  attack  jDrotects  from  another ;  and,  although  there 
are  said  to  be  exce23tions  to  this,  the  writer  has  never  met  with  one.  It  is 
rarely  contracted  from  a  single  exposure,  as  is  often  the  case  with  measles, 
scarlet  fever,  and  small-pox.  On  the  contrary,  a  more  or  less  lengthened 
exposure  is  necessary,  nurses  in  typhus  wards  requiring  usually  an  exj^osure 
of  from  six  weeks  to  three  months ;  but  to  this  there  are  exceptions, 
especially  when  the  exposure  is  close,  the  cubic  space  small,  and  the  ventila- 
tion deficient.  Bodily  exhaustion,  the  depressing  emotions,  etc.,  are  said  to 
predispose  to  it ;  but  of  this  there  is  no  evidence.  Complete  exposure  to 
the  air  is  fatal  to  the  life  of  the  typhus  contagium,  an  excellent  proof  of 
which  is  found  in  the  Irish  epidemic  of  1848;  for  those  who  lay  in  the 
open  by  the  roadside  and  in  tumble-down  shanties  recovered  in  larger 
numbers  than  those  who  were  received  into  the  hospitals.  The  contagium 
does  not  extend  far  beyond  the  patient,  and  therefore,  icitli  due  regard  to 
cubic  space  and  ventilation,  other  patients  may  be  treated  with  safety  in  the 
same  ward,  so  long  as  they  remain  in  bed;  but  when  they  are  "up  and 
about"  they  run  the  risk  of  contracting  the  disease  by  direct  communication 
with  the  typhus  sick ;  and  this  is  the  practical  reason  against  the  treatment 
of  typhus  in  the  general  wards  of  a  hosjjital. 

Pathology  and  Morbid  Anatomy. — In  the  present  state  of  knowledge 
a  pathology  of  typhus  cannot  be  written.  The  characteristic  feature  of  the 
disease  is  the  eruption,  which  is  described  under  symptomatology. 

In  adults  after  death  "  the  blood  is  more  liquid  than  natural,  and  coagu- 
lates imperfectly.  The  heart  is  soft,  flabby,  and  friable,  and  there  is  more 
or  less  fatty,  waxy,  or  granular  degeneration  of  the  muscles.  The  liver,  the 
spleen,  the  kidneys,  and  the  mucous  membranes  are  more  or  less  congested ; 
but  there  are  no  specific  changes  in  these  organs.  In  the  nervous  system 
there  are  few  changes  beyond  congestion.  In  former  times  meningitis  was 
said  to  be  a  common  occurrence  in  ts^phus ;  but  that  was  at  a  time  (not  yet 
wholly  passed  by)  when  most  changes  characterized  by  delirium  were  mis- 
taken for  typhus."     (Collie  "  On  Fevers.") 

Symptoms. — These  in  children  are  not  usually  well  marked,  although 
cases  are  met  with  presenting  all  the  severity  so  common  among  adults. 
The  first  symptoms  are  usually  headache  and  shivering,  followed  by  a  feel- 
ing of  soreness  in  the  limbs  and  back.  The  temperature  rises,  the  pulse 
and  respirations  are  quickened,  the  tongue  is  fiirred,  the  appetite  is  dimin- 
ished, there  is  some  thirst,  and  a  general  feeling  of  weakness  like  to  that 
produced  by  a  severe  cold.  ToAvards  the  fifth  day  the  characteristic  erup- 
tion appears,  and  if  the  case  be  well  marked  it  will  present  the  following 
characters : 

"  It  consists  of  three  parts :  (a)  rose-colored  spots  which  disappear  on 
pressure,  (b)  dark-red  maculae  which  are  modified  by  pressure,  and  (c) 
petechise  upon  which  pressure  produces  no  effect,  and  which  persist  after 
death.     It  is  seen  usually  first  in  the  subclavicular  regions,  along  the  lower 


TEMPEKATUEE-CHAi 


Fanny  Slateb, 

£et.  7. 

Tj'phus  fever. 

Recovery. 


Joanna  Mxjephy, 

aet.  6. 

Typhus  fe-^'er. 

Recovery. 


Ann  Carroll, 

at.  11. 

Typhus  fever. 

Recovery. 


William  Dick, 

set.  6. 

Typhus  fever. 

Recovery. 


Maey  Ann  Parish, 

set.  18  months. 

Typhus  fever. 

Recovery. 


Elizabeth  Ryan, 

Typhus  fever. 

Recovery. 


William  Parrish, 

set.  5. 
Typhus  fever,  fol- 
lowed by  pleu- 
risy of  side. 
Recovery. 


Tempera- 

ture 

F. 

c. 

105.8° 

41° 

104° 

40° 

102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

104° 

40° 

102.2° 

39° 

10Q.4° 

38° 

98.6° 

37° 

104° 

40° 

102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

104° 

40° 

102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

104° 

40° 

i   102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

104° 

40° 

102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

96.8° 

36° 

!   104° 

40° 

102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

I, 

r 

104° 

40° 

102.2° 

39° 

100.4° 

38° 

98.6° 

37° 

96.8° 

36° 

104° 

40° 

102.2° 

39° 

100.4° 

38° 

i    98,6° 

37° 

M 

Ihe  numbers  iu  the  bud 


OF   TYPHUS   FEVER. 


the  chart  indicate  the  probable  day  of  disease. 


Alexander  Collie,  M.D. 


N'ormal  Line. 


Kormal  Line. 


Normal  Line. 


Normal  Line. 


Normal  Line. 


Normal  Line. 


Normal  Line. 


Normal  Line. 


Normal  Line. 


TYPHUS    FEVER.  499 

border  of  the  pectoralis  major,  on  the  wrists,  the  back  of  the  hands,  and  the 
epigastrium,  from  which  parts  it  gradually  covers  the  body  in  from  one  to 
tliree  days.  It  is  not  usually  found  on  the  face  and  neck,  but  to  this  there 
are  exceptions.  At  the  very  beginning  the  eruption  consists  of  red  spots 
which  disappear  on  pressure,  and  if  the  attack  be  mild  the  eruption  may 
consist  chiefly  of  such  throughout  the  Ayhole  course  of  the  disease ;  but  in 
the  severer  cases,  in  addition  to  the  red  spots  there  are  dark-red  maculae,  not 
unlike  '  freckles'  in  form,  connected  together  by  faintly-visible  streaks  which 
partially  disappear  on  pressure,  to  which  are  added,  later  on,  distinct  petechise 
upon  which  pressure  makes  no  impression.  When  the  eruption  is  well  out, 
it  remains  out  until  it  disappears  altogether,  which  it  usually  does  towards, 
or  soon  after,  the  crisis  of  the  fever.  It  diifers  from  enteric  in  that  it  does 
not  come  out  in  successive  crops,  although  at  the  very  beginning  spots  may 
be  seen  to  come  out  and  disappear  on  various  parts  of  the  body  until  the 
general  eruption  appears."     (Collie  "  On  Fevers.") 

The  patient's  condition  in  well-marked  cases  is  now  pathognomonic. 
Generally  he  is  drowsy,  his  face  somewhat  dull  and  dusky ;  his  eyes  are 
injected,  and  his  senses  somewhat  blunted ;  but  his  mind  in  the  majority  of 
cases  is  clear,  so  that  when  roused  he  answers  intelligently.  Delirium  is 
unusual,  and  when  present  is  rarely  marked.  The  temperature  is  usually 
low ;  but  in  cases  of  some  severity  it  fluctuates  between  39°  and  40°  C. 
(See  Chart.)  The  pulse  varies  from  100  to  120  ;  the  respirations  are  slightly 
accelerated ;  the  tongue  is  moist  and  furred, — rarely  dry  and  brown,  as  is 
often  the  case  in  adults  ;  the  abdomen  is  flat,  and  the  bowels  are  variable. 
Throughout,  the  child  sleeps  fairly  well,  although  he  is  sometimes  disturbed 
by  dreams.  The  fever  continues  about  ten  days,  when  a  crisis  occurs.  The 
temperature  falls  suddenly,  the  pulse  becomes  slower,  the  eye  clear,  the  ex- 
pression intelligent,  and  the  tongue  clean.  The  appetite  returns  at  once, 
and  in  two  or  three  days  the  temperature  becomes  normal.  As  a  rule,  there 
are  no  complications  and  no  sequelae,  but  the  writer  has  met  with  noma  and 
pleurisy.  There  are  no  relapses.  The  complications  met  with  in  adults  are 
pneumonia,  pleurisy  with  effusion,  parotid  swelling,  laryngitis,  diphtheria, 
and  nephritis ;  the  sequelae,  deafness  and  gangrene  of  the  extremities. 

Diagnosis. — In  the  case  of  children  it  should  be  remembered  that 
although  they  contract  typhus  it  is  not  usually  found  among  them  except  in 
association  with  cases  among  adults :  so  that  when  a  case  is  met  with  in  a 
child  a  well-marked  case  or  cases  will  probably  be  found  among  its  adult 
relations  or  neighbors.  It  should  be  remembered,  further,  tliat  typhus  is 
usually  epidemic  either  in  the  district,  the  town.,  the  village,  the  street,  or 
tlic  house :  so  that  if  one  case  be  found  there  will  probably  be  others  not 
far  off.  The  diseases  with  which  it  is  most  frequently  confounded,  in  the 
case  of  adults,  are  acute  pneumonia  and  chronic  kidncy-diseasc.  The  former 
may  be  excluded  by  examining  the  chest,  the  latter  in  children  can  hardly 
be  said  to  exist.  The  most  important  and  characteristic  feature  of  typhus 
is  the  eruption ;  but  it  is  unfortunate  for  the  purpose  of  diagnosis  that  it  is 


500  TYPHUS    FEVER. 

rarely  well  marked  in  children.  In  the  case  of  these,  therefore,  help  must 
be  looked  for  in  the  general  surroundings  of  the  patient.  The  history  of 
the  case  should  be  carefully  considered ;  the  presence  of  other  cases  among 
the  adult  relations  of  the  child  should  be  inquired  after,  and  the  existence 
of  other  cases  of  "  fever"  in  the  neighborhood  and  among  the  child's  friends 
and  relations,  because  solitary  cases  are  not  met  with  in  children,  and  con- 
sequently when  they  are  a  case  or  cases  will  be  met  with  among  their  adult 
relations  or  neighbors.  Therefore  an  ill-defined  "  fever"  in  a  child  whose 
adult  relations  or  immediate  neighbors  were  or  had  been  affected  by  typhus 
would  almost  certainly  be  typhus,  assuming  of  course  that  there  were  no 
symptoms  or  physical  signs  pointing  to  local  disease. 

Next  in  importance  to  these  considerations  is  the  general  aspect  of  the 
patient.  The  expression  is  dull  and  heavy,  the  eyes  are  injected,  and  gen- 
erally he  is  somewhat  drowsy.  With  these  symptoms  there  are  no  local 
changes  to  account  for  them,  for  example,  no  chest  or  abdominal  symptoms, 
and  although  the  patient  may  complain  of  headache  he  does  not  cry  out  from 
acute  pains,  as  in  meningitis.  If  with  these  symptoms  there  be  a  faint 
mottling  of  the  skin,  particularly  of  the  wrists  and  subclavicular  regions 
(care  having  been  taken  to  eliminate  "  flea-bites"),  there  can  be  little  doubt 
that  the  disease  is  typhus.  Enteric  fever  should  not,  as  a  rule,  present  any 
difficulty,  because  the  symptoms  in  this  "  fever"  are  a  complete  contrast  to 
those  of  typhus.  In  the  former  the  face  is  pale,  the  expression  intelligent, 
and  the  eye  bright. 

Measles  might  in  some  cases  give  rise  to  difficulty,  for  in  these  the  eye 
is  suffused  and  injected  and  the  expression  drowsy  ;  but  the  eruption  is  most 
abundant  and  most  marked  on  the  face,  whereas  in  typhus  the  eruption  is 
rarely  on  the  face,  and  when  it  is  it  is  but  slightly  marked  and  never 
characteristic.  From  ordinary  small-pox  the  diagnosis  is  so  obvious  that 
nothing  need  be  said ;  but  in  adults  the  hemorrhagic  form  of  that  disease 
has  been  mistaken  for  typhus,  and  the  same  mistake  is  possible  in  the  case 
of  unvaccinated  children.  This  depends  mainly  on  two  conditions  :  first, 
that  in  pure  hemorrhagic  small-pox  there  are  no  papules,  and,  second,  that 
instead  of  these  there  is  an  abundant  purpuric  eruption.  The  diagnosis 
may  be  made  from  attention  to  the  following  considerations.  In  pure 
hemorrhagic  small-pox  the  spots  are  very  large,  often  like  the  spots  which 
may  be  made  by  throwing  ink  from  a  pen  on  white  blotting-paper,  and 
they  exist  in  large  numbers  closely  packed  over  the  lower  abdomen ;  in 
typhus  they  are  minute,  about  one-sixteenth  to  one-twelfth  of  an  inch  in 
diameter,  and  they  are  distributed  all  over  the  body.  In  hemorrhagic 
small-pox  the  petechial  and  purpuric  spots  are  almost  invariably  accom- 
panied by  blood-clots  in  the  conjunctivfe,  and  sometimes  by  large  patches 
exactly  like  the  bruises  produced  by  blows ;  in  typhus  there  is  nothing 
of  the  kind.  In  liemorrhagic  small-pox  the  eruption  is  accompanied  by 
hemorrhage  from  one  or  all,  usually  several,  of  the  mucous  surfaces ;  iu 
typhus  there  is  nothing  like  this.     In  hemorrhagic  small-pox  these  eruptions 


TYPHUS    FEVER. 


501 


are  well  out  on  the  third  or  at  the  latest  on  the  fourth  day  ;  in  typhus  the 
eruption  does  not  begin  to  come  out  until  about  the  fifth  day,  is  not  well 
out  till  about  the  seventh  day,  and  does  not  become  petechial  till  about 
the  tenth  day,  and  in  children  it  is  rarely  petechial,  because  of  the  mildness 
of  the  disease  and  of  the  occurrence  of  the  crisis  at  or  before  that  day. 

Prognosis. — This  is  usually  favorable ;  and  in  the  writer's  experience 
it  has  invariably  been  so.     It  may  be  gathered  from  the  following  tables : 

LONDON   FEVER   HOSPITAL. 


Age  of  Patients. 

Number  of  Cases. 

Number  op  Deaths. 

00 

9 
30 
56 

00 

CO 
00 

1 

2 

• 

CO 
00 

i 
■ 

o 

9 
30 
56 

oo 

i 

C4 

00 

CO 
00 

00 

I> 

00 

00 

00 
tH 

1 

"3 

_ 

1 

Under  5  years 

From  5  to  9  years 

From  10  to  14  years 

i.78 

(LONDON")    EASTEEN 

HOSPITALS 

[FEVER). 

Age  of  Patients. 

Number  of  Cases. 

Number  of  Deaths. 

K  Pi 
O  W 
^(^ 

i.76 

§ 

00 

3 

5 
I'l 

CO 
00 

2 
7 
32 

-*< 

3 

12 
24 
38 

'2 

CO 

2 
2 
3 

to 

3 

10 
16 

5 

1 
5 
6 

00 

1 
i 

s 

1 

2 

1-1 

'. 
1 

3 

o 

24 
54 
113 

.1  . 

.-1    IM 
00    00 

CO 

2 

00 

00 

CO  icn 

00    00 

3 

o 
Eh 

2 

Under  5  years 

These  statistics  are  confirmed  by  the  experience  of  Dr.  McCombie,  of  the 
South-Eastern  Hospital  (fever),  who  during  the  years  1880-87  had  twenty- 
six  cases  of  typhus  under  ten  years  of  age  and  no  deaths.  But  apparently 
this  experience  is  not  universal;  because,  during  the  years  1865-70,  of  one 
hundred  and  forty-eight  cases  under  five  treated  in  the  London  Fever  Hos- 
pital there  were  ten  deaths,  a  mortality  of  6.7  per  cent.,  and  of  six  hun- 
dred and  sixty-four  admissions  from  five  to  ten  there  were  fifteen  deaths,  a 
moi-tality  of  2.2  per  cent.  The  folloAving  table  gives  the  experience  of  the 
South- Western  Hospital  (Loudon) : 


SOUTH-WESTERN 

HOSPITAL 

(FEVER). 

Age  of  Patients. 

Number  of  Cases. 

Number  of  Deaths. 

eAtt 
°? 
^<^ 

5.40 
0.86 
5.80 

i 

pi  Ico  'tj! 

00     30     00 

3  10  12 
13  25  51 
12  45  61 

1 

3 

so 

1 

3 

0 

00 

''5 

00 

6 
3 

7 

2 

3 

o 

1-H 
00 

00 

CO  -ai  'lo  to 
t^  1--  i-i  t~. 

00    00    00    00 

g 

1 

2 

■ 

00 

. 

1 

2 

1 
9 

Under  5  years 

37  . 
116   . 
155 

3 

1. 

1  . 

2  2 

1 

From  ')  t()  y  years 

From  10  to  14  years 

Unfavorable  signs  are  extensive  congestion  and  inflammation  of  the 
lungs,  bronchitis,  pleurisy,  ne])hritis,  laryngitis,  and  diphtheria ;  but  in  chil- 
dren under  ten  these  complications  are  very  rare. 


502  TYPHUS    FEVER. 

Treatment. — Typhus  is  for  the  most  part  so  mild  iu  children  that  active 
treatment  is  rarely  required.  The  child  should  be  placed  in  a  large,  well- 
ventilated  room,  the  temperature  of  which  should  be  about  50°  F.  during 
the  acute  stage.  He  should  be  placed  iu  charge  of  a  trustworthy  nurse, 
who  should  not,  if  possible,  exceed  twenty-five,  so  that  should  she  contract 
the  disease  she  may  have  the  best  possible  chance  of  recovering  from  it. 
He  should  not  be  nursed  by  elderly  persons,  because  of  the  infectious 
nature  of  the  disease  and  of  its  high  mortality  among  those  who  have 
passed  thirty.  He  should  be  fed  on  milk,  beef  tea,  chicken  broth,  bread 
steeped  in  the  beef  tea,  and  raw  eggs,  of  which  he  should  have  as  much  as 
he  chooses  to  take.  His  mouth  should  be  kept  scrupulously  clean  by  washing 
with  a  soft  tooth-brush  as  often  as  may  be  necessary.  He  should  be  sup- 
plied with  as  much  cold  water  as  he  wishes,  and  this  may  sometimes  be 
iced.  He  should  have  a  tepid  bath  and  his  linen  should  be  changed  at 
least  once  daily.  No  drug  beyond  a  dose  of  castor  oil  will  be  required,  and 
the  following  is  an  excellent  method  of  administering  it : 

"  Giving  medicine  so  as  to  cause  the  patient  as  little  disgust  as  possible 
is  no  slight  art,  and  worth  any  trouble  to  accomplish.  In  the  first  place, 
the  glass  or  vessel  in  which  it  is  given  must  be  thoroughly  clean,  not  having 
been  used  to  give  a  previous  dose  and  remaining  unwashed.  The  medicine 
should  never  be  poured  out  within  sight  or  smell  of  the  patient,  if  it  is  in 
any  way  disagreeable  to  him ;  and  if  he  takes  anything  after  it  the  same 
should  be  ready  with  the  dose,  that  he  may  take  it  instantly  after  the  medi- 
cine. These  remarks  apply  particularly  to  the  administration  of  castor  oil 
or  cod-liver  oil,  both  of  which  are  generally  very  obnoxious  to  adults ;  at 
the  same  time  it  is  easy  to  give  them  both  in  such  a  manner  as  to  render 
them  very  little  disgusting.  I  have  often  been  told  by  patients  that  they 
could  not  take  castor  oil,  but  I  never  found  any  one  who  could  not  do  so 
perfectly  well  when  prepared  as  follows.  Put  a  teaspoonful  of  brandy  into 
a  glass  and  wet  the  sides  well  with  it,  then  pour  very  slowly  the  oil  on  to 
it,  taking  care  to  keep  it  so  directly  in  the  middle  of  the  glass  that  none 
shall  touch  the  sides ;  on  the  top  of  the  oil  put  another  teaspoonftil  of 
brandy.  Before  the  patient  takes  it,  give  him  a  little  brandy  with  which 
thoroughly  to  rinse  his  mouth,  that  the  oil  if  it  touches  should  not  stick  to 
it.  If  he  then  opens  his  mouth  wide  and  swallows  the  oil  boldly,  taking 
another  sip  of  brandy  immediately  after  it,  he  will  not  taste  it."  (A'^eitch.) 
It  may  be  given  in  orange-juice  in  the  same  manner. 

Antipyretics,  such  as  the  cold  bath,  quinine,  autipyrin,  kairiu,  and  anti- 
febriu,  will  rarely  be  required  in  the  case  of  children,  because  of  the  mild- 
ness of  the  disease. 

Generally  in  "  fevers"  irritating  applications,  such  as  hot  and  mustard 
poultices,  should  be  avoided,  because  of  the  tendency  of  the  skin  to  slough. 

Bedsores  should  be  extremely  rare  in  children,  and  may  almost  invari- 
ably be  prevented.  For  this  purpose  the  sacral  and  scapular  regions  should 
in  severe  cases  be  examined  daily,  and,  if  the  skin  be  observed  reddening, 


TYPHUS    FEVER.  503 

some  spirit  lotion  should  be  employed  and  a  water-bed  supplied.  Alcohol 
will  rarely  if  ever  be  required  for  the  typhus ;  but  it  may  for  an  accidental 
complication,  such  as  noma.  When  there  is  much  restlessness,  sponging 
with  cold  water  will  be  found  very  grateful.  To  favor  sleep,  the  patient 
should  be  kept  quiet ;  and  if  it  be  necessary  to  procure  it  by  artificial 
means,  a  warm  bath  followed  by  a  dose  of  port  wine  may  be  given,  and, 
generally,  opium  should  be  avoided.  In  adults  retention  of  m'ine  is  an 
occasional  occurrence ;  and,  as  it  might  arise  in  children,  the  lower  abdomen 
should  be  examined  daily  to  see  if  the  bladder  be  full ;  and  the  statement 
of  the  nurse  that  the  patient  is  passing  water  freely  should  not  be  accepted, 
because  when  the  bladder  is  full  sometimes  it  runs  over,  and  this  dribbling, 
making  a  great  show,  leads  the  nurse  to  believe  that  it  is  being  emptied. 
When  the  temperature  has  fallen,  the  child  may  return  at  once  to  his 
ordinary  diet. 


RELAPSING   FEVER. 

By  EOLAND   G.  CUETIN,  M.D. 


Synonymes. — Febris  recurrens,  Recurrent  typhus,  Typhus  recurrens, 
Hunger  typhus,  Hunger  pest,  Spirilkim  fever,  etc. 

Definition. — Relapsing  fever  is  a  contagious,  infectious  fever  of  specific 
origin  (a  spirillum  found  in  the  blood  being  the  supposed  cause).  Its 
greatest  ravages  are  among  the  ill-fed,  unclean,  and  crowded  poor.  Its 
advent  is  remarkable  for  abruptness,  coming  on  with  a  pronounced  chill 
(often  a  rigor)  without  prodromata ;  following  this,  a  sudden  rise  of  tem- 
perature occurs,  running  as  high  as  103°  to  105°  F.  within  twenty-four 
hours.  The  attack  consists  of  two  or  more  paroxysms,  divided  by  an 
apyretic  interval.  The  initial  paroxysm  is  generally  the  longest.  This  is 
followed  by  an  abrupt  subsidence  of  the  temperature  to  a  subnormal  point 
about  the  fifth,  sixth,  or  seventh  day,  with  a  profuse  and  exhausting  per- 
spiration. The  second  paroxysm  begins  about  the  fourteenth  day  from 
the  initial  chill.  It  is  usually  shorter  and  milder.  Headache,  sleeplessness, 
vomiting,  jaundice,  and  conjunctivitis  are  frequent  concomitants.  It  has  no 
peculiar  eruption,  and  no  pathognomonic  lesion  of  the  solids.  The  spleen 
and  liver  are  enlarged,  and  tenderness  is  found  over  these  organs,  also  at 
the  epigastrium.  Death  is  exceedingly  rare,  occurring  usually  in  the  cases 
of  those  who  are  constitutionally  weak  or  unsound,  or  from  complications. 

History. — It  is  quite  evident  that  relapsing  fever  is  a  very  ancient  dis- 
ease. It  was  accurately  described  by  John  Rutty  in  1739  and  1741.  Be- 
fore this  time,  writers  had  noted  the  principal  diagnostic  points  in  the 
disease.  During  an  epidemic  in  Dublin,  Drs.  Barker  and  Cheyne,  in  an 
article  entitled  "An  Account  of  the  Rise,  Progress,  and  Decline  of  the 
Fever  lately  epidemical  in  Ireland,  etc.,"  1821,  remark,  "Certain  it  is 
that  the  fever  of  1800  and  1801  very  generally  terminated  on  the  fifth  or 
seventh  day  by  perspiration ;  that  the  disease  was  then  very  liable  to  recur ; 
that  the  poor  were  chief  sufferers  by  it." 

In  1827  the  disease  was  first  definitely  isolated  from  typhus  and  typhoid 
fevers. 

The  name  relapsing  fever  was  first  applied  to  this  disease  by  a  Scotch 
physician  named  Paterson,  in  1847. 

The  first  recognized  introduction  of  relapsing  fever  into  the  United 
504 


RELAPSIXG   FEA^EE.  505 

States  was  in  1844,  it  having  been  then  traced  directly  to  an  immigrant- 
ship.  It  was  afterwards  similarly  introduced  into  this  country  in  1848, 
and  again  in  1850,  once  more  in  1863,  and  lastly  in  1869.  The  disease  was 
in  every  case  imported  from  Europe.  It  was  during  this  last  epidemic  that 
the  writer's  opportunity  of  observing  the  disease  occurred. 

Etiology. — Relapsing  fever  is  essentially  a  contagious  disease,  as  it 
occurs  in  epidemics,  these  epidemics  arising  from  a  focus  and  spreading 
by  contact  and  fomites. 

Murchison  and.  Begbie  state  as  their  opinion  that  relapsing  fever  is 
more  contagious  in  childhood  than  typhus.  In  Murchison's  table  (in  his 
M'^ork  on  Continued  Fevers),  in  two  thousand  one  hundred  and  eleven  cases 
he  gives  the  following  data  : 

Under  5  years 39  cases  ; 

From    5  to    9  years 126  cases ; 

From  10  to  14      "        234  cases  ; 

From  15  to  19      "        405  cases  ; 

Making  under  20  years  • 804  cases. 

Dr.  Pepper,  in  his  "  System  of  Medicine,"  giving  the  statistics  of  the 
Philadelphia  epidemic,  says  that  in  the  eleven  hundred  and  sixty-four  cases 
collected  by  him,  two  hundred  and  tw^enty-five  were  under  twenty  years  of 
age,  the  youngest  being  children  between  two  and  three  years  old.  It 
would  seem  from  the  foregoing  statistics  that  the  disease  is  very  rare  in 
early  infancy.  In  the  first  year  or  two,  as  is  shown  by  these  tables,  as  in 
many  other  contagious  diseases,  perhaps  the  disease,  if  present  at  all,  is  light 
and  oflen  unrecognized.  It  is  not  now  believed  that  scanty  food  and  filth 
originate  the'disease,  but  we  do  know  that  they  favor  its  propagation.  Em- 
ployment does  not  seem  to  influence  the  attack.  The  essential  cause  seems 
to  be  a  spirillum  in  the  blood,  discovered  by  Obermeier  in  1873.  His 
observations  have  been  confirmed  by  Koch,  Albrecht,  Miilhauser,  and 
others,  which  seems  to  prove  that  the  disease  is  due  to  these  filaments. 
The  cause  being  present,  the  disease  spreads  under  conditions  contributing 
thereto,  especially  among  the  lower  classes. 

Relapsing  fever  has  not  found  a  home  in  the  United  States.  It  occurs 
only  along  the  lines  of  commercial  intercourse  in  slight  epidemics,  and  then 
only  to  reappear  when  again  introduced  from  Europe.  The  probable  cause 
of  this  is  that  our  people  are  better  fed  and  more  free  from  squalor  than 
the  poor  of  some  foreign  countries,  where  famine  and  distress  attend  the 
failure  of  their  few  and  sometimes  scanty  crops.  The  last  epidemic  in 
Philadelphia,  in  1869,  followed  an  epidemic  of  typhus  (1867-1868),  which 
also  succeeded  another  epidemic,  one  of  cerebro-spinal  meningitis  (in  186G 
and  1867).  No  famine,  at  home  or  abroad,  preceded  this  outbreak  of 
relapsing  fever. 

Patholog-y. — Cadaveric  rigidity  in  relapsing  fever  is  of  short  duration. 

The  blood  has  sometimes  been  found  in  an  altered  condition,  the  white 


506  RELAPSING    FEVER, 

corpuscles  being  in  excess,  the  red  ones  crenated  and  distorted  and  not  form- 
ing in  rouleaux.     The  blood  is  found  either  liquid  or  soft  and  grumous. 

The  lungs  are  congested,  and  sometimes  evidences  of  the  early  stage  of 
pneumonia  are  found.  Lobar  pneumonia  was  found  in  thirty-three  per  cent, 
of  the  autopsies  of  the  Philadelphia  epidemic  of  1869  and  1870,  as  reported 
by  Dr.  Pepper;  the  statistics  of  other  writers  show  an  average  of  about 
twenty-four  per  cent. 

The  muscular  tissue  of  the  heart  is  found  in  a  state  of  acute  fatty  de- 
generation, especially  where  death  occurs  in  the  later  stages  of  the  disease. 

The  brain  is  usually  soft  and  flabby,  but  otherwise  normal. 

Little  or  no  change  is  found  in  the  spinal  cord. 

The  mucous  membrane  of  the  stomach  is  sometimes  congested,  and  may 
be  even  ecchymotic,  but  it  is  often  normal. 

The  intestines  are  usually  normal,  being  in  some  rare  cases  dotted  with 
spots  of  ecchymosis. 

The  liver  is  found  enlarged,  congested,  and  fatty.  The  larger  ducts  are 
often  found  in  a  state  of  catarrhal  inflammation ;  and  Miinch  has  observed 
the  same  condition  in  the  minute  bile-ducts. 

The  spleen  is  enlarged,  sometimes  enormously  (one  having  been  found 
to  weigh  sixty-eight  ounces),  and  filled  with  free  granular  blood.  Occasion- 
ally abscesses  are  found,  which  may  be  quite  large  or  perhaps  minute.  On 
section  of  the  capsule,  the  pulp  sometimes  pufls  out,  as  if  under  pressure 
from  within.     Hemorrhagic  infarcts  are  not  rare. 

General  peritonitis  is  sometimes  found,  but  it  is  much  more  frequently 
localized  over  the  spleen, — in  some  instances  produced  by  rupture  of  the 
capsule  of  this  organ,  frdm  extensive  and  rapid  distention. 

Where  jaundice  has  been  present  during  life,  the  internal  tissues  are 
found  stained. 

Emaciation  is  not  marked,  especially  where  death  occurs  early  in  the 
disease. 

Symptomatolog'y. — Relapsing  fever  is  a  disease  which  affects  both 
sexes,  and  all  ages,  with  perhaps  the  exception  of  infants  under  one  year  of 
age.  In  children,  as  a  rule,  the  symptoms  are  less  marked,  and  not  unfre- 
quently  the  disease  is  of  the  abortive  type  ;  that  is,  there  exists  a  tendency 
to  run  a  shorter  and  milder  course  than  in  adults. 

The  invasion  of  this  fever  is  usually  as  follows.  The  adult  patient  is  at 
work,  or  the  child  is  at  play,  during  the  day,  apparently  in  full  health ;  an 
abrupt  chill  or  rigor  comes  on,  and  in  an  hour  the  temperature  may  run  up 
to  105°  F.,  with  a  quick  rapid  pulse,  sharp  pain  in  the  head,  darting  pain 
in  the  limbs  and  loins,  no  desire  for  food,  and  great  thirst.  The  digestive 
tract  especially  suffers,  as  shown  by  vomiting  and  anorexia. 

The  enlargement  of  the  spleen  is  rapid  and  often  great ;  the  liver  is 
similarly  affected,  but  usually  not  to  so  great  an  extent  as  the  spleen. 

Relapses. — The  fever  usually  rises  the  second  time.  The  paroxysm  in 
each  succeeding  relapse  is  usually  shorter  and  less  severe ;  the  temperature 


RELAPSING    FEVER.  507 

is  less ;  during  the  interval  there  is  less  perspiration ;  and  exhaustion  is  not 
so  marked  as  in  the  first  intermission. 

Tongue. — At  first  a  white  fur  uniformly  covers  the  whole  organ,  but  in 
two  days  the  appearance  is  marked  ;  the  tips  and  borders  become  more 
deeply  red  in  color  than  is  natural ;  the  color  of  the  centre  will  be  found 
of  a  silvery  whiteness.  Occasionally,  later  on,  it  appears  as  if  robbed  of  its 
mucous  membrane ;  but  this  is  seldom  the  case  except  in  the  typhoid  form. 
During  the  intermission  it  usually  becomes  clean,  but  may  again  return  to 
the  condition  described  in  the  first  paroxysm,  and  corresjsonding  changes 
may  take  place  with  every  exacerbation,  continuing  to  the  end. 

Appetite. — The  appetite  is  rapidly  lost,  at  the  commencement  of  the 
disease ;  and  even  disgust  for  food  often  ensues,  with  inability  to  retain  it ; 
but  during  the  intermissions  it  is  sometimes  continuously  craving.  This 
appetite  should  be  gratified  with  care  and  judgment. 

Vomiting. — In  about  one-third  of  the  cases  there  is  vomiting ;  the 
stomach  is  irritable  during  the  first  paroxysm,  and  less  so  in  those  which 
follow.  The  matter  first  vomited  consists  of  the  contents  of  the  stomach, 
and,  after  much  retching,  it  is  sometimes  bilious,  though  \e.vy  rarely  bloody. 

Diarrhoea. — This  is  quite  frequently  present  late  in  this  disease.  It  is 
generally  dysj^eptic  in  character.  The  stools  are  dark  and  oiFensive, — the 
latter  condition  being  caused  by  the  undigested  food.  The  abdomen  is 
normal  in  every  respect,  except  in  the  tenderness  found  over  the  region  of 
the  epigastrium,  spleen,  and  liver. 

Liver. — This  organ  is  enlarged,  sometimes  greatly  so,  diminishing  again 
during  the  interval  between  the  paroxysms.  In  the  negro  race  the  liver  is 
usually  more  extensively  afiected. 

Jaundice  to  a  greater  or  less  degree  was  associated  with  the  epidemic  of 
1869  and  1870  in  Philadelphia, — in  about  from  twenty  to  twenty-five  per 
cent,  of  the  cases,  as  reported  by  Dr.  Pepper.  It  is  much  more  frequent  in 
the  African  race  than  in  the  white.  This  is  probably  due  to  obstruction  of 
the  bile-ducts  from  catarrhal  inflammation,  rather  than  to  suppression,  as 
before  stated ;  for  the  large  and  small  ducts  are  often  found  in  a  state  of 
inflammation  after  death. 

Spjleen. — This  organ  is  invariably  enlarged,  and  becomes  so  rapidly, 
causing  tenderness  over  the  splenic  region,  with  heavy,  dull,  dragging, 
aching  pain.  As  in  the  case  of  the  liver,  the  enlargement  generally  sub- 
sides perceptibly  during  the  interval  between  the  paroxysms,  increasing 
again  during  the  exacerbation.  Sometimes  the  capsule  cannot  withstand 
the  strain  of  the  pressure  from  within,  rupture  takes  })lace,  and  abscesses 
occasionally  form,  wliich  may  open  into  the  peritoneal  cavity.  Peritonitis, 
either  general  or  local,  may  be  caused  by  this  accident.  The  spleen  some- 
times continues  enlarged  after  the  patient  recovers. 

Epistaxis  is  quite  frequent,  but  usually  much  less  so  than  in  typhoid 
fever, — some  statistics  giving  five  per  cent.,  others  as  high  as  tvventy-five 
per  cent.,  varying  with  the  type  of  the  epidemic. 


508 


RELAPSIXG   FEVER. 


Heart. — This  the  central  organ  of  the  circulation  is  greatly  crippled, 
especially  in  the  latter  stages  of  the  disease,  from  impairment  of  the  muscular 
tissue.  The  systolic  sound  is  consequently  weakened  or  inaudible,  and  the 
diastolic  sound  is  sharpened.  During  convalescence  an  anaemic  murmur  is 
heard  with  the  systole,  together  with  a  hum  in  the  right  jugular  vein.  Dr. 
Parry  noted  a  blowing  murmur  at  the  base  of  the  heart  and  over  the  great 
vessels  during  both  paroxysms.  This  murmur  disappeared  during  the 
interval. 

Pulse. — The  pulse  is  frequent  during  paroxysms,  subsiding  to  normal 
during  the  intermissions.  It  is  usually  strong  and  full,  earlier  in  the 
disease ;  but  later  it  becomes  weak  and  frequently  dicrotic. 

A   CHAET   FROM    MURCHISON    "ON   EELAPSING   FEYEE." 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

u 

12 

13 

Vk 

15 

16 

17 

18 

19 

1 

1 

i 

1 

1 

I 

1 

1 

lOK 

I 

1 

1 

1 

1    ^ 

1 

1 

1 

1 

1__ 

/-i\— 

/ 1 1 

A 

/  '  \ 

/ 

1 

l\ 

'    1  \ 

^  ' 

' 

\  /  1  I 

/ 

104 

J '  \ 

V' 

\l 

A  1  V 

\! 

1 

/  1 

i  ^ 

N 

f    1 

\' 

1 



— 

^    1 

1 

j 

\J 

/ 

103 

j 

1 

1 

1 

, 











^ 

i_ 

















_ 



„_ 













- 

— 



— 

— 

— 

■ 

— 

— 

— 

— 

— 



— 

1 

Ifll 

/ 

_ 

— 

■ 

1 

I 

I0( 

1 

1 

1 

\ 

' 

- 

1 

1 

a 

' 

;  4 

J- 



1 — 

— 

_ 

— 

l/__ 

-^ 

-.r" 

A 

— 

^ 

-^a 

-f 

^ 

— 

— 1 

— 

— 

—) 

V— 

— 

Wl 

— 

' — 

— ' 

1 — 

— 

— 

lL 

\ 

t 

T 

3 

t 

— 





^ 

h 

^ 

r 









, — 

t 



J 

— 

— 

— 

— 



-1 — 

y 

— 

V 

— 

— 

— 

— 

— 

— i 



— 

— 

— 

— 

' — 

— 



-F 

T 

— 

— 

-^ 

-\-L- 

V 

V 

1 

_ 

[- 





















___^- 

— 

— j 



— 

^; 

— 

:::^ 

i 

^ 

-.^ 

— 1 

— 

1 

The  temperature  is  a  little  irregular.    The  patient  had  passed  through  a  similar  attack  three  months 

previously. 

Pain  and  Soreness. — Besides  the  pain  in  the  head  hereafter  mentioned, 
the  muscles  of  the  limbs  and  back  are  found  to  be  sore  on  pressure,  and  are 
sometimes  excruciatingly  painful.  The  joints  are  often  painfully  affected. 
In  some  cases  these  symptoms  continue  during  the  intervals  between  the 
paroxysms. 

Nervous  System. — Neuralgias  of  spinal  origin  are  often  present.  Paral- 
yses of  muscles  or  limbs  occur,  but  of  short  duration,  rapid  recovery  always 
taking  place. 

Delirium  is  remarkably  rare,  considering  the  great  elevation  of  temper- 
ature. 

Headache  is  quite  common,  generally  frontal,  rarely  extending  to  the 
occipital  region. 


EELAPSIXG   FEVER.  509 

Temperature. — The  temperature  is  so  peculiar  that  the  disease  may  be 
usually  diagnosticated  by  a  chart.  Some  exceedingly  rare  cases  of  malarial 
fever  may  resemble  it,  but  by  close  observation  of  two  or  more  charts  a 
positive  diagnosis  may  be  made.  The  rise  is  abrupt,  and  as  high  as  from 
103°  to  105°  F.  early  in  the  first  paroxysm,  reaching  106°  or  107°  on  the 
day  of  the  remission,  then  falling  to  a  subnormal  point  to  ascend  again  to 
105°  or  106°,  or  even  higher,  during  the  second  paroxysm.  (See  temperature- 
chart.) 

Complications. — In  the  lungs  we  may  have  pneumonia,  or  hypostatic 
congestion,  from  which  the  negro  race  suffers  more  than  the  white.  Acute 
desquamative  nephritis  is  occasionally  noted,  but  it  is  quite  rare.  The 
practitioner  should  be  on  the  watch  for  renal  symptoms,  as  this  complica- 
tion is  a  fruitful  source  of  danger. 

Parotitis  may  occur,  but  is  much  more  rare  in  this  disease  than  in 
tyj)hus  or  typhoid  fever. 

Glandular  swellings  and  abscesses  are  sometimes  present,  especially  in 
ill-conditioned  children. 

Some  authors  state  that  diarrhoea  occurs  in  one  per  cent,  of  the  cases. 
There  have  been  epidemics  where  diarrhoea  has  been  present  in  fifty  per 
cent,  of  the  cases. 

Hemorrhages  from  the  stomach  or  bowels,  or  from  both,  are  not  very 
rare  complications  in  some  epidemics. 

Types. — A  mild  form  is  seen  occasionally  among  children.  Among 
healthy  children  Avith  favorable  surroundings  the  type  is  less  severe  than 
in  the  case  of  adults.  It  is  true  of  this,  as  of  almost  all  other  contagious 
diseases,  that  the  later  cases  in  an  epidemic  are  likely  to  be  less  severe  than 
the  earlier. 

The  bilious  form  of  relapsing  fever  (so  considered  by  most  authors)  is 
separated  by  Lebert  (Ziemssen,  vol.  i..  Am.  ed.),  who  calls  it  typhus  biliosus, 
or  bilious  typhoid  fever.  It  is  seen  in  some  virulent  epidemics,  prevailing 
especially  in  the  negro  race.  In  Ireland  it  was  called  the  congestive  form. 
It  is  the  malignant  type,  and  is  associated  with  typhoid  symptoms.  Jaun- 
dice usually  occurs  at  the  onset  of  the  disease,  associated  with  hemorrhages 
from  the  nose,  stomach,  and  bowels,  petechial  eruptions,  diarrhoea,  and  a 
lower  temperature  tlian  is  found  in  sthenic  cases.  Death  takes  place  from 
exhaustion  and  collapse  during  the  intermission,  occasionally  associated  with 
coma,  and  sometimes  with  ursemic  symptoms. 

The  mortality  in  relapsing  fever  varies  with  the  epidemic,  class,  age,  etc. 

Death  is  usually  due  to  com):»lications,  sequelae,  or  some  weakness  of  the 
patient,  such  as  organic  heart-disease,  renal  diseases,  etc. 

Diagnosis. — The  principal  points  in  the  diagnosis  of  the  disease  are  : 

1.  The  spirillum,  which  is  to  be  found  in  the  l)l()od  by  a  microscopical 
examination, — that  is,  if  the  conclusions  of  Obermeier  and  othei's  are  cor- 
rect. 

2.  The  temperature.      In  relapsing   fever  the  rise  of  temperature  i3 


510 


RELAPSING   FEVER. 


abrupt  and  rapid.  Lebert  says  (Ziemssen,  vol.  i.  p.  283,  Am.  ed.)^ 
"  The  course  of  relapsing  fever  is  so  characteristic,  that  even  in  the 
beginning  of  an  epidemic  a  mistake  can  scarcely  be  made,  providing  the 
temperature  be  noted,"  Within  twenty-four  hours  the  temperature  reaches 
103°  to  105°  F.  On  the  fifth  or  seventh  day  it  falls  precipitately  to  a 
subnormal  point,  where  it  remains  until  about  the  fourteenth  day,  when  it 
rises  abruptly  again,  which  is  the  commencement  of  the  paroxysm.  After 
a  few  days  it  drops  again  as  before.     (See  temperature-chart.) 

The  splenic,  hepatic,  and  gastric  symptoms  are  marked.  The  spleen 
becomes  suddenly  greatly  enlarged,  and  this  enlargement  is  associated  with 
great  tenderness  over  that  region.  The  liver  is  also  usually  enlarged  and 
tender,  and  the  stomach  is  apt  to  be  very  irritable,  and  sore  on  pressure. 
Muscular  pains  and  pain  and  soreness  in  the  joints  are  frequently  present. 
Diarrhoea  is  a  common  symptom,  and  ophthalmia  is  more  frequently  found 
than  in  any  other  disease  likely  to  be  confounded  with  relapsing  fever. 

There  is  no  specific  eruption  in  relapsing  fever,  but  sometimes  patients 
are  seen  with  herpes  labialis,  sudamina,  and  less  commonly  slate-colored, 
spots.  Occasionally  a  rubeoloid  eruption  has  been  noted,  with  catarrhal 
symptoms,  much  less  marked  than  those  which  are  usually  present  in 
measles.  The  brain-disturbances  are  mild  when  compared  with  those 
occurring  in  other  fevers  with  high  temperature. 

Differential  Diagnosis. — From  the  Eruptive  Fevers. — There  is  no 
specific  eruption  in  relapsing  fever,  and  there  are  no  abdominal  symptoms 
such  as  are  found  in  typhoid  fever.  In  relapsing  fever  there  is  sometimes 
seen  a  rubeoloid  eruption  appearing  about  the  fifth  day,  at  the  crisis  or 
subsequently,  with  mild  catarrhal  symptoms  as  compared  with  measles. 

TABLE  EXHIBITING  THE  DIFFEEENTIAL    DIAGNOSIS  OF  KELAPSING,. 
KEMITTENT,    AND    YELLOW   EEYEES. 


Source  .    

Contagion 

Pulse 

Temperature    .... 

•laundice  ...... 

Hemorrhage     .... 

Frost 

Quinine 

Number  of  paroxysms 
Enlargement  of  liver 
and  spleen  .... 
Color  of  liver  .... 
Fatality 


Relapsing  Fevee. 


From  Europe. 


Very  great. 

Very  rapid,  140  to  170. 

105°to  107°  F.,  first  week. 

The  exception,  and  late. 

Rare. 

No  effect. 

No  influence. 

Usually  two. 

Both  much  enlarged. 
Engorged  and  dark. 
Rare. 


Remittent  Fever. 


From  fresh-water 
lowlands,  and 
stagnant  water. 

Not. 

Not  rapid. 

Remittent. 

The  exception. 

None. 

Arrests. 

Cures. 

Usually  one. 

Both  enlarged. 

Bronzed. 

Rare. 


Yellow  Fever. 


From   the  Gulf  of 
Mexico. 

Infection. 
Rarely  over  100. 
Rarely  over  104°  F. 
The  rule. 
Very  frequent. 
Arrests. 
No  effect. 
One. 

Verv  little,  if  any. 
"Butter-yellow." 
Very  great. 


From  typhoid  or  typhus  fever  it  is  distinguished  by  the  muscular  pains,., 
the  remarkable  splenic  symptoms,  and  the  peculiar  temperature. 


RELAPSING   FEVER.  511 

Prognosis. — lu  youth,  relapsing  fever,  like  typhus,  is  generally  of  a 
mild  type ;  hence  the  prognosis  is  more  favorable  than  in  the  case  of  adults. 
The  robust,  and  (when  the  disease  is  uncomplicated)  almost  all  patients, 
recover.  In  the  case  of  the  aged,  the  intemperate,  or  those  with  weak  hearts, 
either  from  fatty  degeneration  or  from  valvular  lesion,  the  prognosis  is  less 
favorable. 

The  mortality  ranges  from  two  to  twenty-eight  per  cent.,  varying  with 
the  type  of  the  epidemic.  The  greatest  number  die  in  the  epidemics  when 
the  malignant  form  is  found.  The  mortality  may  be  increased  by  the  sur- 
roundings of  the  patient,  by  his  habits,  or  by  the  circumstance  of  race 
(the  negro  especially  suffering).  Early  in  the  epidemic  the  disease  is  gener- 
ally more  severe. 

When  ursemic  symptoms  are  found,  with  albuminuria  and  suppressed 
renal  secretion,  the  case  becomes  exceedingly  grave. 

Great  care  should  be  taken  to  avoid  violent  or  too  long  continued  exer- 
cise.    This  precaution  may  save  life  which  would  otherwise  be  lost. 

Treatment. — Hygiene. — Prevent  contagion  by  isolation,  ventilation, 
fumigation,  and  cleanliness  of  the  room  and  of  the  patient. 

Xone  but  the  nurse  should  visit  the  room,  and  no  one  (not  even  the 
nurse)  should  occupy  the  bed  used  by  the  patient.  If  the  patient  is  an 
inmate  of  a  home  or  an  asylum,  he  should  be  removed  to  an  isolated  and 
quiet  location. 

A  plentiful  supply  of  air  should  be  in  the  room,  but  no  draughts  should 
be  allowed,  otherwise  there  may  be  danger  of  pneumonia,  and  other  com- 
plications, the  result  of  exposure. 

Fumigation  with  burning  sulphur  and  other  disinfectant  substances  is 
recommended. 

Cleanliness  of  the  room  and  of  the  patient  should  be  carefully  attended 
to.  The  walls  should  be  cleansed  by  wliitewashing  or  scrubbing,  or,  if 
papered,  the  paper  should  be  removed.  The  bedclothes,  and  the  clothing 
of  the  patient,  should  be  frequently  changed,  and  as  soon  as  they  are 
removed  they  should  be  immersed  in  a  carbolic-acid  solution  (3i  to  Oi), 
or  in  a  dilute  solution  of  chloride  of  lime,  or  in  a  corrosive-sublimate  solu- 
tion (1  to  1000).  The  furniture  may  be  washed  with  a  solution  of  corro- 
sive sublimate  of  the  strength  of  1  to  2000. 

The  body  of  the  patient  should  be  washed  with  some  disinfecting  solu- 
tion. This  is  for  a  twofold  purpose  :  first,  to  cleanse  the  skin ;  secondly, 
to  render  inert  the  poisonous  exhalations  from  the  body. 

This  may  also  be  accomplished  by  carbolic  acid,  a  drachm  to  a  pint  of 
water ;  or  by  a  solution  of  the  sodium  silico-fluoride,  two  grains  to  the  ounce. 
There  are  other  washes  that  will  destroy  the  germ  and  at  the  same  time  not 
injure  the  skin. 

Nourishment. — Give  good,  nourishing,  and  easily-digested  food,  in  mod- 
erate quantities,  and  at  suitable  intervals.  Do  not  overload  or  crowd  the 
stomach. 


512  RELAPSING    FEVER. 

Medication. — All  authors  of  experience  unite  in  the  opinion  that  there 
is  no  specific  treatment  for  relapsing  fever ;  that  is,  there  is  no  remedy  that 
will  prevent  a  recurrence  of  the  paroxysms.  Early  in  the  disease,  and  in 
mild  cases,  which  is  the  tyjse  usually  seen  among  children,  also  among 
the  robust  at  any  age,  very  little  medicine  is  required :  a  laxative,  or  an 
alterative  and  a  laxative  combined,  as  pil.  hydrarg.  or  hydrarg.  chloridum 
mite,  followed  by  a  saline.  Where  vomiting  is  present  (as  is  frequently  the 
case,  and  especially  where  it  is  quite  persistent),  small  doses  of  calomel  and 
opium  combined  will  generally  allay  it. 

In  severe  cases  the  general  principles  laid  down  for  low  fevers  are  to 
be  observed,  with  a  few  specific  suggestions,  which  are  here  given  for  the 
guidance  of  the  practitioner. 

For  headache  during  the  paroxysms,  apply  ice  to  the  head  in  an  ice-bag 
or  bladder,  or  cold  water  in  an  india-rubber  bag,  or  cold-water  cloths.  At 
the  same  time  place  the  feet  in  hot  mustard-water.  This  treatment  should 
be  repeated  if  necessary.  Leeching,  and  dry  or  wet  cupping,  are  sometimes 
of  great  service,  especially  in  plethoric  cases ;  blistering  is  better  than 
taking  blood  for  the  weak  and  anaemic.  Antipyrin  may  be  of  service  in 
such  cases. 

Sleeplessness  is  often  the  cause  of  great  solicitude  and  discomfort. 
Potassium  bromide  is  sometimes  of  value;  opium  and  morphine  can  be 
given,  but  the  latter  two  are  inadvisable  in  cases  with  kidney-complications. 
Chloral  should  be  given  with  caution,  especially  in  the  later  stages,  at  which 
time  the  muscular  weakness  is  marked,  in  which  the  heart  may  participate. 
Chloral  is  not  so  dangerous  when  combined  with  one  or  more  heart  tonics, 
such  as  digitalis,  strophanthus,  fluid  extract  of  cactus  grandiflora,  citrate  of 
caiFeine,  or  caffeine. 

Heart- failure  occurs  either  during  the  stages  of  depression,  attended  by 
exhausting  sweats,  or  late  in  the  disease.  Order  absolute  rest  in  a  recum- 
bent position,  and  at  the  same  time  administer  heart  tonics  (as  mentioned  in 
the  last  paragraph),  along  with  alcohol,  carbonate  of  ammonium,  and  other 
stimulants,  besides  turpentine  stupes,  stimulating  frictions,  and  dry  cupping 
over  heart  and  lungs. 

In  high  temperature,  sponging  the  surface  with  cold  or  tepid  water,  or 
with  vinegar  and  water  combined,  is  of  great  benefit ;  or  large  doses  of 
quinine  or  antifebrin  or  antipyrin  may  be  given.  Phenacetine,  from  its 
less  depressing  influence  on  the  heart,  seems  better  fitted  to  the  later  stages 
of  the  disease.  Avoid  aconite,  veratrum  viride,  and  all  depressing  medi- 
cines, particularly  in  the  later  stage.  A  nice  fever  mixture  which  may  be 
given  to  children  with  irritable  stomach  is  the  following  : 

K    Sodii  bicarb.,  gr.  iv  ; 
Creasoti,  gtt.  ^  ; 
Liq.  potass,  citrat.,  j^ivss  ; 
Syr.  aurantii  cort.,  q.  s.  ad  f  ^i. 
M.  Sig. — A  teaspoonful  every  two  hours  for  a  child  four  years  old. 


RELAPSING   FEVEE.  513 

Jaundice  should  be  treated  by  the  milder  remedies  usually  employed  in 
catarrhal  jaundice. 

Muscular  pains  may  be  palliated  by  rubbing  the  seat  of  the  pain  with 
chloroform  liniment,  alcohol,  soap  liniment,  etc. 

For  splenic  pains,  apply  a  cold-water  bottle  or  bag,  or  a  poultice,  over 
the  splenic  region,  being  governed  by  the  sensation  of  the  patient. 

Typhoid  symptoms  are  to  be  treated  in  the  same  manner  as  any  disease 
with  the  typhoid  condition.  Support  the  heart  and  nervous  system  with 
stimulants,  either  general  or  diffusible,  such  as  alcohol,  digitalis,  armnonium 
carbonate,  and  tonics. 

Vomiting,  which  has  been  before  alluded  to  with  suggestions  for  treat- 
ment, may  be  often  allayed  by  plain  soda-water  in  small  quantity,  or  by 
temporary  abstinence  from  food. 

During  convalescence,  caution  the  patient  and  nurse  as  to  the  impor- 
tance of  absolute  rest,  as  there  is  often  great  danger  of  heart-failure  if 
this  injunction  is  unheeded. 

The  treatment  for  the  convalescent  stage  consists  in  rest,  together  with 
tonics,  such  as  cinchona,  iron,  and  extract  of  malt,  alcohol  also  if  required, 
and  good,  nourishing,  and  easily-digested  food.  Later  on,  a  change  of  air 
may  be  directed,  always  cautioning  the  j)atient  to  avoid  fatigue.  Frictions 
over  the  entire  surface  with  alcohol,  bay  rum,  whiskey,  or  New  England 
rum  are  grateful  as  well  as  strengthening  to  the  patient. 

Pneumonia  should  be  treated  in  the  same  manner  as  tyjjhoid  pneumonia 
complicating  any  fever. 

Abscesses  should  be  treated  on  general  principles. 

Vol.  I.— 33 


CEREBRO-SPINAL  FEVER. 

By  J.   LEWIS  SMITH,   M.D. 


Definition. — Probably  a  microbic  disease.  It  is  manifested  chiefly  by 
the  occurrence  of  cerebro-spinal  meningitis.  Its  prominent  symptoms  are 
such  as  meningitis  gives  rise  to, — to  wit,  fever,  headache,  tonic  contraction 
of  the  muscles  of  the  nucha,  hypersesthesia,  and  neuralgic  pains  in  the  trunk 
and  extremities.  It  is  non-contagious,  or  contagious  in  a  very  low  degree, 
and,  as  with  most  of  the  microbic  diseases,  its  victims  are  chiefly  the  young. 
It  is  ordinarily  a  primary  disease,  but  it  sometimes  occurs  as  a  complication 
of  other  acute  as  well  as  chronic  maladies.  It  begins  abruptly  or  without  a 
premonitory  stage,  and  it  is  often  speedily  fatal  from  the  intense  hypersemia 
of  the  nervous  centres  or  the  severity  of  the  cerebro-spinal  meningitis.  In 
other  cases,  after  weeks  or  months  of  suifering  and  progressive  loss  of  flesh 
and  strength,  death  occurs  in  a  state  of  extreme  prostration.  In  those  who 
recover,  convalescence  is  protracted  and  slow. 

This  disease  has  been  designated  by  different  terms  in  different  countries, 
as  spotted  fever,  cerebro-spinai  fever,  malignant  purpuric  fever,  typhu& 
petechialis,  typhus  syncopalis,  and  febris  nigra,  expressive  of  its  constitu- 
tional nature.  Those  who  employ  such  terms  regard  it  as  a  general  or 
systemic  disease  with  the  meningitis  as  its  local  manifestation,  just  a& 
pharyngitis  is  a  local  manifestation  of  scarlet  fever  or  bronchitis  of  measles 
or  pertussis.  This  opinion  of  its  nature  receives  strong  support  from  the 
clinical  fact  that,  in  severe  forms  of  the  disease,  extravasations  of  blood 
occur  early  under  the  skin,  indicating  a  profoundly  altered  state  of  the 
blood  and  systemic  infection.  The  disease  has  also  been  designated  by  terms 
expressive  of  its  local  nature,  as  epidemic  meningitis,  epidemic  cerebro-spinal 
meningitis,  typhoid  meningitis,  malignant  meningitis.  We  will  treat  here- 
after of  the  nature  of  this  malady,  and  endeavor  to  justify  the  opinion  which 
has  led  to  the  use  of  terms  that  indicate  its  constitutional  character. 

My  views  upon  this  disease  have  been  carefully  elaborated  in  my  various 
publications  upon  the  subject,  both  in  medical  journal  literature  and  in  my 
text-book  upon  the  Diseases  of  Children.  On  that  account  I  shall  freely 
quote  from  these  sources  in  the  preparation  of  this  article. 

History. — Whether  cerebro-spinal  fever  occurred  previous  to  the  pres- 
ent century  is  uncertain.  If  it  did,  it  was  confounded  with  other  diseases. 
514 


CEREBEO-SPINAL   FEVER.  515 

Vieussens  in  1805  was  apparently  the  first  who  wrote  a  clear  and  unmis- 
takable description  of  it,  designating  it  "  a  malignant  non-contagious  fever." 
He  described  an  epidemic  of  it  which  appeared  in  Geneva,  Switzerland,  in 
a  family  of  three  children,  of  whom  two  died  in  twenty-four  hours.  Two 
weeksdater,  four  children  in  another  family  died  of  it,  after  an  illness  of  less 
than  a  day,  and  a  young  man  in  another  house  died  with  similar  symptoms 
after  an  equally  brief  illness,  his  surface  having  a  deeply  congested  or  violet 
appearance.  In  these  and  subsequent  cases  the  attack  began  in  the  latter 
part  of  the  day,  or  at  night,  and  was  attended  by  vomiting,  violent  head- 
ache, convulsions,  dysphagia,  petechise,  and  tonic  contraction  of  the  posterior 
muscles  of  the  neck  and  trunk,  producing  retraction  of  the  head  and  opis- 
thotonus. Thirty-three  lost  their  lives  during  this  epidemic,  after  a  sick- 
ness varying  from  twelve  hours  to  five  days.  Within  the  next  two  years 
epidemics  of  cerebro-spinal  fever  occurred  in  Bavaria,  Holland,  Germany, 
and  at  about  the  same  time  or  soon  after  in  parts  of  England. 

The  first  American  cases  of  the  disease,  so  far  as  is  now  known,  were 
at  Medfield,  Massachusetts,  in  1806.  From  1806  to  1816  occasional  out- 
breaks of  it  occurred  in  England,  France,  and  America,  in  several  localities. 
It  appeared  in  both  Canada  and  the  United  States.  From  1816  to  1828, 
so  far  as  is  now  known,  only  two  epidemics  of  it  occurred,  and  they  were 
limited  to  small  areas  and  were  of  brief  duration.  The  one  was  at  Middle- 
town,  Connecticut,  and  the  other  at  Vesoul,  France.  In  1828  it  occurred 
in  Trumbull  County,  Ohio,  in  1830  at  Sunderland,  England,  and  in  1833 
at  Naples.  After  the  Naples  epidemic  a  respite  from  the  disease  appeare 
to  have  occurred,  in  both  the  Eastern  and  the  Western  hemisphere,  until 
1837.  In  that  year  it  appeared  in  the  south  of  France,  in  and  around 
Bayonne,  and  gradually  extended  to  isolated  localities  over  almost  the  whole 
of  France.  It  occurred  at  this  time  among  troops  in  their  barracks  as  well 
as  civilians,  and  in  some  localities  of  the  troops  affected  from  fifty  to  seventy- 
five  per  cent.  died.  Even  Versailles  and  Paris  did  not  escape.  During  the 
twelve  years  from  1837  to  1849  France  suffered  far  more  than  any  other 
country  from  this  disease.  It  was  especially  common  and  fatal  among  the 
soldiers  in  many  localities,  and  at  some  of  the  military  stations  in  France 
several  successive  epidemics  occurred.  In  the  decade  from  1839  to  18-19, 
cerebro-spinal  fever  extended  to  Naples,  the  Romagna,  Sicily,  Gibraltar, 
Algeria,  and  various  places  in  Denmark,  England,  and  Ireland. 

In  1842  the  United  States  were  again  visited  by  ccrebro-spiual  fever,  in 
localities  at  a  distance  from  the  seaboard,  and  therefore,  apparently,  not  by 
communication  from  Europe.  In  1842-43  it  occurred  in  Kentucky,  Ten- 
nessee, Alabama,  Illinois,  Mississippi,  and  Arkansas.  From  1848  to  1850 
it  visited  Montgomery  in  Alabama,  Beaver  County  in  Pennsylvania,  Cayuga 
County  in  New  York,  and  New  Orleans  in  Louisiana.  Between  1850  and 
1854  there  is  no  record  of  its  occurrence  in  either  hemisphere,  but  from 
1854  to  1860  it  ravaged  the  Scandinavian  peninsula  and  caused  more  than 
four  thousand  deaths. 


516  CEEEBRO-SPINAL    FEVER. 

Since  1860  certain  localities  in  nearly  every  civilized  country  have  been 
severely  visited  by  this  disease.  In  all  these  countries  it  is  justly  regarded 
as  one  of  the  most  fatal  and  important  of  the  epidemic  maladies. 

An  interesting  fact  in  regard  to  these  many  epidemics  on  both  conti- 
nents, which  have  been  reported  by  competent  observers,  is  that  they  have 
occurred  in  isolated  localities  far  apart,  and  without  the  least  evidence  of 
transportation.  Cerebro-sj)inal  fever  has  not,  so  far  as  I  am  aware,  in  any 
instance  extended  from  one  locality  to  an  adjacent  one  in  the  manner  of 
contagious  diseases.  The  cause  of  the  malady  has  evidently  arisen  or  been 
created  in  the  places  where  the  cases  have  occurred,  and  is  not  susceptible  of 
transportation  so  as  to  produce  the  disease  elsewhere.  Cerebro-spinal  fever 
resembles  in  this  respect  the  diseases  due  to  marsh  miasm. 

But  since  1860  this  disease  has  appeared  in  this  country  in  another 
phase.  It  has  become  or  is  being  established,  or,  to  use  the  phrase  commonly 
employed  in  medical  literature,  naturalized,  in  the  cities  of  the  United 
States.  For  some  years  not  a  week  has  passed  without  the  report  of  deatlis 
from  this  cause  in  New  York,  Philadelphia,  Jersey  City,  and  Chicago. 
It  is  probably  already  permanently  established  in  Cincinnati,  St.  Louis, 
Minneapolis,  Newark,  and  San  Francisco,  since  deaths  from  it  have  been 
reported  in  these  cities  during  many  consecutive  weeks. 

In  New  York  City  prior  to  1866  only  four  deaths  occurred  from  what 
was  perhaps  cerebro-spinal  fever,  since  in  1838  two  deaths  were  reported 
from  so-called  spotted  fever,  one  in  1850,  and  one  in  1861.  What  was  the 
nature  of  this  spotted  fever  is  now  a  matter  of  conjecture.  In  1866, 
eighteen  patients  died  of  cerebro-spinal  fever  within  the  city  limits,  and  not 
a  year  has  passed  since,  and  in  the  last  few  years  not  a  week,  without  deaths 
from  it.  From  1866  to  1872  the  annual  deaths  from  this  disease  in 
New  York  varied  from  eighteen  to  forty-eight.  Commencing  in  Decem- 
ber, 1871,  and  continuing  during  the  first  half  of  1872,  a  severe  epidemic 
occurred,  producing  a  large  mortality.  Many  who  recovered  permanently 
lost  their  hearing  and  some  their  sight  from  the  attack.  In  this  epidemic 
the  physicians  of  New  York  were  fully  aroused  to  the  importance  of  the 
disease,  which  was  causing  so  much  suffering,  and  which  attacked  the  lower 
animals,  especially  the  jaded  horses  of  the  city  car-  and  stage-lines,  not  a 
few  of  them  dropping  down  in  harness,  so  suddenly  did  the  attacks  occur. 
In  1872,  seven  hundred  and  eighty-two  deaths,  chiefly  of  children,  resulted 
from  cerebro-spinal  fever  within  the  city  limits.  This  epidemic  appeared 
to  produce  a  greater  dissemination  of  the  disease  and  more  firmly  establish 
it  in  the  city ;  for  since  then  the  annual  deaths  from  it  have  varied  between 
ninety-seven  in  1878  and  four  hundred  and  sixty-one  in  1881.  In  Phila- 
delphia cerebro-spinal  fever  began  in  1863,  causing  forty-nine  deaths  in 
that  year,  and  it  has  never  been  absent  from  that  city  since.  Prof.  Stille 
states  that  between  1863  and  1882  it  has  cau.sed  two  thousand  and  forty- 
nine  deaths  within  the  city  limits.  In  Philadelphia,  as  in  New  York,  it 
has  for  some  years  produced  a  nearly  uniform  weekly  mortality.      The 


CEREBRO-SPINAL    FEVER.  517 

prevalence  of  cerebro-spinal  fever  in  the  United  States  and  its  probable 
importance  in  the  future  may  be  inferred  from  the  fact  that  it  has  recently 
occurred  also  in  Cincinnati,  Minneapolis,  Denver,  Norfolk,  Boston,  Woi- 
cester,  New  Haven,  Albany,  Syracuse,  Auburn,  Milwaukee,  Wilmington, 
Detroit,  Baltimore,  Charleston,  Toledo,  Mobile,  Salt  Lake,  Grand  Rapids, 
Providence,  Chattanooga,  Hartford,  New  Orleans,  Fall  River,  Richmond, 
Knoxville,  and  Nashville. 

Etiology. — That  this  disease  is  produced  by  a  micro-organism  is  gener- 
ally believed.  Dr.  A.  Frankel  and  other  European  microscopists  have  care- 
fully examined  the  bacteria  found  in  the  blood  and  tissues  of  those  affected 
by  it.  At  a  meeting  of  the  Berlin  Medical  Society,  held  February  12,  1883, 
Herr  Leyden  showed  under  the  microscope  specimens  of  micrococci  found 
in  a  case  of  cerebro-spinal  fever.  They  had  an  oval  shape,  were  mostly  in 
pairs,  and  were  faintly  tremulous.  They  resembled  those  found  in  pneu- 
monia and  erysipelas ;  but  Leyden  did  not  think  them  identical.  At  the 
same  meeting  Herr  Bagiusky  related  cases  which  seemed  to  show  that  in 
some  instances  the  cause  of  cerebro-spinal  fever  and  that  of  pneumonia  might 
be  identical.^ 

Dr.  V.  O.  Pushkareff,  connected  with  one  of  the  barrack-infirmaries  of 
St.  Petersburg,  states  that  in  five  cases  of  croupous  pneumonia  in  which 
cerebro-spinal  meningitis  occurred  as  a  complication  he  discovered  in  the 
pus  taken  from  the  cerebral  meninges  swarms  of  micrococci,  Avhose  appear- 
ance under  the  microscope  seemed  identical  with  that  of  Friedliinder's 
pneumococcus.  They  were  either  isolated  or  in  groups  of  two,  seldom  in 
four,  having  distinct  capsules,  and  they  were  absent  from  the  fluid  taken 
from  the  meninges  in  simple  pneumonia.  Pushkareff  was  able  to  cultivate 
the  micrococcus  taken  from  the  meningeal  pus,  and  the  cultivated  microbes, 
like  their  parents,  presented  an  appearance  identical  with  that  of  the  pneu- 
mococcus.^ Moreover,  Eberth,  in  a  case  of  meningitis  following  pneumonia, 
believes  that  he  found  the  same  micrococcus  in  the  lungs  and  in  the  liquid 
exuded  from  the  inflamed  pia  mater.  Frankel  also  states  that  he  obtained 
from  the  purulent  exudation  in  the  pia  mater,  in  a  case  of  meningitis  occur- 
ring with  pneumonia,  a  microbe  resembling  that  in  the  pneumonic  exuda- 
tion.^ 

From  the  investigations  of  so  many  competent  microscopists,  therefore, 
it  appears  that  the  microbe  found  in  the  exudate  of  the  meninges  in  cerebro- 
spinal fever,  and  which  is  supposed  to  sustain  a  causal  relation  to  this  disease, 
bears  a  close  resemblance  in  form  to  tlie  pneumococcus,  if  it  be  not  identical 
Avitli  it.  But  we  would  infer  from  the  fact  that  croupous  pneumonia  is  so 
universal  a  disease  occurring  in  localities  where  there  is  no  cerebro-spinal 
fever,  that  the  cause  of  the  two  must  be  different ;  or,  if  there  be  a  form  of 


1  Deutsch.  Med.  Wochenschr.,  April  4,  1883. 

2  Ejen.  Klin.  Gazeta,  April  21,  1885. 

^  Deutsch.  Med.  Wochenschr.,  Nov.  13,  1886. 


518  CEEEBRO-SPINAL    FEVER. 

croupous  pneumonia  which  is  produced  by  the  same  microbe  as  that  of 
cerebro-spinal  fever,  the  pneumonia  which  is  universal  must  have  a  different 
origin.  The  microbic  causation  of  cerebro-spinal  fever  needs  further  inves- 
tigation, which  it  will  doubtless  receive,  before  positive  statements  can  be 
made. 

Among  the  conditions  which  are  favorable  for  the  occurrence  of  cerebro- 
spinal fever,  and  may  therefore  be  regarded  as  predisposing  to  it,  we  may- 
mention  the. winter  season.  Statistics  collected  in  Europe  and  the  United 
States  show  that  while  one  hundred  and  sixty-six  epidemics  occurred  in  the 
six  months  commencing  with  December,  only  fifty  were  in  the  remaining 
six  months  of  the  year.  According  to  the  statistics  of  Prof  Hirsch,  which 
were  collected  mainly  from  Central  Europe,  fifty-seven  epidemics  were  in 
winter  or  in  winter  and  spring,  eleven  in  spring,  five  between  spring  and 
autumn,  four  commenced  in  autumn  and  extended  into  winter,  or  into 
winter  and  the  ensuing  spring,  and  six  lasted  the  entire  year.  I  suspect 
that  the  opinion  expressed  by  Prof.  Hirsch  is  correct,  that  the  excess  of 
epidemics  in  the  winter  months  is  due  mainly  to  the  greater  crowding  and 
less  ventilation  in  the  domiciles  during  the  cold  than  during  the  warm 
months,,  especially  among  European  peasantry.  In  New  York  City, 
where  the  state  of  the  domiciles  is  about  the  same  the  year  round,  the 
season  appears  to  exert  little  influence  on  the  prevalence  of  the  disease. 

The  fact  has  repeatedly  been  observed  that  anti-hygienic  conditions 
increase  the  liability  to  cerebro-spinal  fever.  Soldiers  in  barracks  and  the 
poor  in  tenement-houses  suffer  most  severely  when  the  epidemic  is  prevailing. 
In  New  York  City  the  fact  is  often  remarked  that  multiple  cases  occur  foi 
the  most  part  where  obvious  insanitary  conditions  exist,  as  in  apartments 
which  are  unusually  crowded  and  filthy,  or  in  tenement-houses  around  which 
refuse  matter  has  collected  or  which  have  defective  drainage.  The  inter- 
esting  chart  prepared  under  the  direction  of  Dr.  Moreau  Morris  for  the 
Health  Board  shows  that  comparatively  few  cases  occurred  in  the  epidemic 
of  1872  in  those  portions  of  the  city  where  the  sanitary  conditions  were  good. 
Anti-hygienic  conditions  probably  predispose  to  cerebro-spinal  fever,  in  the 
same  way  that  they  do  to  other  grave  epidemic  disease,  as,  for  example,  to 
Asiatic  cholera,  whose  ravages  are  chiefly  where  hygienic  requirements  are 
most  neglected.  We  will  presently  relate  striking  examples  which  show 
how  foul  air  increases  the  number  and  malignancy  of  cases.  Insanitary 
conditions  not  only  enervate  the  system  and  render  it  more  liable  to  con- 
tract any  prevailing  disease,  but  probably  promote  the  development  and 
activity  of  the  specific  principle. 

Is  Cerebro-Spinal  Fever  Contagious  ? — It  is  tlie  almost  unanimous 
opinion  of  those  who  are  most  competent  to  judge  from  their  observations, 
that  it  is  either  not  contagious  or  is  contagious  in  a  very  slight  degree.  It 
is  certain  that  the  vast  majority  of  cases  occur  without  the  possibility  of 
personal  communication.  Thus,  in  the  commencement  of  an  epidemic,  the 
first  patients  are  affected  here  and  there,  at  a  distance  from  eacli  other, 


CEREBRO-SPINAL   FEVER.  519 

often  miles  apart,  and  throughout  an  epidemic  usually  only  one  is  seized  in 
a  family.  Children  may  be  around  the  bedside  of  the  patient,  passing  in 
and  out  of  the  room  without  restriction,  and  yet  we  can  confidently  predict 
that  none  of  them  will  contract  the  malady,  if  there  be  proper  ventilation 
and  cleanliness  and  none  of  the  conditions  of  insalubrity  exist  within  or 
around  the  domicile.  Moreover,  when  multiple  cases  occur  in  a  family, 
the  disease  begins  at  such  irregular  intervals  in  the  different  patients  that 
there  can  be  little  doubt  in  most  instances  that  it  is  not  communicated  from 
one  to  the  other,  but,  like  the  fevers  from  marsh  miasm,  is  produced  by 
exposure  to  the  same  morbific  cause,  existing  outside  the  individuals,  but 
within  or  around  the  premises.  Thus,  in  the  Brown  family  treated  by  the 
late  Dr.  John  G.  Sewall,^  of  New  York,  the  first  child  sickened  January  30, 
and  subsequently  the  remaining  five  children  at  intervals  respectively  of 
five,  seven,  eleven,  twenty-five,  and  forty-five  days.  That  so  many  were 
affected  in  one  family  was  attributed  by  the  doctor  to  the  filthy  state  of  the 
house  and  the  bad  plumbing  which  allowed  the  free  escape  of  sewer-gas. 
In  my  own  practice,  in  the  family  which  suffered  the  most  severely  of  all, 
four  patients  were  seized  in  succession,  and  yet  I  could  see  no  evidence  of 
contagiousness.  The  family  occupied  a  small  plot  of  ground,  not  more 
than  thirty  feet  by  one  hundred,  and  their  occupation  was  to  prepare  for 
the  meat-market  what  is  known  as  head-cheese.  They  lived  on  the  second 
floor  of  the  two-story  wooden  house  in  which  the  work  was  carried  on. 
At  the  time  of  the  sickness  the  shop  contained  four  hundred  heads  of 
animals  from  which  the  meat  for  the  cheese  was  obtained,  and  it  was  evident 
that  decaying  animal  matter  was  present.  The  occupation  and  surroundings 
of  this  family  afforded  sufficient  explanation  of  the  fact  that  so  many  were 
attacked.  Two  workmen  contracted  the  disease  within  about  one  week  of 
each  other,  and  were  removed  from  the  house.  On  January  26,  four  weeks 
after  the  commencement  of  the  malady  in  the  workman  who  was  first  at- 
tacked, one  child  sickened  with  it,  and  died  on  February  1.  Fifteen  days 
subsequently  (February  16)  a  second  child  was  attacked,  and,  after  a  tedious 
sickness,  finally  recovered.  The  long  and  irregular  intervals  between  these 
eases  indicate  that  the  disease  was  not  contracted  by  one  from  the  other. 
The  important  factor  in  causing  so  severe  an  outbreak  of  cerebro-spinal  fever 
in  this  family  was  probably  the  miasm  produced  by  such  an  occupation  in  the 
house  where  the  family  resided,  with  neglect  of  ventilation  and  cleanliness. 
But  the  strongest  evidence  that  cerebro-spinal  fever  is  either  non- 
contagious or  very  feebly  contagious  is  afforded  by  the  fact  that  a  large 
majority  of  the  cases  occur  singly  in  families,  although  there  is  no  isolation 
of  tlie  patients.  The  following  are  the  statistics  relating  to  this  point,  in 
the  cases  which  I  have  observed  since  cerebro-spinal  fever  commenced  in 
New  York,  in  1871  :  single  cases  occurred  in  seventy  families;  dual  cases 
occurred  in  nine  families ;  three  cases  occurred  in  one  family,  and  four  cases 

1  Medical  Record,  July,  1872. 


520  CEEEBEO-SPINAL   FEVER. 

in  one  family.  Intercourse  with  the  sick-room  was  unrestricted  in  all  these 
fiimilies,  so  that  children  frequently  went  out  and  in,  and  sometimes  assisted 
in  the  nursing. 

The  most  striking  example  of  apparent  contagiousness  which  has  come 
to  my  knowledge  was  related  by  Hirsch,  and  is  quoted  by  Von  Ziemssen. 
A  young  man  sickened  with  cerebro-spinal  fever  on  February  8.  The 
woman  who  nursed  him  returned  to  her  home  in  a  neighboring  village,  and 
there  died  of  the  same  disease  on  February  26.  To  her  funeral  mournere 
came  from  a  neighboring  township,  and  after  their  return  home  three  of 
them  died  with  the  same  disease,  one  within  twenty-four  hours,  another  on 
March  4,  and  a  third  on  the  7th. 

In  one  instance  only  in  my  practice  did  the  facts  point  to  contagious- 
ness. A  boy  of  twelve  years  died  of  cerebro-spinal  fever  and  was  buried 
on  Saturday  or  Sunday.  On  Monday  the  mother  washed  the  linen  and 
bedclothes  of  the  boy,  which  had  accumulated  and  were  in  a  very  filthy 
state.  Two  days  subsequently  she  was  attacked,  and  her  infant  soon  after- 
wards, both  perishing.  The  state  of  the  bedding  and  apartments  in  this 
house,  as  seen  by  myself,  was  such  as  would  be  likely  to  concentrate  and 
intensify  the  poison,  rendering  it  peculiarly  active,  for  they  were  very  dirty, 
and  the  mother,  exhausted  by  her  long  and  incessant  watching  and  lack  of 
sleep,  and  depressed  by  grief,  rendered  her  system  more  liable  to  the  disease 
by  her  self-imposed  duties  on  the  day  after  the  funeral.  One  in  her  state 
of  mind  and  body,  standing  for  a  considerable  part  of  a  day  over  the  bed- 
clothes and  bedding  of  her  child,  soiled  by  the  excreta,  would  certainly  be 
in  a  condition  to  contract  the  disease  if  it  were  contagious  in  any,  even  in 
the  lowest,  degree.  In  the  present  state  of  our  knowledge,  therefore,  upon 
this  important  subject,  the  evidence  leads  us  to  believe  that  with  proper 
ventilation  and  cleanliness,  and  the  suppression  of  anti-hygienic  conditions 
in  an  infected  domicile,  those  who  are  in  a  good  state  of  body  and  mind 
will  not  contract  the  disease,  but  in  the  opposite  conditions  it  is  not  improb- 
able that  the  poison  may  be  so  intensified,  and  the  system  rendered  so  liable 
to  receive  the  prevailing  malady,  through  impairment  of  the  general  health 
and  diminished  resisting  power,  that  cerebro-spinal  fever  may,  though 
rarely,  be  communicated  either  by  the  breath  of  the  patient,  or  by  exhala- 
tions from  his  surface  or  from  soiled  clothing. 

The  occurrence  of  cerebro-spinal  fever  in  certain  of  the  lower  animals 
is  a  very  interesting  fact,  especially  as  the  question  is  sometimes  asked 
whether  it  may  not  be  communicated  from  them  to  man.  In  the  epidemic 
of  1811  in  Vermont,  according  to  Dr.  Gallop,  even  the  foxes  seemed  to  be 
affected,  so  that  they  were  killed  in  numbers  near  the  dwellings  of  the  in- 
habitants. Cerebro-spinal  fever,  previously  unknown  in  New  York  City, 
began,  as  stated  above,  in  1871,  among  the  horses  in  the  large  stables  of  the 
city  car-  and  stage-lines,  disabling  many  and  proving  very  fatal,  while 
among  the  people  the  epidemic  did  not  ]>roperly  commence  till  January, 
1872,  although  a  few  isolated  cases  occurred  in  December  of  1871.     No 


CEREBEO-SPINAL   FEVER.  521 

evidence  exists,  so  far  as  I  am  aware,  that  the  disease  was  in  any  instance 
communicated  by  these  animals  to  man.  Those  who  had  charge  of  the 
infected  horses,  as  the  veterinary  surgeons  and  stable-men,  did  not  contract 
the  malady,  certainly  not  more  frequently  than  others  who  were  not  so  ex- 
posed. Although  we  may  admit  slight  contagiousness,  there  has  probably 
been  no  well-establislied  example  of  the  transmission  of  cerebro-spinal  fever 
from  animals  to  man.  If  transmission  ever  does  occur,  it  is  so  rare  that 
practically  no  account  need  be  made  of  it. 

In  some  instances  we  are  able  to  discover  an  exciting  cause.  An  indi- 
vidual whose  system  is  affected  by  the  epidemic  influence  may  perhaps 
escape  by  a  quiet  and  regular  mode  of  life,  but  if  there  be  any  unusual 
excitement,  or  if  the  normal  functional  activity  of  the  system  be  seriously 
disturbed,  an  outbreak  of  the  malady  may  occur.  Among  the  exciting- 
causes  we  may  mention  overwork  and  lack  of  sleep,  fatigue,  mental  excite- 
ment, depressing  emotions,  prolonged  abstinence  from  food  followed  by  over- 
eating, and  the  use  of  indigestible  and  improper  food.  Thus,  in  one  instance 
among  my  cases,  a  delicate  young  woman,  at  the  head  of  one  of  the  depai-t- 
ments  in  a  well-known  Broadway  store,  was  anxious  and  excited,  and  her 
energies  overtaxed,  at  the  annual  reopening.  Within  a  day  or  two  subse- 
quently the  disease  began.  Another  patient,  a  boy,  was  seized  after  a  day 
of  unusual  excitement  and  exposure,  having  in  the  mean  time  bathed  in  the 
Hudson  when  the  weather  was  quite  cool.  Those  children  have  seemed  to 
me  especially  liable  to  be  attacked  who  were  subjected  to  the  severe  disci- 
pline of  the  public  schools,  returning  home  fatigued  and  hungry  and  eating 
heartily  at  a  late  hour.  In  one  instance  which  I  observed,  a  school-girl,  ten 
years  of  age,  returned  from  school  excited  and  crying  because  she  had  failed 
in  her  examination  and  had  not  been  promoted.  In  the  evening,  after  she 
had  closely  studied  her  lessons,  the  fever  began  with  violent  headache. 

Dr.  Frothingham^  writes  as  follows  of  the  brigade  in  which  cerebro- 
spinal fever  occurred  in  the  Army  of  the  Potomac :  "  Under  General  Butter- 
field,  a  stern  disciplinarian,  .  .  .  the  men  were  drilled  to  the  full  extent 
of  their  powers,  often  to  exhaustion.  I  did  not  at  the  time  recognize  this 
as  the  cause  of  the  disease  in  question,  but  I  learnt  that  in  the  present  epi- 
demic in  Pennsylvania  the  attack  generally  follows  unusual  exertion  and 
exposure  to  cold." 

Many  observers  have  noticed  that  bodily  fatigue  and  mental  depression 
and  excitement  are  important  factors  in  causing  an  attack  of  cerebro-spinal 
fever,  when  this  disease  is  epidemic.  Dr.  Gallop,  in  his  history  of  cerebro- 
spinal fever  as  it  occurred  in  Vermont  in  1811,  directs  attention  to  the 
severity  of  the  cases  among  the  troops  under  General  Dearborn,  who  were 
fatigued  by  marches  and  greatly  dispirited  on  account  of  a  repulse  which 
they  had  sustained  from  the  British.  In  one  case,  M'hicli  occurred  in  my 
practice,  a  boy,  six  years  and  eleven  months  of  age,  was  punished  at  school 

'  American  Medical  Times,  April  30,  1864. 


522  CEEEBRO-SPINAL   FEVER. 

and  came  home  with  cheeks  flushed  from  excitement,  the  excitement  con- 
tinuing during  the  ensuing  niglit.  On  the  following  day  cerebro-spinal 
fever  began  with  vomiting  and  chilliness,  the  attack  ending  fatally  on  the 
seventeenth  day.  In  another  case,  which  was  related  to  me  by  the  mother 
and  the  physician,  the  patient,  a  bright  girl,  twelve  years  of  age,  of  nervous 
temperament,  and  forward  in  her  studies,  had.  been  much  excited  in  com- 
peting for  a  prize  in  athletic  exercises.  In  the  evening  of  the  same  day  a 
violent  thunder-storm  occurred,  and  after  a  severe  clap  she  started  from  bed, 
pallid  and  excited,  and  expressed  the  belief  that  she  had  been  struck  by 
lightning.  The  disease  began  immediately  after  this,  and  terminated  fatally 
on  the  fifth  day. 

Secondary  Cerebro-Spinal  Fever. — Fagge  ^  says,  "  Several  observers 
bave  found  that  during  or  just  after  an  epidemic  of  cerebro-spinal  fever 
meningitis  has  presented  itself  with  unusual  frequency  as  a  complication  of 
other  acute  diseases."  He  mentions  croupous  pneumonia,  pleurisy,  acute 
tonsillitis,  and  scarlatinal  nephritis  as  the  diseases  upon  which  it  is  very 
liable  thus  to  supervene.  In  this  respect  cerebro-spinal  fever  resembles 
diphtheria  and  erysipelas,  which  we  know  are  very  liable  to  occur  in  those 
who  are  suffering  from  other  diseases. 

A  striking  example  of  cerebro-spinal  fever  occurring  as  a  complication 
was  recently  seen  by  me  in  consultation.  A  child  of  about  ten  years  with 
typical  typhoid  fever  had  reached  about  the  twelfth  day  of  a  mild  form  of 
the  disease.  The  initial  headache  had  ceased,  there  was  no  delirium,  the 
temperature  was  but  moderately  elevated,  and  no  doubt  had  arisen  in  the 
mind  of  the  experienced  physician  in  attendance  that  the  disease,  which 
presented  the  chara  teristic  signs,  would  terminate  favorably  after  the  usual 
time.  Suddenly  violent  headache  occurred,  the  temperature  rose  to  103°  or 
104°  F.,  and  in  a  few  days  fatal  coma  terminated  the  case.  Another  dis- 
ease in  which  I  have  seen  cerebro-spinal  fever  occur  as  a  complication  is 
gastro-intestinal  catarrh. 

Sex. — It  is  stated  by  certain  writers  that  more  males  are  affected  than 
females.  The  statistics  of  hospitals  and  camps  show  this,  for  men  subject 
to  lives  of  hardship  are  especially  liable  to  be  attacked ;  but  in  family  prac- 
tice, in  which  a  large  proportion  of  the  patients  are  children,  the  number  of 
males  and  females  is  about  equal.  Thus,  in  one  hundred  and  five  cases, 
occurring  chiefly  in  my  practice,  but  a  few  of  them  in  the  practice  of  two 
other  physicians  of  this  city,  I  find  that  fifty-nine  were  males  and  forty-six 
females.  Ninety-one  of  these  were  children.  In  New  York  City,  during 
the  epidemic  of  1872,  nine  hundred  and  five  cases  of  cerebro-spinal  fever 
were  reported  to  the  Health  Board  between  January  1  and  November  1, 
and  of  these  four  hundred  and  eighty-four  were  males  and  four  hundred 
and  twenty-one  females.  Dr.  Sanderson's  statistics  of  the  epidemic  in  the 
provinces  around  the  Vistula,  the  cases  being  chiefly  children,  give  also  but 

^  Practice  of  Medicine,  vol.  i.  p.  614. 


CEREBRO-SPINAL   FEVER. 


523 


a  slight  excess  of  males.  Probably,  therefore,  in  the  same  conditions  and 
occupations  of  life  the  sexes  are  equally  liable  to  contract  this  malady,  and 
the  excess  of  males  is  due  to  the  fact  that  they  lead  a  more  irregular  life  and 
are  more  subject  to  privations  and  exposures.  That  soldiers  on  duty  or 
in  barracks  have  been  attacked  while  families  in  the  vicinity  escape,  thus 
increasing  the  proportion  of  male  cases,  must  be  due  to  irregularities,  hard- 
ships, and  perhaps  the  lack  of  sanitary  regulations  in  their  mode  of  life. 

Ag-e. — My  observations  lead  me  to  think  that  the  younger  the  patient 
the  more  frequently  is  cerebro-spinal  fever  overlooked  and  some  other  dis- 
ease diagnosticated.  Nevertheless,  all  published  statistics,  so  far  as  I  am 
able  to  ascertain,  show  that  a  large  proportion  of  cases  occur  under  the  age 
of  five  years,  and  that  a  larger  proportion  of  fatal  cases  are  in  the  first  year 
of  life  than  in  any  other  year.  Thus,  in  New  York  City  the  ages  of  those 
who  died  from  this  disease  in  1883  were  as  follows  : 


Under  1  year 57 

From    1  to    2  years 31 


From 
From 
From 
From 


2  to    3 

3  to    4 

4  to    5 

5  to  10 


From  10  to  15 
From  15  to  20 


22 
12 
9 
37 
18 
15 


From  20  to  25 

^ears  .... 

...      7 

From  25  to  30 

...      3 

From  30  to  35 

...      4 

From  35  to  40 

...      3 

From  40  to  45 

.    .    .      1 

From  45  to  50 

...      2 

From  50  to  60 

...      1 

Over   60  years 

.    .    .      1 

The  following  are  the  statistics  of  the  New  York  Health  Board  relating 
to  the  ages  of  the  cases  during  the  epidemic  of  1872  : 


Under  1  year 125 

From    1  to  5  years 336 

From    5  to  10    "         204 

From  10  to  15    "         106 


From  15  to  20  years 54 

From  20  to  30    "         79 

Over   30  years 71 

Total 975 


In  the  cases  which  occurred  in  my  own  practice,  and  in  a  few  cases  in 
the  practice  of  other  physicians  added  to  mine,  I  find  that  the  ages  were  as 
follows : 


Under  1  year 16 

From    1  to    3  years 27 

From    3  to    5     " 25 

From    5  to  10     " 20 


From  10  to  15  years 10 

Over    15  years 15 

Total 113 


In  my  practice,  therefore,  three- fourths  of  the  cases  have  been  under  the 
age  of  ten  years ;  and  the  statistics  of  epidemics  in  otlicr  localities  corre- 
spond with  mine  in  giving  a  large  excess  of  cases  in  childhood.  Thus,  Dr. 
Sanderson,  in  examining  the  records  of  deaths  in  one  epidemic,  ascertained 
that  two  hundred  and  eighteen  liad  perished  under  the  age  of  fourteen  years, 
and  only  seventeen  above  that  age ;  and  although  this  does  not  show  the 
exact  ratio  of  children  to  adults  in  the  entire  number  of  cases,  it  is  evident 
that  the  children  were  s-reatlv  in  excess. 


524  CEEEBEO-SPIXAL    FEVER. 

The  more  advanced  -the  age  after  the  tenth  year,  the  less  the  liabihty 
to  this  malady,  so  that  very  few  who  have  passed  the  thirty-fifth  year  are 
attacked,  and  old  age  possesses  nearly  an  immunity.  In  New  York  City, 
in  which,  as  we  have  seen,  cerebro-spinal  fever  has  been  occurring  since 
1871,  only  two  cases  have  come  to  my  knowledge  which  had  passed  the 
fortieth  year.  The  age  of  one  was  forty-seven,  and  of  the  other  sixty-three 
years.  But  nearly  every  year  the  statistics  of  the  Health  Board  show  that 
one  or  two  old  people  have  died  of  this  disease. 

jSFot  a  few  cases  occur  in  this  city  in  infants  of  the  age  of  three  or  four 
months.  An  infant  of  four  months  died  of  cerebro-spinal  fever  in  the  New 
York  Infant  Asylum,  the  nature  of  the  disease  not  being  known  until  it 
was  revealed  by  the  autopsy. 

Symptoms. — During  the  prevalence  of  cerebro-spinal  fever  cases  now 
and  then  occur  in  Avhich  the  symptoms  are  mild  and  transient  and  the 
health  is  soon  fully  restored.  It  seems  proper  to  regard  some,  at  least,  of 
these  as  genuine  but  aborted  forms  of  the  disease.  The  following  cases 
which  occurred  in  my  practice  may  be  cited  as  examples : 

A  boy,  eight  years  of  age,  previously  well,  was  taken  with  headache  and  vomiting, 
attended  by  moderate  fever,  on  April  2,  1872.  The  evacuations  were  regular,  and  no  local 
cause  of  the  attack  could  be  discovered.  On  the  following  day  the  symptoms  continued, 
except  the  vomiting,  but  he  seemed  somewhat  better.  On  April  4  the  febrile  movement  was 
more  pronounced,  and  in  the  afternoon  he  was  drowsy  and  had  a  slight  convulsion.  The 
forward  movement  of  the  head  was  apparently  somewhat  restrained.  On  the  6th  the  symp- 
toms had  begun  to  abate,  and  in  about  one  week  from  the  commencement  of  the  attack  his 
health  was  fully  restored. 

A  boy,  aged  six,  was  well  till  the  second  week  in  May,  1872,  when  he  became  feverish 
and  complained  of  headache.  At  my  first  visit,  on  May  14,  he  still  had  headache,  with 
a  pulse  of  112.  The  pupils  were  sensitive  to  light,  but  the  right  pupil  was  larger  than  the 
left.  The  bromide  and  iodide  of  potassium  were  prescribed,  with  moderate  counter-irrita- 
tion behind  the  ears.  The  headache  and  febrile  movement  in  a  few  days  abated,  the  equality 
of  the  pupils  was  restored,  and  within  a  little  more  than  one  week  from  the  commencement 
of  the  disease  he  fully  recovered. 

These  cases  occurred  when  the  epidemic  of  1872  was  at  its  height;  but 
if  the  symptoms  are  so  mild,  and  the  duration  of  the  disease  short,  as  in 
these  two  cases,  the  diagnosis  must  sometimes  be  doubtful.  Observers  in 
diiferent  epidemics  report  similar  cases,  and  as  the  symptoms,  so  far  as  they 
appeared  in  my  patients,  seemed  characteristic,  I  have  not  hesitated  to 
regard  them  as  genuine  but  aborted  cases.  On  such  patients  the  epidemic 
influence  acts  so  feebly,  or  their  ability  to  resist  it  is  so  great,  that  they 
escape  with  a  short  and  trivial  ailment. 

Occasionally,  also,  during  the  progress  of  an  epidemic,  v>'e  meet  patients 
who  present  more  or  fewer  of  the  characteristic  symptoms,  but  in  so  mild  a 
form  that  they  are  never  seriously  sick,  and  never  entirely  lose  their  appe- 
tite, but  the  disease,  instead  of  aborting,  continues  about  the  usual  time. 

Thus,  on  .January  4,  1873,  I  was  called  to  a  girl  aged  thirteen,  who  had  been  seized 
with  headache  followed  by  vomiting  in  the  last  week  in  December.  During  a  period  of 
six  to  eight  weeks,  or  till  nearly  March  1,  she  had  the  following  symptoms :  daily  par- 


CEEEBEO-SPIXAL    FEVEE.  525 

oxysmal  headache,  often  most  severe  in  the  forenoon ;  neuralgic  pain  in  the  left  hypochon- 
driura,  and  sometimes  in  the  epigastric  region ;  pulse  and  temperature  sometimes  nearly 
normal,  and  at  other  times  accelerated  and  elevated,  both  with  daily  variations  ;  inequality 
of  the  pupils,  the  right  being  larger  than  the  left  during  a  portion  of  the  sickness.  The 
patient  was  never  so  ill  as  to  keep  the  bed,  usually  sitting  quietly  during  the  day  in  a  chair 
or  reclining  on  a  lounge,  and  she  never  fully  lost  her  appetite.  Quinine  had  no  appreciable 
etfect  on  the  fever  or  paroxysms  of  pain. 

There  can,  iu  my  opinion,  be  little  doubt  that  this  girl  was  affected  by 
the  epidemic,  but  so  mildly  that  there  was,  for  a  considerable  time,  much 
uncertainty  iu  the  diagnosis. 

Cases  like  these,  in  which  the  disease  is  so  feebly  developed  that  the 
patient  is  never  seriously  sick,  though  unimportant  pathologically,  must  be 
recognized  in  a  treatise  on  cerebro-spinal  fever. 

Mode  of  ComrQencement. — Cerebro-spinal  fever  rarely  begins  in  the 
forenoon  after  a  night  of  quiet  and  sound  sleep.  In  the  cases  which  I 
observed  in  the  severe  and  fatal  epidemic  of  1872,  and  in  the  thirty-six 
cases  of  which  I  have  records  observed  since  1872,  the  commencement  was 
almost  without  exception  between  mid-day  and  midnight.  The  fact  that 
this  disease  does  not  commence  after  the  repose  of  night,  till  several  hours 
of  the  day  have  passed,  shows  the  propriety  and  need  of  enjoining  a  quiet 
and  regular  mode  of  life,  free  from  excitement,  and  with  sufficient  hours  of 
sleep,  during  the  time  in  which  the  epidemic  is  prevailing. 

The  commencement  is  usually  without  premonitory^  stage,  and  sudden, 
— unlike,  therefore,  the  beginning  of  other  forms  of  meningitis,  which  come 
on  gradually  and  are  preceded  by  symptoms  which,  if  rightly  interpreted, 
direct  attention  to  the  cerebro-spinal  system.  Exceptionally  certain  pre- 
monitions occur  for  a  few  hours  or  days  before  the  advent  of  the  disease, 
such  as  languor,  chilliness,  etc.  Mild  cases  more  frequently  begin  gradually, 
and  with  certain  premonitions,  than  severe  cases.  The  ordinary  mode  of 
commencement  is  as  follows :  the  patient  is  seized  with  vomiting,  headache, 
and  perhaps  a  chill  or  chilliness,  so  that  there  is  a  sudden  change  from  per- 
fect health  to  a  state  of  serious  sickness.  Rigor  or  chilliness  is  a  common 
initial  symptom,  especially  in  adult  patients.  One  patient,  an  adult  female, 
had  three  or  four  chills  of  considerable  severity  in  the  commencement  of 
the  attack.  Children  often  have  clonic  convulsions  in  place  of  the  chill,  or 
immediately  after  it,  partial  or  general,  slight  or  severe.  Stupor  more  or 
less  profound,  or  less  frequently  delirium,  succeeds.  In  the  gravest  cases 
semi-coma  occurs  within  the  fir.st  few  hours,  in  which  patients  are  with 
difficulty  aroused,  or  profound  coma,  which,  in  spite  of  prompt  and  appro- 
priate treatment,  is  speedily  fatal.  Those  thus  stricken  down  by  the  violent 
onset  of  the  disease,  if  aroused  to  consciousness,  complain  of  severe  head- 
ache, with  or  without,  or  alternating  with,  equally  severe  neuralgic  pains  in 
some  part  of  the  trunk  or  in  one  of  the  extremities.  The  pain  frequently 
shifts  from  one  part  to  another.  Among  the  early  symptoms  of  cerebro- 
spinal fever  are  those  which  pertain  to  the  eye.  The  pupils  are  dilated,  or 
less  frequently  contracted,  and  they  respond  feebly,  or  not  at  all,  to  light  if 


526  CEEEBRO-SPIXAL    FEVER. 

the  attack  be  severe  and  dangerous ;  often  they  oscillate,  and  occasionally 
one  is  larger  than  the  other.  Vomiting  with  little  apparent  nausea,  and 
often  projectile,  is  common  in  the  commencement  of  cerebro-spinal  fever. 
It  occurred  as  an  early  symptom  in  fifty-one  of  fifty-six  cases  observed  by 
Dr.  Sanderson.  In  ninety-seven  cases  occurring  in  Xew  York,  most  of 
them  observed  by  myself,  but  a  few  of  them  related  to  me  by  the  late  Dr. 
John  G.  Sewall,  vomiting  occurred  as  an  early  symptom  in  sixty-eight  cases. 
Its  absence  on  the  first  day  was  recorded  in  only  three  cases,  while  in  the 
remaining  twenty-seven  patients  the  records  of  the  first  day  make  no  men- 
tion of  its  presence  or  absence.  It  was  probably  present  in  most  of  these 
twenty-seven  cases  as  one  of  the  first  symptoms. 

Since  the  epidemic  of  1872,  in  examining  patients,  now  nimibering 
thirty-six,  as  has  been  already  stated,  I  have  made  carefiil  inquiry  in  regard 
to  the  mode  of  commencement,  and  with  only  two  or  three  exceptions  either 
the  pre\aous  health  had  been  good,  or,  if  symptoms  of  ill  health  antedated 
the  cerebro-spinal  fever,  they  were  due  to  some  ailment  entirely  distinct 
from  this  disease.  In  a  boy  fom'  and  a  half  years  of  age,  living  in  Broad- 
way, it  was  stated  to  me  that  the  cerebro-spinal  fever  came  on  gradually, 
with  pains  in  the  head  and  elsewhere :  this  case  was  mild  throughout,  and 
the  patient  was  never  in  imminent  danger.  In  nearly  all  the  cases,  if  the 
patients  were  at  home  and  under  observation,  the  exact  moment  of  the 
beginning  of  the  disease  could  be  stated.  Thus,  a  man  aged  twenty-eight 
returned  from  his  work  at  mid-day,  April  23,  1883,  in  good  health  and 
cheerful,  ate  a  hearty  meal  at  twelve  m.,  and  at  one  p.m.  had  a  chill,  v^ath 
intense  headache  and  severe  vomiting.  Minute  red  points  appeared  on  his 
face  after  vomiting,  from  capillary  extravasations.  In  this  case  the  interest- 
ing fact  was  observed  of  a  cessation  of  the  symptoms,  so  that  on  the  24th 
and  25th,  being  free  from  pain,  he  went  to  Brooklyn.  On  the  26th,  how- 
ever, the  symptoms  returned.  He  had  pains  in  the  head,  back,  and 
extremities,  and  was  seriously  sick.  Occasional  remissions,  so  that  very 
grave  symptoms  become  mild  for  a  time  and  then  return  in  full  severity,  as 
well  as  distinct  intermissions  as  in  this  case,  have  been  frequently  noticed 
by  observers  in  different  epidemics.  A  little  girl,  previously  entirely  well, 
was  slightly  punished  on  June  11,  1882;  immediately  she  vomited,  and 
seemed  quite  sick  ;  by  kind  nursing  on  the  part  of  the  mother  she  became 
better,  so  that  on  the  12th  she  had  some  appetite  and  went  out.  On  the  13th, 
cerebro-spinal  fever  began,  with  a  temperature  of  103°  F.,  and  its  course 
was  tedious.  A  robust  girl,  aged  thirteen,  vivacious  and  cheerful,  went  as 
usual  in  the  morning  to  one  of  the  public  schools,  entirely  well.  Before 
the  school  was  dismissed  she  returned  home  crying,  on  account  of  dizziness 
and  violent  pain  in  the  top  of  her  head,  in  her  knees,  and  in  the  calves  of 
the  legs.  The  case  was  attended  by  Prof  Alonzo  Clark,  Prof.  Knapp, 
and  myself,  and  was  fatal  after  four  and  a  half  weeks.  A  boy,  aged  ten, 
returned  from  another  public  school  in  a  similar  manner,  having  gone  to  it 
in  the  morning  in  apparently  perfect  health. 


CEEEBRO-SPINAL   FEVER.  527 

We  may,  therefore,  summarize  as  follows  the  symptoms  which  commonly 
attend  the  commencement  of  cerebro-spinal  fever :  violent  pain  in  some  part 
of  the  head,  and  sometimes  also  in  the  trunk  or  limbs,  vomiting,  a  chill  or 
chilliness,  clonic  convulsions,  dizziness,  dilated,  sluggish,  or  altered  pupils, 
fever  of  greater  or  less  intensity  according  to  the  severity  of  the  attack, 
heat  of  head,  and  in  most  patients  heat  of  the  surface  generally.  If  the 
disease  be  of  a  severe  and  dangerous  type,  these  symptoms  are  frequently 
followed  within  a  few  hours  by  delirium,  semi-coma,  or  coma. 

Nervous  System. — Since  in  cerebro-spinal  fever  extensive  and  intense 
inflammation  of  the  cerebral  and  spinal  meninges  occurs,  with  more  or  less 
congestion  of  the  brain  and  spinal  cord,  lesions  which  we  will  consider  here- 
after, we  should  expect  that  this  disease  would  be  attended  by  severe  and 
dangerous  symptoms,  inasmuch  as  the  cerebro-spinal  axis  exerts  such  a  con- 
trolling influence  upon  the  functions  of  the  body.  Also  we  should  expect 
that  the  symptoms  would  vary  according  to  the  portion  of  the  meninges 
which  happens  to  be  most  severely  inflamed.  There  is,  indeed,  variation  in 
symptoms  according  to  the  extent  and  intensity  of  the  meningitis  and  the 
degree  in  which  the  cerebro-spinal  axis  is  congested  or  implicated,  but  cer- 
tain symptoms  occur  in  all  or  nearly  all  cases,  and,  as  they  are  characteristic, 
they  render  diagnosis  easy. 

Pain,  already  described  as  an  initial  symptom,  continues  during  the 
acute  period  of  the  malady.  It  is  ordinarily  severe,  eliciting  moans  from 
the  sufferer,  but  its  intensity  varies  in  different  patients.  Its  most  frequent 
seat  is  the  head,  and  the  location  of  the  cephalalgia  varies  in  different 
patients  and  in  the  same  patient  at  different  times.  One  refers  it  to  the  top 
of  the  head,  another  to  the  occiput,  and  another  to  the  frontal  region,  and 
the  same  patient  at  different  times  may  complain  of  all  these  parts.  The 
pain  is  described  as  sharp,  lancinating,  or  boring.  It  is  also  common  in  the 
neck,  especially  in  the  nucha,  the  epigastrium,  the  umbilical  and  lumbar 
regions,  along  the  spine  (rachialgia),  and  in  the  extremities,  where  it  shifts 
from  one  part  to  another.  It  is  more  common  and  persistent  in  the  head 
and  along  the  spine  than  elsewhere.  The  patient,  if  old  enough  to  speak, 
and  not  delirious  or  too  stupid,  often  exclaims,  "  Oh,  my  head  !"  from  the 
intensity  of  his  suffering,  but  after  some  moments  complains  equally  of 
pain  in  some  other  part,  while  perhaps  the  headache  has  ceased  or  is  milder. 
In  a  few  instances  the  headache  is  absent,  or  is  slight  and  transient,  while 
the  pain  is  severe  elsewhere.  After  some  days  the  pain  begins  to  abate,  and 
by  the  close  of  the  second  week  is  much  less  pronounced  than  previously. 
Vertigo  occurs  with  the  headache,  so  that  the  patient  reels  in  attem})ting  to 
stand  or  walk.  I  have  stated  above  that  vertigo  may  be  a  prominent  initial 
symptom,  as  in  the  girl  of  thirteen  years  who  suddenly  became  sick  in  the 
public  school  where  she  was  attending,  and  reached  her  home  with  difficulty 
on  account  of  the  headache  and  dizziness.  Contributing  to  the  unsteadiness 
of  the  muscular  movements  is  a  notable  loss  of  flesh  and  strength,  which 
occurs  early  and  increases. 


528  CEREBEO-SPINAL    FEVER. 

The  state  of  the  patient's  mind  is  interesting.  It  is  well  expressed  in 
ordinary  cases  by  the  term  apathy  or  indifference,  and  between  this  inental 
state  and  coma  on  the  one  hand,  and  acute  delirium  on  the  other,  there  is 
every  grade  of  mental  disturbance.  Some  patients  seem  totally  unconscious 
of  the  words  or  presence  of  those  around  them,  when  it  subsequently 
appears  that  they  understood  what  was  said  or  done.  Delirium  is  not  in- 
frequent, especially  in  the  older  children  and  in  adults.  Its  form  is  various, 
most  frequently  quiet  or  passive,  but  occasionally  maniacal,  so  that  forcible 
restraint  is  required.  It  sometimes  resembles  intoxication  or  hysteria,  or  it 
may  appear  as  a  simple  delusion  in  regard  to  certain  subjects.  Thus,  one 
of  my  patients,  a  boy  of  five  years,  appeared  for  the  most  part  rational, 
protruding  his  tongue  when  requested,  and  ordinarily  answering  questions 
correctly,  but  he  constantly  mistook  his  mother — who  was  always  at  his 
bedside — for  another  person.  Severe  active  delirium  is  commonly  preceded 
by  intense  headache.  In  favorable  cases  the  delirium  is  usually  short,  but 
in  the  unfavorable  it  often  continues  with  little  abatement  till  coma  super- 
venes. 

On  account  of  the  pain  and  the  disordered  state  of  the  mind,  patients 
seldom  remain  quiet  in  bed  unless  they  are  comatose  or  the  disease  be  mild 
or  so  far  advanced  that  muscular  movements  are  difficult  from  weakness. 
In  severe  cases  they  are  ordinarily  quiet  for  a  few  moments,  as  if  slumber- 
ing, and  then,  aroused  by  the  pain,  they  roll  or  toss  from  one  part  of  the 
bed  to  another.  One  of  my  patients,  a  boy  of  five  years,  repeatedly  made 
the  entire  circuit  of  the  bed  during  the  spells  of  restlessness.  In  mild  cases, 
or  cases  attended  by  less  headache  or  mental  disturbance,  patients  are  quiet, 
usually  with  their  eyes  closed,  unless  when  disturbed. 

Hypersesthesia  of  the  surfece  is  another  common  symptom.  Few 
patients,  not  comatose,  are  free  from  it  during  the  first  weeks,  and  it  ma- 
terially increases  the  suffering.  Friction  upon  the  surface,  and  even  slight 
pressure  with  the  fingers  upon  certain  parts,  extort  cries.  Gently  separating 
the  eyelids  for  the  purpose  of  inspecting  the  eyes,  and  moving  the  limbs,  or 
changing  the  position  of  the  head,  evidently  increase  the  suffering,  and  are 
resisted.  I  have  sometimes  heard  such  expressions  of  suffering  from  slowly 
introducing  the  thermometer  into  the  rectum  that  I  was  led  to  believe  that 
the  anal  and  perhaps  rectal  surfaces  were  hypersensitive.  The  hypersesthesia 
has  diagnostic  value,  for  there  is  no  disease  with  which  cerebro-spinal  fever 
is  likely  to  be  confounded  in  which  it  is  so  great.  It  is  due  to  the  spinal 
meningitis,  and  is  appreciable  even  in  a  state  of  semi-coma.  The  headache 
and  hypersesthesia  fluctuate  greatly  in  the  course  of  the  disease,  and  the 
former  sometimes  recurs  at  times,  especially  from  mental  excitement,  or 
from  an  afflux  of  blood  to  the  brain  from  physical  exertion,  for  months 
after  the  health  is  otherwise  fully  restored. 

Some  contraction  of  certain  muscles  or  groups  of  muscles  is  present  in 
all  typical  cases.  In  a  small  proportion  of  patients  it  is  absent  or  is  not  a 
prominent  symptom, — to  wit,  in  those  in  whom  the  encephalon  is  mainly 


CEREBRO-SPINAL    FEVER.  529 

iuvolved,  the  spiual  cord  aud  meuiuges  being  but  slightly  affected  or  not  at 
all.  This  contraction  is  most  marked  in  the  muscles  of  the  nucha,  causing 
retraction  of  the  head,  but  it  is  also  common  in  the  posterior  muscles  of  the 
trunk,  causing  opisthotonus,  and  in  less  degree  in  those  of  the  abdomen  and 
lower  extremities,  and  hence  the  flexed  position  of  the  thighs  and  legs,  in 
which  patients  obtain  most  relief  The  muscular  contraction  is  not  an  initial 
symptom.  I  have  ordinarily  first  observed  it  about  the  close  of  the  second 
da}',  but  sometimes  as  early  as  the  close  of  the  first  day,  and  in  other 
instances  not  till  the  close  of  the  third  day.  Attempts  to  overcome  the 
rigidity,  as  by  bringing  forward  the  head,  are  very  painful,  and  cause  the 
patient  to  resist.  In  young  children  having  a  mild  form  of  the  fever,  with 
little  retraction  of  the  head,  the  rigidity  is  sometimes  not  easily  detected. 
I  have  been  able  in  such  cases  to  satisfy  myself  and  the  friends  of  its 
presence  by  placing  the  child  in  an  upright  position,  as  on  the  lap  of  the 
mother,  and  observing  the  difficulty  with  which  the  head  is  brought  for- 
ward on  presenting  to  the  patient  a  tumblerful  of  cold  water,  which  is 
craved  on  account  of  the  thirst.  The  usual  position  of  the  patient  in  bed, 
in  a  typical  or  marked  case,  is  with  the  head  thrown  back,  the  thighs  and 
legs  flexed,  with  or  without  forward  arching  of  the  spine.  The  muscular 
contraction  and  rigidity  continue  from  three  to  five  weeks,  more  or  less,  and 
abate  gradually;  occasionally  they  continue  much  longer.  Through  the 
kindness  of  Dr.  Henry  Griswold  I  was  allowed  to  see  an  infant  of  seven 
months  in  the  tenth  week  of  the  disease.  It  v^as  still  very  fretful,  and 
exhibited  decided  prominence  of  the  anterior  fontanel,  probably  from  intra- 
cranial serous  effusion  and  marked  rigidity  of  the  muscles  of  the  nucha, 
with  retraction  of  the  head. 

Paralysis  is  another  occasional  symptom,  but  complete  paralysis  of  any 
muscle  or  group  of  muscles  is  less  frequent  than  one  would  suppose  from 
the  nature  of  the  malady.  It  may  occur  early,  but  is  sometimes  a  late 
symptom.  It  may  be  limited  to  one  or  two  of  the  limbs,  as  the  legs,  or  an 
arm  and  a  leg,  or  it  may  be  more  general.  In  a  case  occurring  in  Roose- 
velt Hospital,  and  published  in  the  New  York  Iledical  Record  for  October 
10,  1878,  the  patient,  a  boy  of  ten  years,  was  unable  to  move  his  legs  one 
hour  after  the  commencement  of  the  disease.  This  sudden  development  of 
paraplegia  in  the  commencement  of  cerebro-spiual  fever  resembled  that  of 
infantile  paralysis,  and  was  probably  due  to  the  same  cause,  to  wit,  active 
inflammatory  congestion  of  the  anterior  coruua  of  the  spinal  column.  The 
sudden  and  complete  loss  of  speech  which  occurs  in  certain  cases,  when  con- 
sciousness is  retained  and  the  vocal  organs  are  in  their  normal  state,  seems 
to  be  due  to  the  fact  that  the  portion  of  the  brain  Avhich  controls  the 
function  of  speech  is  acutely  congested,  or  is  the  seat  of  effusion.  Thus,  in 
June,  1882,  a  girl  of  three  years  whom  I  attended  lost  her  speech  on  the 
second  dav  of  cerel)ro-spinal  fever,  and  she  was  unable  to  articulate  even 
the  simplest  word  for  two  and  a  half  mouths.  Finally  she  began  to  utter 
slowly  and  with  difficulty  tlie  easiest  monosyllables;  and  after  the  lapse 
Vol.  T.— 34 


530 


CEREBEO-SPI^'AL    FEVER. 


of  more  than  a  year  her  speech  was  slow  and  lisping,  her  hands  were 
tremulous  and  unsteady,  she  was  easily  fatigued,  and  cried  often  from  over- 
sensitiveness.  During  the  long  period  of  speechlessness  she  daily  made 
eiForts  to  talk,  but  without  uttering  a  sound.  Strabismus,  to  which  we  will 
allude  hereafter  in  treating  of  the  eye,  is  a  common  symptom,  either  transient 
or  protracted,  due  to  paralysis  of  certain  of  the  motor  muscles  of  the  eye. 

Paralysis  of  more  or  fewer  muscles  has  been  noticed  and  recorded  by 
many  observers  in  this  country  and  in  Europe.  Dr.  Law  observed  a  patient 
in  the  epidemic  of  1865,  in  Dublin,  who  could  move  neither  arms  nor 
legs,  and  Wunderlich  saw  one  who  had  paralysis  of  both  lower  extremities 
and  of  a  considerable  part  of  the  trunk.  As  this  symptom  is  due  tq  the 
inflammatoiy  process  in  the  cerebro-spinal  axis,  it  usually  disappears  in  a 
few  weeks  as  the  inflammation  abates  and  absorption  of  the  inflammatoiy 
products  occurs ;  but  it  may  be  more  protracted.  In  Wnnderlich's  case- 
there  was  only  partial  recovery  from  the  paralysis  after  the  lapse  of  5ve 
months. 


Clonic  convulsions  have  already  been  alluded  to  among  the  early  symp- 
toms  of  the  attack.  They  indicate  a  grave  form  of  the  disease,  and  are 
not  infrequent  in  young  children,  in  whom  they  appear  to  occur  in  place 
of  the  chill  which  is  common  in  those  of  a  more  advanced  age.  The 
eclamptic  attack  may  be  short  and  not  repeated,  or  it  may  be  protracted,  or 
return  again  and  again  when  the  medicines  which  control  it  are  suspended. 
Under  such  circumstances  it  is  likely  to  end  in  profound  coma,  and  is,  of 
course,  a  symptom  of  great  gravity.  Thus,  an  infant  of  seven  months  had 
unilateral  eclamptic  attacks  daily  during  the  first  week  of  the  attack.  The 
mother  informed  me  that  the  convulsions  seldom  lasted  longer  than  three 
minutes,  and  that  the  intervals  between  them  were  short.  The  child  re- 
covered with  loss  of  sight  from  the  cerebro-S})inal  fever,  but  still  after  the 
lapse  of  a  year,  when  I  examined  him,  had  symptoms  which  were  appar- 
ently due  to  hydrocephalus.  Another  infant  of  eleven  months  had  clonic 
convulsions  nearly  constantly  during  the  first  twenty-four  hours,  but  with 
occasional  brief  intermissions.  On  the  following  day  he  was  in  profound 
coma,  and  apparently  dying,  with  a  temperature  of  105°  F.    To  my  astonish- 


CEREBRO-SPINAL    FEVER.  531 

meut,  he  gradually  emerged  from  the  state  of  unconsciousness,  and  after  a 
week  was  able  to  sit  in  his  cradle  long  enough  to  take  drinks. 

Occasionally  eclampsia  does  not  occur  in  the  first  days,  but  in  the  second 
or  third  week,  when  it  is  usually  accompanied  by  an  increase  of  other 
symptoms,  due  to  a  recrudescence  of  the  disease.  A  female  infant,  aged 
eleven  months,  treated  by  me  in  1882,  had  been  sick  one  week,  when,  during 
an  increase  in  the  febrile  movement,  she  had  one  eclamptic  seizure.  Her 
recovery,  though  slow,  was  complete.  A  boy,  aged  eleven  and  one-half 
years,  whose  attack  began  with  a  chill,  violent  headache,  and  a  febrile  move- 
ment, and  whom  I  visited  frequently,  died  on  the  fourth  day.  Clonic  con- 
vulsions did  not  occur  in  his  case  until  within  twenty-four  hours  of  his 
death,  when  he  had  six  seizures,  which  ended  in  coma. 

Though  adult  patients  are  much  less  liable  to  eclampsia  than  children, 
they  are  not  entirely  exempt.  A  male  patient,  aged  twenty -eight  years, 
whom  I  saw  in  consultation,  had  a  single  clonic  convulsion  lasting  ten  to 
fifteen  minutes  on  the  third  day  of  his  illness.  In  five  weeks  he  had  fully 
recovered,  except  that  his  headache  returned  upon  any  excitement.  Even 
drinking  a  cup  of  beer  caused  it.  Clonic  convulsions  are,  however,  much 
less  common  than  tonic  muscular  contraction  and  rigidity  already  alluded 
to.  This  occurs  to  a  greater  or  less  extent  in  nearly  all  cases,  and  is  a 
symptom  of  diagnostic  value,  the  rigidity  often  extending  to  the  muscles  of 
the  extremities.  Thus,  in  a  child,  aged  three  years,  who  had  no  eclampsia, 
the  tonic  contraction  of  the  muscles  of  the  extremities  did  not  relax  till 
after  the  twelfth  day. 

Choreic  or  choreiform  movements  are  occasionally  observed.  I  do  not 
refer  to  the  tremulousness  which  sometimes  occurs  from  weakness,  or  as  a 
premonition  of  eclampsia,  but  to  a  movement  which  has  the  character  of  true 
chorea.  An  infant,  aged  ten  mouths,  began  to  have  choreic  movements 
during  the  acute  stage  of  the  disease,  most  marked  in  the  upper  extremities, 
and  ceasing  in  sleep.  They  continued  during  the  remainder  of  the  life  of 
the  child,  death  occurring  ten  months  subsequently  from  diphtheria.  Rarely 
a  choreiform  movement  of  the  eyes  is  also  observed,  a  lateral  movement 
from  right  to  left,  and  from  left  to  right.  I  have  seen  from  recollection 
two  such  cases. 

Drowsiness,  already  spoken  of,  is  a  common  symptom,  and  it  exists  in 
all  grades,  from  slight  stupor  to  ])rofound  coma.  In  some  jxiticnts  it  is 
present  from  the  first  hour,  while  in  otliers  it  occurs  after  a  period  of  rest- 
lessness or  delirium,  or  it  alternates  with  it.  Stupor  more  or  less  profound 
is  common  after  the  attack  of  eclampsia  or  tlio  cliill.  That  it  is  a  frequent 
symptom  in  severe  ca.ses  receives  ready  explanation  from  the  state  of  the 
brain  and  its  meninges,  for  the  exudation  which  occurs  upon  the  surface  of 
the  brain  and  the  serous  effusion  within  the  ventricles  are  sufficient  to  cause 
it,  by  compressing  the  cerebral  substance.  It  is  surjirising  in  some  cases 
how  profound  tiie  stupor  may  be,  a  state  indeed  of  coma,  and  yet  the  patient 
gradually  emerges  from  it  and  recovers.     In  the  epidemic  of  1872,  in  New 


532  CEEEBRO-SPINAL    FEVER. 

York  City,  when  the  malady  was  new  with  us,  many  physicians  pre- 
dicted certain  death,  and  employed  remedies  without  expectation  of  any 
benefit,  on  account  of  the  apparently  hopeless  state  of  patients,  who  seemed 
to  be  in  profound  coma,  and  yet  not  a  few  of  them  gradually  and  fully 
recovered. 

Digestive  System. — Vomiting,  which  is  the  most  prominent  symptom 
referable  to  the  digestive  system,  has  already  been  mentioned.  Occurring 
early  in  the  disease,  it  may  cease  in  a  few  hours,  or  not  till  after  several 
days,  and  often  it  returns  during  the  periods  of  recrudescence  wliich  are 
common  in  the  progress  of  the  fever.  It  occurs  with  little  effort,  and  with- 
out previous  nausea,  or  with  little  nausea,  as  is  usual  when  it  has  a  cerebral 
origin.  It  does  not  differ  as  a  symptom  from  the  vomiting  which  is  so 
common  in  other  forms  of  meningitis.  The  substance  vomited  consists  of 
the  ingesta  and  the  secretions,  as  mucus  and  bile.  Having  a  similar  origin 
is  a  sensation  of  faintness  or  depression  referred  to  the  epigastrium. 

The  appetite  is  usually  impaired  or  lost  during  the  active  period  of  the 
attack,  and  it  is  not  fully  restored  till  convalescence  is  well  advanced. 
Occasionally  considerable  nutriment  is  taken,  and  with  ajjparent  relish,  as 
by  one  of  my  patients,  twenty-eight  years  of  age,  who  always  had  some 
appetite.  Ordinarily,  on  account  of  repeated  vomitings,  constant  febrile 
movement,  impaired  appetite  and  digestion,  patients  progressively  lose  flesh 
and  strength,  so  that  in  protracted  cases  emaciation  is  always  a  prominent 
symptom,  and  is  often  extreme.  Great  emaciation  and  loss  of  strength, 
which  attend  many  cases  after  the  lapse  of  several  weeks,  greatly  diminish 
the  chances  of  a  favorable  termination.  Thirst,  already  referred  to,  and 
constipation  are  common  in  this  as  in  other  forms  of  meningitis,  but  retrac- 
tion of  the  abdomen  is  not  a  notable  symptom,  except  in  protracted  and 
greatly-wasted  cases.  The  diarrhoea  which  is  occasionally  present  in  cerebro- 
spinal fever  in  the  summer  months  must  be  regarded  as  a  distinct  disease 
and  a  complication.  The  tongue  and  the  buccal  and  faucial  surfaces  present 
nothing  unusual  in  their  appearance.  It  is  seldom,  even  in  the  most  pro- 
tracted and  emaciated  cases,  that  the  sordes  and  dry  and  brownish  fur  occur 
which  are  so  common  in  typhus  and  typhoid  fevers.  The  tongue  is  usually 
moist  and  but  slightly  furred. 

I  have  seen  in  consultation  two  patients  that  perished  early  with  in- 
ability to  swallow  as  the  prominent  symptom,  attended  in  both  by  an 
abundant  secretion  upon  the  faucial  surface,  without  any  redness,  swelling, 
or  other  evidence  of  inflammation.  The  early  death  of  these  young  chil- 
dren, whose  ages  were  ten  months  and  two  years,  rendered  the  diagnosis  less 
certain  than  in  most  other  patients,  but  the  attending  physician  as  well  as 
myself  diagnosticated  cerebro-spinal  fever  with  suddenly  developed  paralysis 
of  the  muscles  of  deglutition,  so  that  no  nutriment  could  be  taken.  If  our 
understanding  of  these  interesting  cases  is  correct,  the  paralysis  was  caused 
by  lesion  of  that  portion  of  the  medulla  oblongata  which  controls  the  func- 
tion of  deglutition,  or  else  by  injury  of  the  intracranial  portions  of  the 


CEREBRO-SPINAL   FEVER.  533 

nerves  which  supply  the  muscles  concerned  in  this  act.  The  following  were 
the  cases  in  question  : 

O ,  male,  two  years  of  age,  became  feverish  aud  dull,  but  without  vomiting,  on 

October  22,  1882  ;  axillary  temperature,  102°  F.  On  the  following  day  inability  to  swallow 
occurred,  and  the  muscles  of  deglutition  appeared  totally  inactive.  Death  occurred  on  the 
third  day,  suddenly,  and  apparentl^y  easily,  as  if  from  arrested  function  of  important  nerves, 
especially  the  pneumogastric.  The  abundant  secretion  of  thin  mucus  or  transudation  of 
serum  covering  the  faucial  surface,  and  reaccumulating  as  soon  as  removed,  without  any 
notable  change  in  the  appearance  of  the  fauces,  was  remarkable.  The  physician  in  attend- 
ance, who  for  more  than  thirty  years  had  had  a  large  city  practice,  had  seen  no  similar  case, 
nor  had  I  at  the  time. 

Soon  afterwards  the  second  case  occurred.  An  infant  of  ten  months,  without  cough  or 
embarrassment  of  respiration,  or  faucial  redness  or  swelling,  lost  the  power  of  deglutition 
soon  after  the  commencement  of  the  supposed  cerebro-spinal  fever,  so  that  in  the  attempts 
to  swallow  the  drinks  entered  the  larynx,  and  the  secretion  or  exudation  was  abundant  as 
in  the  other  case.  Death  occurred  in  forty-eight  hours.  The  rectal  temperature  was  only 
101°  F. 

In  another  case,  which  was  ultimately  fatal,  and  in  which  the  diagnosis 
of  cerebro-spinal  fever  was  certain,  a  robust  girl,  aged  twelve,  suddenly  lost 
the  power  of  deglutition  at  one  time  during  her  sickness,  although  she  was 
entirely  conscious  and  repeatedly  endeavored  to  swallow.  The  ability  to 
swallow  returned  in  a  few  days. 

Pulse. — This  is  usually  accelerated,  and  the  more  severe  and  dangerous 
the  attack,  the  more  rapid  is  the  heart's  action,  except  occasionally  in  the 
comatose  state,  when  probably,  in  consequence  of  compression  of  the  brain 
from  an  abundant  exudation,  the  pulse  may  be  subnormal.  Thus,  in  one 
of  my  patients,  an  adult,  the  pulse  fell  to  40  per  minute,  and  in  two  others 
to  between  60  and  70  per  minute.  With  the  exception  of  these  three,  the 
pulse  in  all  cases  which  I  have  observed,  so  far  as  I  recollect,  has  varied 
from  the  normal  number  of  beats  per  minute  to  such  frequency  that  it  was 
difficult  to  count  it.  As  death  draws  near,  the  pulse  ordinarily  becomes 
more  frequent  and  feeble.  Intermissions  in  the  pulse  do  not  seem  to  be  as 
common  as  in  other  forms  of  meningitis,  but  marked  variations  in  its 
frequency  during  different  hours  of  the  day,  and  on  consecutive  days,  con- 
stitute a  conspicuous  symptom.  Thus,  in  a  case  which  was  fatal  in  the 
fifth  week,  consecutive  enumerations  of  the  pulse,  in  the  acute  stage,  were 
as  follows:  128,  120,  88,  130,  84,  112. 

Temperature. — Some  of  the  older  writers,  before  the  days  of  clinical 
thermometry^,  stated  that  the  temperature  is  not  increased.  North  remarked 
as  follows  :  "  Cases  occur,  it  is  true,  in  which  the  temperature  is  increased 
above  the  natural  standard,  but  these  are  rare ;"  and  Foot  and  Gallop  make 
similar  statements.  Some  recent  writers  have  held  the  simie  opinion.  Thus, 
Lidell  wrote  as  follows  in  a  treatise  bearing  the  date  of  1873:  "Febrile 
symptoms  do  not  necessarily  belong  to  epidemic  cerebro-spinal  meningitis 
as  a  substantive  disease,  for  it  may,  aud  not  unfrequcntly  does,  occur  with- 
out exhibiting  any  such  symptoms."  We  should  naturally  expect  that 
meningitis,  accompanied  as  it  is  by  active  congestion  of  the  bmin  and  spinal 


534  CEREBRO-SPINAL    FEVEE. 

cord,  would  produce  more  or  less  fever,  and  in  eighty-six  cases  which  I 
examined  by  the  thermometer  I  found  elevation  of  temperature  in  every 
case  during  the  acute  stage,  except  in  the  beginning  of  the  attack  in  two 
instances.  In  a  young  man,  aged  twenty-eight  years,  who  had  severe  head- 
ache and  seemed  seriously  sick,  the  thermometer  under  the  tongue  showed 
no  rise  of  temperature  on  the  first  and  second  days,  but  on  the  third  day  it 
was  at  100°  F.,  and  it  remained  elevated  till  his  death,  on  the  thirteenth  day. 
The  second  case  was  that  of  a  young  woman  whom  I  saw  in  consultation, 
and  who  at  the  time  of  my  visit  had  fever,  but  had  had  none  previously, 
according  to  the  statement  of  the  attending  physician. 

In  the  eighty-six  cases  which  I  examined,  the  heat  of  the  surface  occa- 
sionally did  not  seem  above  normal  to  the  touch,  and  now  and  then  the 
thermometer,  applied  in  the  axilla  or  groin,  did  not  indicate  fever,  but  the 
rectal  temperature  was  always  elevated  above  that  of  health  after  the  disease 
was  fully  established.  The  temperature  fluctuated  from  day  to  day,  and 
in  different  hours  of  the  same  day,  but  there  was  no  exception  after  the 
second  day  to  the  rule  that  it  was  above  the  normal  during  the  active  stage 
of  the  malady.  Sometimes  the  elevation  of  temperature  was  slight,  as  in 
•a  female  patient,  forty-seven  years  of  age,  in  whom  the  thermometer  showed 
no  elevation  of  temperature  when  it  was  placed  in  the  mouth  and  axilla, 
but  on  introducing  it  into  the  rectum  it  rose  to  99J°  F. 

The  highest  temperature  which  I  have  thus  far  observed  was  107f  °  F., 
in  a  child  aged  two  years.  This  was  in  the  commencement  of  the  attack. 
Subsequently  it  fell  a  little,  but  rose  again  on  the  third  day  to  107°,  when 
she  died.  In  two  other  cases  the  temperature  was  106°  F.  on  the  first  day, 
and  it  did  not  afterwards  reach  so  high  an  deviation.  One  of  these  died 
on  the  ninth  day,  and  the  other  in  the  ninth  week.  The  next  highest  tem- 
perature was  105|^°  F.,  also  on  the  first  day,  in  an  infant  aged  eight  months, 
who  died  on  the  ninth  day.  The  first  and  last  of  these  cases  occurred  in 
an  old  wooden  tenement-house  in  the  suburbs  of  the  city  and  upon  an 
elevated  outcropping  of  rock.  The  highest  temperature  in  any  case  in  New 
York  City  which  has  come  to  my  notice  was  observed  in  a  male  patient, 
aged  twenty-eight  years,  who  had  active  delirium  and  died  on  the  fifth  day 
in  Roosevelt  Hospital.  The  temperature  on  the  last  day,  taken  four  times, 
was  as  follows  :  102|°,  106f  °,  and,  when  the  pulse  had  become  imper- 
ceptible, 109°  and  107f  °  F.  Wunderlich  has  recorded  a  temperature  of 
110°  F.  in  one  or  two  cases,  but  so  great  an  elevation  must  be  very  rare, 
and  is,  of  course,  prognostic  of  an  unfavorable  ending. 

The  external  temperature  undergoes  still  greater  fluctuations  than  the 
internal,  rising  above  and  falling  below  the  normal  standard  several  times 
in  the  course  of  the  same  day.  Similar  fluctuations  occur  in  other  forms 
of  meningitis,  but  they  are,  according  to  my  experience,  less  pronounced 
than  in  cerebro-spinal  fever,  especially  as  I  observed  them  in  the  epidemic 
of  1872.  Perhaps  since  that  epidemic  they  have  been  less  marked  in  the 
cases  occurring;  in  this  citv.     The  more  ffrave  the  attack  in  those  not  coma- 


CEREBRO-SPINAL    FEVER.  535 

tuse,  the  greater  these  variations.  The  following  is  a  common  example  of 
these  sudden  thermometric  changes,  occurring  in  a  child  of  two  years.  The 
internal  temperature  varied  from  101°  to  104f°  F.  as  the  extremes,  while 
that  of  the  fingers  and  hands  at  the  first  examination  was  90^°,  at  the 
second  90°,  at  the  third  103°,  and  at  the  fourth  83°.  Hence  at  the  third 
examination  the  temperature  of  the  extremities  had  risen  13°,  so  as  nearly 
h>  equal  that  of  the  blood,  and  at  the  fourth  examination  it  had  fallen  20°. 
The  patient  recovered.  These  great  and  sudden  variations  in  the  pulse,  and 
the  internal  and  external  temperature,  have  considerable  diagnostic  value  in 
obscure  and  doubtful  cases. 

Respiratory  System. — This  system  is  not  notably  involved  in  ordinary 
cases.  Intermittent,  sighing,  or  irregular  respiration  appears  to  be  less 
frequent  than  in  tubercular  meningitis,  but  it  does  occur.  In  most  patients 
the  respiration  is  quiet,  but  somewhat  accelerated,  and  without  any  marked 
disturbance  in  its  rhythm.  In  thirty-one  observations  in  children  who  had 
no  complication,  I  found  the  average  respirations  42  per  minute,  while  the 
average  pulse  was  137.  Therefore  the  respiration,  as  compared  with  the 
pulse,  was  proportionately  more  frequent  than  in  health,  due  perhaps  to 
the  fact  that  certain  muscles  concerned  in  respiration,  as  the  abdominal, 
are  embarrassed  in  their  movements  by  tonic  contraction. 

Various  observers,  in  different  epidemics,  have  recorded  an  unusual 
{prevalence  of  croupous  pneumonia  occurring  simultaneously  with  cerebro- 
spinal fever. ,  Bascome,  in  his  history  of  epidemics,  stated  that  "  epidemic 
encephalitis  and  malignant  pneumonias  prevailed  in  Germany  in  the  six- 
teenth century"  (Webber).  Webber,  in  his  prize  essay,  describes  a  variety 
of  cerebro-spinal  fever,  which  he  designates  pneumonic,  in  which  the  cere- 
bro-spinal  axis  is  involved  but  slightly  or  not  at  all,  and  the  brunt  of  the 
disease  falls  upon  the  respiratory  organs.  According  to  him,  in  certain 
epidemics  the  pneumonic  form  has  been  common  and  in  others  infrequent. 
This  fact  is  interesting  taken  in  connection  with  the  examination  of  the 
microbes  of  croupous  pneumonia  and  cerebro-spinal  fever,  as  detailed  in 
our  remarks  under  the  head  of  etiology. 

Cutaneous  Surface. — The  features  may  be  pallid,  of  normal  appearance, 
or  flushed,  in  the  first  days  of  the  disease,  but  in  advanced  cases  they  are 
pallid,  as  is  the  skin  generally.  A  circumscribed  patch  of  deep  congestion 
often  a])]')ears,  as  in  sporadic  meningitis,  upon  some  part  of  them,  as  the 
forehead,  the  cheek,  or  an  ear,  and  after  a  short  time  disa])pears.  The  hyper- 
semic  streak,  the  tache  c^r6brale  of  Trousseau,  produced  by  drawing  the 
finger  firmly  across  the  surface,  also  appears  as  in  other  forms  of  meningitis, 
if  the  temperature  of  the  surface  be  not  too  much  reduced. 

The  following  arc  the  abnormal  a|)pparances  of  the  skin  most  frequently 
observed  :  1.  Papilliform  elevations,  the  so-called  goose-skin,  due  to  con- 
tractions of  the  muscular  fibres  of  the  corium.  This  is  not  uncommon  in 
the  first  weeks.  2.  A  dusky  mottling,  also  common  in  tlie  first  and  second 
weeks  in  grave  cases,  and  most  marked  when  the  temperature  is  reduced. 


536  CEEEBRO-SPIXAL   FEVER. 

3.  Numerous  miuute  red  poiuts  over  a  lai-ge  part  of  the  surface,  bluish 
spots  a  few  lines  in  diameter,  due  to  extravasation  of  blood  under  the 
cuticle,  resembling  bruises  in  appearance,  and  large  patches  of  the  same 
color,  an  inch  or  more  in  diameter,  less  common  than  the  others,  of  irregular 
shape  as  "sv^ell  as  size,  and  usually  not  more  than  two  or  three  upon  a  patient. 
These  last  resemble  bruises,  and  they  may  sometimes  be  such,  received 
durino-  the  times  of  restlessness  :  but  ordinarilv  extravasations  of  this  kind 
result  entirely  from  the  altered  state  of  the  blood.  In  Xew  York  in  the 
epidemic  of  1872  they  were  common,  but  since  this  epidemic,  in  the  thirty- 
six  cases  which  I  have  observed,  I  have  rarely  seen  either  the  reddish  points 
or  the  extravasations  of  blood.  They  were  probably  common  in  the 
epidemics  in  the  first  part  of  this  century  in  this  country,  since  the  disease 
was  designated  by  the  name  spotted  fever  by  the  American  physicians  who 
wrote  upon  it  at  that  time.  That  they  are  unusual  in  the  European  epi- 
demics at  the  present  time  we  infer  from  the  fact  that  Von  Ziemssen  ex- 
presses surprise  that  the  disease  should  ever  have  been  designated  in  America 
by  such  a  title.  4.  Herpes.  This  is  common.  It  sometimes  occurs  as 
early  as  the  second  or  third  day,  but  in  other  instances  not  till  towards  the 
close  of  the  first  week  or  in  the  second.  The  number  of  herpetic  eruptions 
varies  from  six  or  eight  to  clusters  as  large  as  or  larger  than  the  hand. 
This  cutaneous  disease  evidently  has  a  nervous  origin,  the  vesicles  occurring 
in  most  instances  on  those  parts  of  the  surface  which  are  supplied  by  branches 
of  the  fifth  pair  of  nerves.  Its  most  common  seat  is  upon  the  lips,  but  occa- 
sionally it  appears  upon  the  cheek,  upon  and  around  the  ears,  and  upon  the 
scalp.  Erythema  and  roseola,  both  transient  skin-eruptions,  occasionally 
appear,  and  in  one  instance  in  my  practice  erysipelas  occurred.  During 
the  first  days  the  skin  is  frequently  dry ;  afterwards  perspirations  are  not 
unusual,  and  free  perspirations  sometimes  occur,  especially  about  the  head, 
face,  and  neck. 

Urinary  Organs. — In  other  forms  of  meningitis  it  is  well  known  that 
the  quantity  of  urine  excreted  is  usually  diminished,  but  in  this  disease  it  is 
normal,  and  it  may  be  more  than  normal.  Polyuria  has  been  noticed  in 
different  cases  by  various  observers.  IMosler  observed  a  boy  aged  seven 
years  who  had  an  excessive  secretion  of  urine,  which  dated  back  to  an 
attack  of  cerebro-spinal  fever  in  his  third  year.  The  polyuria  is  probably 
due  to  injury  of  the  nervous  centre,  since  it  is  established  by  physiological 
experiment  that  irritation  of  the  central  end  of  the  vagus,  of  certain  parts 
of  the  cerebellum,  and  of  the  walls  of  the  fourth  ventricle,  sometimes  pro- 
duces this  effect.  The  urine  occasionally  contains  a  moderate  amount  of 
albumen,  and  in  exceptional  instances  cylindrical  easts  and  blood-corpuscles. 

Arthritic  inflammation,  apparently  of  a  rheumatic  character,  has  been 
occasionally  observed.  It  is  commonly  slight,  producing  merely  an  oedema- 
tous  appearance  around  one  or  more  joints.  Thus,  in  one  case  which  came 
under  my  notice,  and  which  was  subsequently  fatal,  the  parents,  who  were 
poor,  and  were  therefore  without  medical  advice  till  the  case  was  somewhat 


CEEEBRO-SPINAL    FEVER.  537 

advanced,  had  already  diagnosticated  rheumatism  on  account  of  the  puffi- 
ness  which  they  had  noticed  around  one  of  the  wrists. 

The  Special  Senses. — Taste  and  smell  are  rarely  aifected,  so  far  as  is 
known,  but  it  is  possible  that  they  are  sometimes  perverted,  or  even  tempo- 
rarily lost,  during  the  time  of  greatest  stupor.  In  one  case  which  I  saw, 
the  sense  of  smell  was  entirely  lost  in  one  nostril,  and  I  do  not  know 
whether  it  was  ever  fully  restored. 

The  aifections  of  the  eye  and  ear  are  important  and  of  frequent  occur- 
rence. Strabismus  is  common.  It  may  occur  at  any  period  of  the  fever, 
continuing  a  few  hours  or  several  days,  and  it  may  appear  and  disappear 
several  times  before  convalescence  is  established  :  occasionally  it  continues 
several  weeks,  after  which  the  parallelism  of  the  eyes  is  gradually  and  fully 
restored.     In  other  instances  it  is  permanent. 

Changes  in  the  pupils  are  among  the  first  and  most  noticeable  of  the 
initial  symptoms,  as  I  have  already  stated  in  describing  the  mode  of  com- 
mencement. These  are  dilatation,  less  frequently  contraction,  oscillation^ 
inequality  of  size,  feeble  response  to  light,  etc.  Most  patients  present  one 
or  more  of  these  abnormalities  of  the  pupils,  and  they  continue  during  the 
first  and  second  weeks,  and  gradually  abate,  if  the  course  of  the  disease  be 
favorable.  Inflammatory  hypersemia  of  the  conjunctiva  often  occurs.  It 
begins  early,  and  now  and  then  the  conjunctivitis  is  so  intense  that  consid- 
erable tumefaction  of  the  lids  results,  with  a  free  muco-purulent  secretion. 
The  false  diagnosis  has  indeed  been  made  of  purulent  ophthalmia,  in  cases 
in  which  this  affection  of  the  lids  was  early  and  severe.  But  such  intense 
inflammation  is  quite  exceptional.  More  frequently  there  is  a  uniform  dif- 
fused redness  of  the  conjunctiva,  not  so  dusky  as  in  typhus,  and  the  injected 
vessels  cannot  be  so  readily  distinguished  as  in  that  disease. 

In  certain  cases  almost  the  whole  eye  (all,  indeed,  of  the  important  con- 
stituents) becomes  inflamed ;  the  media  grow  cloudy,  the  iris  discolored,  and 
the  pupils  uneven  and  filled  up  with  fibrinous  exudation.  The  deep  struc- 
tures of  the  eye  cannot,  therefore,  be  readily  explored  by  the  ophthalmo- 
scope, but  they  are  observed  to  be  adherent  to  each  otlier  and  covered  by 
inflammatory  exudation.  They  present  a  dusky  red  or  even  a  dark  color, 
when  the  inflammation  is  recent.  Exceptionally  the  cornea  ulcerates  and 
the  eye  bursts,  Avith  the  loss  of  more  or  less  of  the  licjuids,  and  shrinking 
of  the  eye.  "  But  ordinarily  no  ulceration  occurs,  and,  as  the  patient  con- 
valesces, the  oedema  of  the  lids,  the  hyperemia  of  the  conjunctiva,  the  cloudi- 
ness of  the  cornea  and  of  the  humors,  gradually  abate,  and  the  exudation 
in  the  pupils  is  absorbed.  The  iris  bulges  forward,  and  the  deep  tissues  of 
the  eye,  viewed  through  the  vitreous  humor,  which  before  had  a  dusky  red 
color  from  hyperaemia,  now  present  a  dull  white  color."  The  lens  itself,  at 
first  transparent,  after  a  while  becomes  cataractous.  Sight  is  lost  totally  and 
forever. 

If  the  patient  live,  the  volume  of  the  eye  diminishes,  as  the  inflamma- 
tion abates,  to  less  than  the  normal  size,  even  when  there  has  been  no  rup- 


538  CEREBEO-SPIXAL    FEVER. 

ture,  and  escape  of  the  fluids,  and  divergent  strabismus  is  likely  to  occur. 
Prof.  Knapp,  whose  description  of  the  eye  I  have  for  the  most  part 
followed,  says,  "  The  nature  of  the  eye-affection  is  a  purulent  choroiditis, 
probably  metastatic."  Fortunately,  so  general  and  destructive  an  inflam- 
mation of  the  eye  as  has  been  described  above  is  comparatively  rare.  On 
the  other  hand,  conjunctivitis  of  greater  or  less  severity,  and  hypersemia  of 
the  optic  disk,  consequent  upon  the  brain-disease,  are  not  unusual,  but  they 
subside  leaving  the  function  of  the  organ  unimpaired.  "  In  some  cases 
incurable  blindness  is  noticed  under  the  ophthalmoscope  picture  of  optic 
nerve  atrophy,  probably  the  sequence  of  choked  disk."     (Knapp.) 

Inflammation  of  the  middle  ear,  of  a  mild  grade,  and  subsiding  without 
impairment  of  hearing,  is  common.  The  membrana  tympani,  during  its 
continuance,  presents  a  dull-yellowish,  and  in  places  a  reddish,  hue.  Occa- 
sionally a  more  severe  otitis  media  occurs,  ending  in  suppuration,  perfora- 
tion of  the  membrana  tymjDani,  and  otorrhoea,  which  ceases  after  a  variable 
time.  But  otitis  media  is  not  the  most  severe  of  the  affections  of  the  organs 
of  hearing.  Certain  patients  lose  their  hearing  entirely  and  never  regain 
it,  and  that,  too,  with  little  otalgia,  otorrhoea,  or  other  local  symptoms  by 
which  so  grave  a  result  can  be  prognosticated.  This  loss  of  hearing  does 
not  occur  at  the  same  period  of  the  disease  in  all  cases.  Some  of  those  who 
become  deaf  are  able  to  hear  as  they  emerge  from  the  stupor  of  the  disease, 
but  lose  this  function  during  convalescence,  while  the  majority  are  observed 
to  be  deaf  as  soon  as  the  stupor  abates  and  full  consciousness  returns. 

Two  important  facts  have  been  observed  in  reference  to  the  loss  of 
hearing  in  these  patients, — to  wit,  it  is  bilateral  and  complete.  When  first 
observed  it  is  in  some,  as  stated  above,  complete,  but  in  others  partial,  and 
Avhen  partial  it  gradually  increases -till  after  some  days  or  weeks,  when  it 
becomes  complete.  I  have  the  records  of  ten  cases  of  this  loss  of  hearing, 
most  of  them  occurring  in  my  own  practice  in  the  epidemic  of  1872,  but  a 
few  of  them  detailed  to  me  by  the  physicians  who  observed  them  in  the 
same  epidemic.  According  to  these  statistics,  about  one  in  every  ten  patients 
became  deaf,  but  in  the  milder  form  of  cerel)ro-spinal  meningitis  which  has 
prevailed  since  1872  the  proportionate  number  thus  affected  has  been  less 
among  my  patients,  and  the  same  may  be  said  in  reference  to  the  loss  of 
sight.  One  of  the  ten  cases  was  a  young  lady,  but  the  rest  were  children 
under  the  age  of  ten  years.  Prof.  Knapp  has  examined  thirty-one  cases. 
"  In  all,"  says  he,  "  the  deafness  was  bilateral,  and,  with  two  exceptions  of 
faint  perceptions  of  sound,  complete.  Among  the  twenty-nine  cases  of 
total  deafness,  there  is  only  one  who  seemed  to  give  some  evidence  of  hear- 
ing afterwards."  The  same  author  has  recently  informed  me  that  further 
experience  has  confirmed  his  previous  statement,  that  while  the  blindness 
produced  by  cerebro-spinal  fever  is  in  the  majority  of  cases  mouolateral, 
but  one  case  had  come  to  his  notice  in  which  the  deafness  was  on  one  side 
only. 

One  theory  attributes  the  loss  of  hcariug  to  inflammatory  lesions  either . 


CEREBRO-SPIXAL   FEVER.  539 

at  the  centre  of  auditiou,  within  the  brain,  or  in  the  course  of  the  auditory 
nerves  before  they  enter  the  auditory  foramina.  The  other  theory,  which 
is  the  better  established  of  the  two,  and  must  be  accepted,  attributes  the  loss 
of  hearing  to  inflammatory  disease  of  the  ear,  and  especially  of  the  laby- 
rinth. 

Symptoms  of  Endemic  or  Naturalized  Cerebro-Spinal  Fever. — 
The  numerous  monographs  on  this  disease  which  have  appeared  during  the 
last  few  years  relate  to  its  epidemic  form,  and  no  published  observations,  so 
far  as  I  am  aware,  describe  the  character  or  symptoms  which  it  presents,  or 
the  changes  which  it  undergoes,  when  it  occurs  as  an  endemic  or  naturalized 
disease.  The  endemic  disease  must,  of  course,  be  observed  in  the  cities  or 
populous  towns,  for  there  is  no  rural  locality,  so  far  as  I  am  aware,  in 
which  this  disease  is  permanently  established.  In  New  York  the  natural- 
ized disease  appears  to  be  accompanied  by  a  less  profound  blood-change 
than  occurs  in  epidemic  cases.  Although  every  year  seeing  a  considerable 
number  of  cases,  I  have  not  in  the  last  ten  years  seen  one  with  the  livid 
spots  upon  the  surface,  due  to  subcutaneous  extravasation  of  blood,  which 
were  so  common  in  the  epidemic  of  1872,  and  which  have  been  so  common 
in  epidemics  both  in  this  country  and  in  Europe  as  to  give  rise  to  the  term 
spotted  fever.  Occasionally  petechise  occur  in  severe  cases  5f  the  naturalized 
disease. 

Nature. — The  theory  that  cerebro-spinal  fever  is  a  local  disease,  occur- 
ring epidemically,  was  commonly  held  in  the  first  part  of  this  century,  but 
is  now  discarded.  Job  Wilson,  in  1815,  considered  it  a  form  of  influenza, 
and  could  see  no  utility  in  drawing  a  distinction  between  spotted  fever 
and  influenza.  We  at  the  present  time  can  see  no  resemblance  between 
the  two,  except  that  both  occur  as  epidemics.  The  theory  that  cerebro- 
spinal fever  is  a  peculiar  local  disease  occurring  in  epidemics  is  more 
plausible  than  that  which  holds  that  it  is  a  form  of  influenza.  Even 
Niemeyer  says  that  it  presents  no  symptoms  except  such  as  are  referable  to 
the  local  affection.  But  the  evidence  is  strong  that  cerebro-spinal  fever  is  a 
constitutional  malady  with  the  meningitis  as  a  local  manifestation,  just  like 
measles  with  its  bronchitis,  or  scarlet  fever  with  its  pharyngitis.  The 
abrupt  and  severe  commencement,  unlike  that  of  those  forms  of  meningitis 
which  are  known  to  be  strictly  local,  and  the  early  blood-change,  as  shown 
in  certain  cases  by  the  appearance  of  the  skin  and  extravasations  under  it, 
indicate  a  general  disease.  Constitutional  diseases  having  prominent  local 
symptoms  and  lesions  are  usually  regarded  at  first  as  local.  It  is  only  as 
time  goes  on,  and  they  are  more  thoroughly  studied  and  understood,  and 
clinical  observations  multiply,  that  their  constitutional  nature  is  recognized. 

The  theory  that  cerebro-spinal  fever  is  a  form  of  typhus  once  had 
advocates,  but  it  is  now  so  generally  discarded,  as  untenable  and  absurd, 
that  it  would  be  a  waste  of  time  to  consider  tlie  fiicts  which  diiferentiate 
the  two  maladies.  Cerebro-spinal  fever  should,  therefore,  be  considered  as 
distinct  from  all  other  diseases,  a  malady  sui  genens,  and  in  nosological 


540  CEEEBRO-SPINAL    FEVER. 

writino-s  it  should  be  classified  with  those  constitutional  maladies  which 
have  specific  causes. 

Although  this  disease  ordinarily  occurs  in  an  epidemic  fiDrm  in  localities 
widely  separated  from  one  another,  and,  after  continuing  a  few  weeks  or 
months,  totally  disappears,  perhaps  never  to  return,  or  not  till  after  the 
lapse  of  years,  nevertheless  in  localities  it  becomes  established,  so  that  it  is 
proper  to  describe  it  as  an  endemic,  a  fact  to  which  we  have  already  referred 
as  regards  certain  American  cities.  I  do  not  know  that  it  is  endemic  in  any 
village  or  rural  locality  in  this  country.  The  large  cities,  with  their  pro- 
miscuous population,  foreign  and  native,  their  crowded  tenement-houses,  and 
their  many  sources  of  insalubrity,  furnish  in  an  eminent  degree  the  conditions 
which  are  favorable  for  the  development  and  perpetuation  of  the  specific 
principle.  Those  diseases  which  in  the  present  state  of  our  knowledge  we 
have  reason  to  believe  are  caused  by  micro-organisms,  we  should  expect  to 
prevail  most  where  domiciles  are  crowded  and  filthy,  and  systems  are  ener- 
vated by  impure  air,  hardships,  and  privation.  Hence  in  New  York  City, 
in  the  crowded  quarters  of  the  poor,  cerebro-spinal  fever,  like  diphtheria, 
is  seldom  or  never  absent. 

Number 
OF  Deaths. 

170 

461 

238 

223 

210 

202 

223 

.........  203 


Number 

OF  Deaths. 

1872 

782 

1880 

1873   .  .  .  . 

290 

1881 

1874 

158 

1882 

1875  .... 

146 

1883 

1876  .... 

127 

1884 

1877 

116 

97 

1885 

1878  .... 

1886 

1879  .... 

108 

1887 

It  is  seen  that  the  greatest  mortality  was  in  the  first  year  after  the  in- 
troduction of  the  disease  into  the  city,  after  which  the  number  of  deaths 
gradually  diminished,  year  by  year,  till  1878,  when  the  lowest  mortality 
was  reached.  After  1878  the  mortality  gradually  increased  till  1881,  in 
which  year  the  number  of  deaths  was  double  that  of  any  other  year  except 
1872. 

The  mortuary  reports  of  Philadelphia  likewise  show  that  cerebro-spinal 
fever  has  remained  in  that  city  since  its  introduction  in  1863,  a  period  of 
twenty-five  years,  the  annual  deaths  produced  by  it  varying  between  36,  the 
minimum,  in  1869  and  1870,  and  384,  the  maximum,  in  1864.  In  Provi- 
dence, also,  as  appears  from  Dr.  Snow's  reports,  cerebro-spinal  fever  has 
caused  annually  more  or  fewer  deaths  since  1871.  Therefore,  we  repeat, 
this  fact  may  be  added  to  the  sum  of  our  knowledge  of  this  disease,  that 
once  gaining  a  lodgement,  where  the  conditions  are  favorable  for  it,  as  in  a 
large  city,  it  may  become  established  and  remain  an  indefinite  time. 

Anatomical  Characters. — I  have  notes  of  the  post-mortem  appear- 
ances in  seventy-six  cases,  published  chiefly  in  British  and  American 
journals :   twenty-nine  died  withjn  the  first  three  days,  twenty-eight  be- , 


CEREBRO-SPINAL    FEVER.  541 

tween  the  third  and  twenty-first  days,  and  the  duration  of  the  remaining 
nineteen  was  unknown.  These  records  furnish  the  data  for  the  following 
remarks. 

The  blood  undergoes  changes  which  are  due  in  part  to  the  inflammatory 
and  in  part  to  the  constitutional  and  asthenic  nature  of  the  disease.  The 
proportion  of  fibrin  is  increased  in  cases  that  are  not  speedily  fatal,  as  it 
ordinarily  is  in  idiopathic  inflammations.  Analyses  of  the  blood  by  Ames, 
Tourdes,  and  Maillot  show  a  variable  proportion  of  fibrin  from  three  and 
four-tenths  to  more  than  six  parts  in  one  thousand.  In  sthenic  cases  aiccom- 
panied  by  a  pretty  general  meningitis,  cerebral  and  spinal,  there  is,  after  the 
fever  has  continued  some  days,  the  maximum  amount  of  fibrin,  while  in  the 
asthenic  and  suddenly  fatal  cases,  with  inflammation  slight  or  in  its  com- 
mencement, the  fibrin  is  but  little  increased.  The  most  common  abnormal 
appearance  of  the  blood  observed  at  autopsies  is  a  dark  color  with  unusual 
fluidity  and  the  presence  of  dark  soft  clots.  Exceptionally  bubbles  of  gas 
have  been  observed  in  the  large  vessels,  and  the  cavities  of  the  heart.  An 
unusually  dark  color  of  the  blood,  small  and  soft  dark  clots,  and  the  pres- 
ence of  gas-bubbles,  when  only  a  few  hours  have  elapsed  after  death,  indi- 
cate a  malignant  form  of  the  disease,  in  which  the  blood  is  early  and  pro- 
foundly altered.  In  certain  cases  this  fluid  is  not  so  changed  as  to  attract 
attention  from  its  appearance.  The  points  or  patches  of  extravasated  blood 
which  are  observed  in  and  under  the  skin  during  life  in  some  patients 
usually  remain  in  the  cadaver.  When  an  incision  is  made  through  them 
the  blood  is  seen  to  have  been  extravasated  not  only  in  the  layers  of  the 
skin,  but  also  in  the  subcutaneous  connective  tissue.  Extravasations  of 
small  extent  are  likewise  sometimes  observed  upon  and  in  thoracic  and  ab- 
dominal organs. 

In  those  who  die  after  a  sickness  of  a  few  hours  or  days,  namely,  in  the 
stage  of  acute  inflammatory  congestion,  the  cranial  sinuses  are  found  en- 
gorged with  blood  and  containing  soft  dark  clots.  The  meninges  envelop- 
ing the  brain  are  also  intensely  hypersemic  in  their  entire  extent,  in  most 
cadavers;  but  in  some  cases  the  hyperemia  is  limited  to  a  portion  of  the 
meninges,  wliilc  other  portions  appear  nearly  normal.  In  those  cases  which 
end  fatally  within  a  few  liours,  this  hypersemia  is  ordinarily  the  only  lesion 
of  the  meninges ;  but  if  the  case  be  more  protracted,  serum  and  fibrin  are 
soon  exuded  from  the  vessels  into  the  meshes  of  the  pia  mater,  and  under- 
neath this  membrane,  over  the  surface  of  the  brain.  Pus-cells  also  occur 
mixed  with  the  fibrin,  sometimes  so  few  that  they  are  discovered  only  with 
the  microscope,  but  in  other  cases  in  such  quantity  as  to  be  much  in  excess 
of  the  fibrin  and  to  be  readily  detected  by  the  naked  eye.  Pus,  which  in 
these  cases  probably  consists  of  Avhite  blood-corpuscles  Avhich  liave  escaped 
with  the  fibrin  from  the  meningeal  vessels,  often  appears  early  in  the  attack. 
The  arachnoid  soon  loses  its  transparency  and  ])olish,  and  presents  a  cloudy 
appearance  over  a  greater  or  less  extent  of  its  surface.  This  cloudiness  is 
usually  greatest  along  the  course  of  the  vessels  in  the  sulci  and  depressions, 


542  CEREBRO-SPIXAL    FEVER. 

and  where  the  fibrinous  exudation  is  greatest,  but  it  occurs  also  in  places 
where  no  such  exudation  is  apparent  to  the  naked  eye. 

The  exudation — serous,  fibrinous,  and  purulent — occurs,  as  in  other  forms 
of  meningitis,  within  the  meshes  of  the  pia  mater,  and  underneath  this  mem- 
brane over  the  surface  of  the  brain.  The  fibrin  is  raised  from  the  surface 
of  the  brain  with  the  meninges  in  making  the  autopsy.  It  is  most  abundant 
in  the  intergyral  spaces,  around  the  course  of  the  vessels,  over  and  around 
the  optic  commissure,  pons  Varolii,  cerebellum,  and  medulla  oblongata, 
and  aiong  the  Sylvian  fissures.  It  is  most  abundant  in  the  depressions, 
where  it  sometimes  has  the  thickness  of  one-tenth  to  one-fourth  of  an  inch, 
but  it  often  extends  over  the  convolutions  so  as  to  conceal  them  from  view. 

Most  other  forms  of  meningitis  have  a  local  cause,  and  are  therefore 
limited  to  a  small  extent  of  the  meninges,  as,  for  example,  meningitis  from 
tubercles  or  caries  of  the  petrous  portion  of  the  temporal  bone,  in  both  of 
which  it  is  commonly  limited  to  the  base  of  the  brain ;  or  from  accidents, 
when  the  meningitis  commonly  occurs  upon  the  side  or  summit  of  the  brain. 
The  meningitis  of  cerebro-spinal  fever,  on  the  other  hand,  having  a  general 
or  constitutional  cause,  occurs  with  nearly  equal  frequency  upon  all  parts 
of  the  meningeal  surface,  except  that  it  is  perhaps  most  severe  in  the  de- 
pressions, where  the  vascular  supply  is  greatest.  In  cases  of  great  severity 
the  inflammatory  exudation,  fibrinous  or  purulent,  or  both,  covers  nearly  or 
quite  the  entire  surface  of  the  brain. 

In  those  Avho  die  at  an  early  stage  of  the  attack,  the  vessels  of  the  brain, 
like  those  of  the  meninges,  are  hyperasmic,  so  that  numerous  "  puncta  vas- 
culosa"  appear  upon  its  incised  surface.  At  a  later  period  this  hypersemia, 
like  that  of  the  meninges,  may  disappear.  If  there  be  much  effusion  of 
serum  within  the  ventricles,  and  over  the  surface  of  the  brain,  the  convolu- 
tions are  liable  to  be  flattened,  and  th^  pressure  may  be  so  great  that  the 
amount  of  blood  circulating  in  the  brain  is  reduced  below  the  normal  quan- 
tity. Thus,  in  the  case  of  a  child  of  three  years,  who  lived  sixteen  days, 
and  was  examined  after  death  by  Burdon-Sanderson,  the  ventricles  con- 
tained a  large  amount  of  turbid  serum,  and  the  brain-substance  was  every- 
where pale  and  anaemic  from  compression. 

Cerebral  ramollissement  occurs  in  certain  cases.  At  one  of  the  examina- 
tions in  Charity  Hospital,  the  patient  having  been  only  three  days  sick,  the 
brain  was  found  much  softened.  The  dissection  was  made  seven  hours  after 
death,  so  that  the  softening  could  not  have  been  the  result  of  decomposition. 
At  one  of  the  post-mortem  examinations  in  Bellevue  Hospital,  softening 
of  the  fornix,  corpus  callosum,  and  septum  lucidum  was  observed,  and  in 
another,  softening  in  the  neighborhood  of  the  subarachnoid  space.  In  a 
case  related  by  Dr.  Moorman,^  it  is  stated  that  portions  of  the  brain, 
medulla  oblongata,  and  pons  Varolii  were  softened.  In  a  case  observed  by 
Dr.  Upham,  softening  of  the  superior  portion  of  the  left  cerebral  hemi- 

1  American  Journal  of  the  Medical  Sciences,  October,  1866. 


CEREBRO-SPINAL   FEVER.  543 

sphere  had  occurred.  Occasionally  the  whole  brain  is  somewhat  softened. 
Burdon-Sanderson,  Russell,  and  Githens  each  relate  such  a  case.  More- 
over, the  walls  of  the  lateral  ventricles  are  ordinarily  more  or  less  softened 
in  fatal  cases  of  cerebro-spinal  fever,  as  they  are  in  other  forms  of  menin- 
gitis. In  rare  instances  the  brain  is  cedematous,  as  in  a  case  published 
by  Dr.  Hutchinson.^  In  this  case  the  patient  was  only  four  days  sick,  and 
the  whole  brain  was  oedematous,  serum  escaping  from  its  incised  surface. 

The  ventricles  contain  liquid,  in  some  patients  transparent  serum,  in 
(jthers  serum  turbid  and  containing  flocculi  of  fibrin,  or  fibrin  with  pus.  The 
liquids  in  the  different  ventricles,  since  they  intercommunicate,  are  the  same. 
The  choroid  plexus  is  either  injected  or  it  is  infiltrated  with  fibrin  and  pus. 
With  the  abatement  of  the  inflammation  absorption  commences.  The  serum^ 
from  its  nature,  is  readily  absorbed,  and  the  pus  and  fibrin  more  slowly 
by  fatty  degeneration  and  liquefaction.  Occasionally  the  serum  remains, 
and  chronic  hydrocephalus  results.  An  infant  who  contracted  the  disease 
at  the  age  of  five  months,  and  appeared  to  be  convalescent,  had,  two  months 
subsequently,  great  prominence  of  the  anterior  fontanel,  and  other  symp- 
toms indicating  the  presence  of  a  considerable  amount  of  efiiision  within 
the  cranium.  In  another  case,  one  year  afterwards,  examination  showed  the 
enlargement  of  the  head  and  prominence  of  the  fontanel  which  characterize 
chronic  hydrocephalus.  A  boy  of  ten  years,  treated  in  Roosevelt  Hospital 
in  1878,  died  three  months  after  the  commencement  of  cerebro-spinal  fever. 
The  records  of  the  autopsy  state,  "  Body  a  skeleton  ;  brain,  dura  mater,  and 
pia  mater  appear  normal,  except  a  little  thickening  of  latter  at  base  of  brain  ; 
ventricles  much  enlarged  and  full  of  clear  serum ;  surface  of  walls  of  ven- 
tricles appears  normal,  but  is  soft ;  spinal  cord  and  membranes  apparently 
normal ;  heart,  lungs,  stomach,  and  intestines  normal ;  liver  congested ;  kid- 
neys pale."  In  this  case,  therefore,  all  the  other  lesions  of  the  cerebro-spinal 
axis,  except  the  serous  effusion,  had  nearly  disappeared.  No  post-mortem 
examinations,  so  far  as  I  am  aware,  have  yet  revealed  the  state  of  the  brain 
and  its  meninges  in  those  who  have  had  this  malady  at  some  former  time 
and  have  fully  recovered,  whether  there  may  not  be  some  traces  of  it  Avhich 
are  permanent,  as  opacity  or  adhesions. 

The  remarks  made  in  reference  to  the  cerebral  apply,  for  the  most  part, 
also  to  the  spinal  meninges.  There  is  at  first  intense  hypersemia  of  the 
membranes,  usually  over  the  entire  surface  of  the  cord,  soon  folk)wcd  by 
fil)riu(jus,  purulent,  and  serous  exudation  in  the  meshes  of  the  pia  mater 
and  underneath  this  membrane.  This  exudation  is  sometimes  confined  to  a 
portion  of  the  meninges,  more  fre(juently  that  covering  the  posterior  than 
the  anterior  aspect  of  the  cord,  and  when  it  is  general  it  is  ordinarily  thicker 
posteriorly  than  anteriorly.  In  severe  cases  nearly  or  quite  the  entire  spinal 
pia  mater  may  be  infiltrated  by  inflammatory  products.  Thus,  in  tlie  case 
of  an  infant  that  died  of  cerebro-spinal  fever  at  the  age  of  ten  weeks,  in  the 

^  American  .Journal  of  the  Medical  Sciences,  July,  1866. 


544  CEEEBRO-SPIXAL    FEVER. 

service  of  Dr.  H.  D.  ChajDin,  in  the  out-door  department  at  Bellevue,  the 
entire  sj)inal  cord  was  covered  by  a  fibrino-purulent  exudation,  except  a 
space  about  six  lines  in  extent  upon  the  anterior  surface. 

jSTo  constant  or  uniform  lesions  occur  in  the  organs  of  the  trunk,  and 
those  observed  are  not  distinctive  of  this  disease.  Hypostatic  congestion 
of  the  lungs,  bronchitis,  atelectasis,  and  broncho-pneumonia  are  common. 
Pleuritic,  endocardial,  and  pericardial  inflammations  have  occasionally  been 
observed,  but  are  rare.  Effusion  of  serum,  sometimes  blood-stained,  occia- 
sionally  occurs  in  the  pleural  and  other  serous  cavities.  The  auricles  and 
ventricles  of  the  heart,  as  already  stated,  contain  more  or  less  blood,  with 
soft  dark  clots  in  the  more  malignant  and  rapidly  fatal  cases,  but  larger  and 
firmer  in  those  which  have  been  more  protracted.  The  spleen  is  enlarged 
in  less  than  half  the  patients.  The  absence  of  uniformity  as  regards  the 
state  of  the  spleen,  the  fact  that  in  many  it  undergoes  no  appreciable  change, 
is  important,  since  this  organ  is  so  generally  enlarged  and  softened  in  the 
infectious  diseases.  The  stomach,  intestines,  and  liver  are  sometimes  more 
or  less  congested,  but  in  other  cases  their  appearance  is  normal.  The 
agminate  and  solitary  glands  of  the  intestines  have  ordinarily  been  over- 
looked, but  in  certain  cases  they  have  been  found  prominent.  The  kidneys 
are  normal,  or  they  exhibit  the  lesions  of  nephritis.  In  one  of  eight  autop- 
sies made  by  Prof.  AVelch  acute  diffuse  nephritis  had  been  present,  as  shown 
by  the  state  of  the  kidneys.  In  the  case  of  a  child  of  nine  years,  treated 
by  Dr.  F.  A.  Burrall,  in  the  Presbyterian  Hospital,  the  urine  was  very  albu- 
minous and  the  kidneys  presented  a  fatty  appearance.  Anatomical  changes 
in  these  organs,  however,  are  not  common,  unless  in  slight  degree,  so  that  in 
most  patients  their  function  is  fully  and  properly  performed. 

Prognosis. — Cerebro-spinal  fever  is  justly  regarded  as  one  of  the  most 
dangerous  maladies  of  childhood.  It  is  dreaded  not  only  on  account  of  the 
great  mortality  w^hich  attends  it,  but  also  on  account  of  its  pi'otracted  course, 
the  suffering  which  it  causes,  the  possible  permanent  injury  of  the  important 
organ  which  is  chiefly  involved,  and  the  not  infrequent  irreparable  damage 
which  the  eye  and  ear  sustain. 

I  have  the  records  of  the  jcesult  in  fifty-two  cases  which  I  attended  or 
saw  in  consultation  in  the  epidemic  of  1872.  Of  these  just  one-half  re- 
covered. Sixteen  of  the  twenty-six  who  died  were  hopelessly  comatose 
within  the  first  seven  days,  most  of  them  dying  within  that  time,  and  some 
even  on  the  first  and  second  days,  while  others  of  the  sixteen  lingered  into 
the  second  week  and  died  without  any  sign  of  returning  consciousness.  The 
remaining  ten,  who  subsequently  died,  but  did  not  become  comatose  in  the 
first  week,  were  nevertheless  seriously  sick  from  the  first  day,  but  their 
symptoms,  though  severe,  were  not  siich  as  necessarily  indicated  a  fatal 
result,  so  that  there  was  some  expectation  of  a  favorable  ending  till  near 
death,  which  occurred  for  the  most  part  from  asthenia.  One  succumbed  to 
purpura  hsemorrhagica,  the  hemorrhages  occurring  from  the  mucous  sur- 
faces.   The  patient  died  after  a  sickness  of  more  than  two  months,  in  a  state 


CEREBEO-SPIXAL    FEVER.  545 

of  extreme  emaeiatiou  and  prostration.  The  twenty-six  who  recovered  con- 
valesced slowly,  and  usually  after  many  fluctuations.  Their  highest  tem- 
perature and  most  severe  and  dangerous  symptoms  occurred  in  the  first 
week.  Most  of  them  were  several  weeks  under  observation  and  treatment 
before  they  sufiiciently  recovered  to  be  out  of  danger.  The  statistics  of 
this  epidemic  therefore  show,  and  the  same  is  true  of  other  epidemics,  that 
the  first  week  is  the  time  of  greatest  danger,  and  if  no  fatal  symptoms  are 
developed  during  this  week  recovery  is  probable  with  proper  therapeutic 
measures  and  kind,  intelligent,  and  efficient  nursing,  which  is  very  important. 

Since  1872  I  have  seen  a  larger  number,  but  have  preserved  records  of 
thirty-eight  cases  which  I  was  able  to  follow  to  the  close.  Some  were  seen 
in  consultation.  Of  these  thirty-eight,  twenty  recovered  and  eighteen  died. 
Of  the  eighteen  fatal  cases,  nine  died  in  the  first  week,  five  in  the  second 
week,  one  on  the  twenty-fifth  day,  one  on  the  thirty-first  day,  and  one  in 
the  sixteenth  week.  This  last  patient,  a  boy  of  ten  years,  would,  in  my 
opinion,  have  recovered  with  better  nursing.  His  death  occurred  from  large 
bed-sores  which  extended  to  the  bones,  produced  by  lying  a  long  time  in 
one  position  on  a  hard  bed,  when  he  was  too  weak  to  move,  and  often  with 
soiled  bedclothes  underneath  him.  The  remaining  case  of  the  eighteen 
died  after  a  prolonged  sickness. 

There  is  probably  no  disease  which  falsifies  the  predictions  of  the 
physician  more  frequently  than  cerebro-spinal  fever.  This  is  due  partly  to 
the  severity  of  the  cerebral  symptoms  in  the  commencement,  which,  did 
they  occur  in  other  forms  of  meningitis  with  which  he  is  more  familiar, 
would  justify  an  unfavorable  prognosis,  and  partly  to  the  remissions  and 
exacerbations,  the  occurrence  alternately  of  symptoms  of  apparent  con- 
valescence and  recrudescence  or  relapse,  which  characterize  the  course  of 
this  malady.  Grave  initial  symptoms,  which  may  appear  to  have  a  fatal 
augury,  are  often  followed  by  such  a  remission  that  all  danger  seems  past, 
and  in  a  few  hours  later,  perhaps,  the  symptoms  are  nearly  or  quite  as  grave 
as  at  first. 

Under  the  age  of  five  years  and  over  that  of  thirty  the  prognosis  is 
less  favorable  than  between  these  ages.  An  abrupt  and  violent  commence- 
ment, profound  stupor,  convulsions,  active  delirium,  and  great  elevation  of 
temperature  are  symptoms  which  should  excite  solicitude  and  render  the 
prognosis  guarded.  If  tlie  temperature  remain  above  105°  F.,  death  is 
probable,  even  with  moderate  stupor.  Numerous  and  large  petechial  erup- 
tions show  a  profoundly  altered  state  of  the  blood,  and  are  therefore  a  bad 
prognostic,  and  so  is  continued  albuminuria,  since  it  shows  great  blood- 
change,  or  nephritis,  while  other  organs  than  the  kidneys  are  probably  also 
involved.  In  one  case,  a  boy,  whom  I  examined  nearly  a  year  after  the 
cerebro-spinal  fever,  the  kidneys  were  still  affected.  He  had  anasarca  of 
the  face  and  extremities,  with  albuminuria.  Clironic  Bright's  disease  had 
occurred  from  tlie  acute  ncpliritis  wliich  complicated  cerebro-spinal  fever. 
Profound  stupor,  thougli  a  dangerous  symptom,  is  not  necessarily  fatal  so 
Vol.  I.— C.3 


546  CEREBRO -SPINAL   FEVER. 

long  as  the  patient  can  be  aroused  to  partial  consciousness  and  the  pupils 
are  responsive  to  light ;  so  long  as  it  does  not  pass  into  actual  coma  it  is 
less  dangerous  than  active  or  maniacal  delirium,  which  is  likely  to  eventuate' 
in  this  coma. 

A  mild  commencement,  with  general  mildness  of  symptoms,  as  the 
ability  to  comprehend  and  answer  questions,  moderate  pain  and  muscular 
rigidity,  some  appetite,  moderate  emaciation,  little  vomiting,  etc.,  justify  a 
favorable  prognosis,  but  even  in  such  cases  it  should  be  guarded  till  conva- 
lescence is  fully  established. 

We  may  repeat  and  emphasize  the  important  fact  shown  by  the  above 
statistics,  that  patients  wlio  live  till  the  close  of  the  second  week  without 
serious  complications  will  probably  recover.  The  danger  after  this  period 
is,  in  most  instances,  from  exhaustion  and  feeble  action  of  the  heart,  result- 
ing from  the  impaired  nutrition  and  the  protracted  course  of  the  disease. 

Complications,  which  most  frequently  pertain  to  the  lungs,  increase 
greatly  the  gravity  of  many  cases  and  contribute  to  the  fatal  ending.  The 
fact  that  Webber,  in  his  prize  essay,  describes  a  variety  of  cerebro-spinal 
fever  which  he  designates  pneumonic,  and  that  those  who  make  post-mortem 
examinations  find  that  "oedema,  hypostatic  congestion  of  the  lungs,  bron- 
chitis, atelectasis,  and  broncho-pneumonia  are  extremely  common  lesions  in 
cerebro-spinal  meningitis"  (Welch),  indicates  a  source  of  danger  in  addition 
to  that  located  in  the  cerebro-spinal  system.  One  close  observer  of  an 
epidemic  writes,  "  In  all  the  fatal  cases  which  came  under  my  notice,  the 
most  prominent  symptoms  which  preceded  death  were  those  which  indicate 
impairment  and  perversion  of  the  respiratory  functions.  As  the  breathing 
became  more  hurried  and  difficult,  the  general  depression  became  more  in- 
tense, the  pulse  became  weaker  and  quicker,  and  the  temperature  of  the  skin 
more  elevated." 

Parenchymatous  degeneration  of  the  liver  and  kidneys  is  another  serious 
complication.  The  kidneys  are  probably  more  frequently,  and  to  a  greater 
extent,  diseased  tlian  the  liver.  We  have  already  stated  that  nephritis  was 
present  in  one  qf  the  eight  cases  examined  by  Prof.  Welch.  In  the  Revue 
Medicals  for  Jnne  3, 1882,  M.  Ernest  Gaudier  published  the  case  of  a  female 
who  died  comatose  on  the  sixth  day  of  cerebro-spinal  fever.  Examination 
of  the  urine  had  revealed  the  presence  of  "retractile  albumen  of  Prof. 
Bouchard,  attributable  to  renal  lesions,  and  non-retractile  albumen,  consid- 
ered as  an  indication  of  some  general  infection  of  the  system."  Microscopic 
examination  of  the  kidneys  "  showed  considerable  swelling  and  granular 
degeneration  of  the  renal  epithelial  cells,  with  effusion  of  granular  matter 
within  the  lumina  of  the  tubules."  We  have  seen  from  the  case  referred  to 
above  that  the  renal  complication  may  persist  and  become  chronic.  Those 
who  fully  recover  often  exhibit  symptoms  usually  of  a  nervous  character, 
as  irritability  of  disposition,  headache,  etc.,  for  months  or  years  after  con- 
valescence is  established. 

Diag-nosis. — Cerebro-spinal  fever,  on  account  of  the  nature  and  severity 


CEREBEO-SPINAL   FEVER.  547 

of  its  symptoms  and  tlie  suddenness  of  its  onset,  may  be  mistaken  for 
scarlet  fever,  and  vice  versd.  In  one  instance,  to  my  knowledge,  this  mis- 
take was  made.  High  febrile  movement,  vomiting,  convulsions,  and  stupor 
are  common  in  the  commencement  of  scarlet  fever,  and  the  same  symptoms 
commonly  usher  in  the  severer  forms  of  cerebro-spinal  fever.  It  will  aid 
in  diagnosis  to  ascertain  whether  there  be  redness  of  the  fauces,  for  this  is 
present  in  the  commencement  of  scarlet  fever,  and  a  few  hours  later  the 
characteristic  efflorescence  appears  on  the  skin. 

The  diagnosis  of  cerebro-spinal  fever  from  the  common  forms  of  menin- 
gitis is  ordinarily  not  difficult,  for  while  in  the  former  the  maximum  in- 
tensity of  symptoms  occurs  in  the  first  days,  in  the  latter  there  is  a  gradual 
and  progressive  increase  of  symptoms,  from  a  comparatively  mild  com- 
mencement. Moreover,  cases  of  ordinary  or  sporadic  meningitis  occurring 
at  the  age  when  cerebro-spinal  fever  is  most  frequent  are  commonly  second- 
ary, being  due  to  tubercles,  caries  of  the  petrous  portion  of  the  temporal 
bone,  or  other  lesion,  and  are  therefore  preceded  and  accompanied  by  symp- 
toms which  are  directly  refemble  to  the  primary  disease.  We  have  seen 
how  different  it  is  in  cerebro-spinal  fever,  which  in  most  patients  begins 
abruptly  in  a  state  of  previous  good  health.  Again,  in  cerebro-spinal  fever, 
afler  the  second  or  third  day,  hypersesthesia,  retraction  of  the  head,  and 
other  characteristic  symptoms  occur,  which  are  either  not  present  or  arc 
much  less  pronounced  in  ordinary  meningitis.  Some  of  the  milder  cases 
of  cerebro-spinal  fever  might  be  mistaken  for  hj^steria,  but  the  pain  in  the 
head  and  elsewhere,  the  muscular  rigidity,  and  especially  the  occurrence  of 
more  or  less  febrile  movement,  enable  us  to  make  the  diagnosis.  Continued 
fever,  typhus  or  typhoid,  resembles  cerebro-spinal  fever  in  certain  particu- 
lars, but  it  lacks  the  muscular  contraction  and  rigidity  which  characterize 
the  latter.  It  does  not  usually  begin  so  abruptly,  with  such  severe  symp- 
toms, especially  such  severe  headache,  has  less  marked  fluctuations,  and  a 
more  definite  duration.  These  facts,  in  connection  with  the  character  of  the 
prevailing  epidemics,  will  enable  us  to  make  the  diagnosis.  In  one  instance 
commencing  retro-pharyngeal  abscess,  probably  associated  wdth  vertebral 
caries,  was  at  first  mistaken  by  me  for  cerebro-spinal  fever.  The  patient 
was  an  infant,  had  a  temperature  of  104°  F.,  stiffness  of  the  neck  with  some 
retraction  of  the  head,  imd  cried  from  pain  when  the  head  was  brought  for- 
ward. The  speedy  occurrence  of  two  large  abscesses  in  other  parts  of  the 
system,  difficult  deglutition,  and  noisy  respiration,  led  to  a  digital  exploration 
of  the  fauces,  when  the  abscess  was  found  and  opened. 

Treatment. — Since  in  epidemics  of  cerebro-spinal  fever  cases  are  more 
frequent  and  severe  where  anti-hygienic  conditions  exist,  it  is  evident  that 
measures  looking  to  the  removal  of  such  conditions,  measures  designed  to 
procure  pure  air  in  the  domicile,  wholesome  diet,  and  a  quiet  and  regular 
mode  of  life, — in  fine,  measures  designed  to  produce  the  highest  degree  of 
health, — are  of  the  first  importance  for  the  prevention  of  the  disease. 
Cleanliness  of  the  streets  and  areas,  as  well  as  of  the  apartments,  good 


548  CEEEBRO-SPINAL   FEVER, 

sewerage  and  drainage,  the  prompt  removal  of  all  refuse  matter,  avoidance 
of  overcrowding, — in  a  word,  the  strict  observance  of  sanitary  requirements 
in  every  particular, — will,  there  can  be  little  doubt  from  what  we  know 
of  the  causation  and  nature  of  cerebro-spinal  fever,  diminish  the  number 
and  severity  of  the  cases.  The  avoidance  of  fatigue  and  overwork  and  of 
mental  excitement,  the  use  of  plain  and  wholesome  diet,  sufficient  sleep,  the 
utmost  regularity  in  the  mode  of  life,  with  the  least  possible  exposure  to 
depressing  agencies,  are  the  important  preventive  measures  which  should  be 
recommended  during  an  epidemic  of  cerelDro-spinal  fever. 

The  enjoining  of  a  quiet  and  regular  mode  of  life  as  a  preventive 
measure,  during  the  occurrence  of  an  epidemic  of  cerebro-spinal  fever,  is 
not  inconsistent  with  the  theory  that  the  cause  is  a  micro-organism.  It  is 
not  unreasonable  to  suppose  that  the  system  may  be  more  or  less  under  the 
influence  of  the  specific  principle,  and  that  this  principle  may  obtain  lodge- 
ment in  the  blood  or  tissues  without  result  until  some  exciting  cause  occurs 
whicli  depresses  the  system  and  disturbs  the  functions,  when  the  resisting 
power  fails  and  cerebro-spinal  fever  appears  ;  just  as  those  exposed  to 
Asiatic  cholera  may  remain  well  until  some  imprudence  in  the  diet  or  the 
mode  of  life  causes  an  outbreak  of  the  malady. 

Curative  Treatment. — In  the  commencement  of  cerebro-spinal  fever, 
intense  inflammatory  congestion  occurs  of  the  cerebral  and  spinal  mejiinges, 
and  also  to  a  certain  extent  of  the  brain  and  spinal  cord.  As  regards  treat- 
ment, the  obvious  indication  is  to  reduce  the  hyper?emia  of  the  vessels  as 
quickly  as  possible  and  subdue  or  diminish  the  inflammation.  For  this 
purpose  bags  or  bladders  of  ice  should  be  immediately  applied  over  the 
head  and  to  the  nucha,  and  constantly  retained  there  as  long  as  there  is 
no  complaint  of  chilliness,  no  marked  diminution  of  temperature,  and  the 
patient  experiences  some  relief  from  the  intense  headache  and  other  symp- 
toms. Bran  mixed  with  pounded  ice  produces  a  more  uniform  coldness 
and  is  sometimes  more  agreeable  to  the  patient  than  the  ice  alone.  The 
bag  or  bags  should  be  about  one-third  full,  so  as  to  fit  upon  the  head  like 
a  cap,  and  the  nurse  should  be  instructed  to  renew  the  ice  as  soon  as  it 
melts.  In  severe  cases,  with  marked  elevation  of  temperature,  it  is  proper 
to  apply  cold  over  the  dorsal  and  lumbar  vertebr£e,  as  well  as  upon  the  head 
and  nuclia.  A  hot  mustard  foot-bath  or  a  general  warm  bath  in  those  cases 
in  which  convulsions  are  present  or  threatening,  or  in  which  there  is  de- 
lirium or  great  agitation  or  severe  peripheral  pains,  is  also  useful,  since  it 
has  a  calmative  effect  and  acts  as  a  derivative  from  the  hypersemic  nerve- 
centres.  One  writer  states  that  he  obtained  marked  benefit  in  a  case  by 
immersing  the  body  to  the  neck  in  hot  water. 

Tlie  abstraction  of  blood,  usually  by  leeches  applied  to  the  temples, 
behind  the  ears,  or  along  the  spine,  has  been  employed,  but  even  in  the 
commencement  of  the  present  century,  when  it  was  customary  to  bleed  gen- 
erally and  locally  in  the  treatment  of  inflammatory  and  febrile  diseases,  a 
majority  of  the  American  physicians  whose  writings  are  extant  discoun- 


CEREBEO-SPINAL    FEVER.  549 

teuanced  the  use  of  such  measures  iu  the  treatmeut  of  this  disease.  Drs. 
Strong,  Foot,  and  Miner,  though  under  the  influence  of  the  Broussaian 
doctrine,  were  good  observers,  and  they  soon  abandoned  the  use  of  the  lancet 
and  leeches  iu  the  treatmeut  of  these  patients  for  more  sustaining  measures. 
Strong  ^  states  that  certain  physicians  employed  venesection  as  a  means  of 
relieving  the  internal  congestions,  but,  finding  that  the  pulse  became  more 
frequent  after  a  moderate  loss  of  blood,  they  soon  laid  aside  the  lancet. 
Some  experienced  physicians  of  that  period,  however,  continued  to  recom- 
mend and  practise  depletion,  general  as  well  as  local,  as,  for  example,  Dr. 
Gallop,  who  treated  many  cases  in  Vermont  in  the  epidemic  of  1811. 

Venesection  in  the  treatment  of  cerebro-spinal  fever  is  universally  dis- 
carded at  the  present  time  in  this  country  and  Europe,  but  some  intelligent 
physicians,  as  Sanderson  and  Niemeyer,  approve  of  local  bleeding  in  certain 
cases.  It  is,  iu  my  opinion,  after  examining  the  histories  of  many  cases, 
uncertain  whether  the  abstraction  of  blood  should  ever  be  recommended, 
but  if  it  be  prescribed  it  should  be  on  the  first  day,  when  the  hyperemia  is 
greatest,  by  the  application  of  only  a  few  leeches  behind  the  ears,  and  never 
except  w^ien  coma  or  convulsions  are  present  or  threatening  and  the  patient 
is  robust.  The  fact  should  not  be  forgotten  that  cerebro-spinal  fever  is  in 
its  nature  asthenic  and  protracted,  and  that  the  intense  inflammatory  con- 
gestion of  the  nervous  centres  can  ordinarily  be  relieved,  if  relieved  at  all, 
by  the  other  measures  recommended,  which  do  not  reduce  the  strength.  The 
alarming  symptoms  which  usher  in  an  attack,  the  intense  headache,  restless- 
ness, delirium,  sometimes  eclampsia  or  coma,  seem  to  demand  the  most  ener- 
getic treatment,  and  yet  it  is  surprising  to  one  who  has  his  first  experiences 
with  this  malady  how  patients  under  proper  treatment,  without  the  ab- 
straction of  blood,  emerge  from  an  apparently  almost  hopeless  state  and 
ultimately  recover.  There  may  be  total  unconsciousness,  the  pupils  dilated 
like  rings  and  insensible  to  light,  the  head  intensely  hot,  tonic  convulsions 
present  or  alternating  with  frequent  clonic  convulsions,  and  yet  these  symp- 
toms, which  in  any  other  disease  would  be  regarded  as  sufficient  to  justify 
the  prognosis  of  certain  death,  may  gradually  pass  off  towards  the  close  of 
the  first  or  in  the  second  week,  and  the  case  afterwards  progress  favorably. 
In  the  New  York  epidemic  of  1872,  previous  to  which  physicians  of  this 
city  had  no  personal  experience  with  cerebro-spinal  fever,  many  cases  w^ere 
pronounced  hopeless  which  ultimately  did  well  without  abstraction  of  blood. 
In  a  case  occurring  in  the  ju-actice  of  Dr.  Griswold  the  patient  was  comatose 
for  three  days,  with  pupils  not  responding  or  but  very  feebly  responding 
to  light,  but  he  recovered  without  the  abstraction  of  blood,  and  Avith  the 
remedies  ordinai'ily  employed.  In  a  case  which  wc  will  ]iresently  relate  in 
speaking  of  another  local  treatment,  the  patient  was  still  insensible  in  the 
third  week,  witii  pupils  greatly  dilated  and  insensible  to  light,  and  yet  re- 
covered without  losing  blood.     Such  cases  show  that  the  most  urgent  symp- 

'  Medical  and  Physiological  Kegister,  1811. 


550  CEEEBRO-SPINAL   FEVEE. 

fcoms,  such  as  seem  to  indicate  the  prompt  employment  of  leeches  in  order 
to  reduce  the  meningeal  hypersemia  and  the  consecutive  congestion  of  the 
nerve-centres,  may  be  relieved  and  the  patient  recover  without  such  deple- 
tion, and  with  the  preservation  of  the  blood,  which  is  so  much  needed  in 
the  subsequent  asthenic  course  of  the  malady. 

In  only  one  case  have  I  recommended  the  abstraction  of  blood,  and  this 
was  so  instructive  that  I  will  briefly  relate  it.  A  girl,  four  years  of  age, 
was  seized  on  March  7,  1873,  with  vomiting,  chilliness,  and  trembling, 
followed  by  severe  general  clonic  convulsions  lasting  about  fifteen  minutes; 
was  semi-comatose;  pulse  132,  and  a  few  hours  later,  156;  temperature 
101  J°  F. ;  respiration  44 ;  eyes  closed,  pupils  moderately  dilated  and  feebly 
responsive  to  light,  dusky  mottling  of  skin,  constant  tremulousness  with 
twitching  of  limbs.  Bromide  of  potassium  was  administered  in  hourly 
doses  of  four  grains,  ice  applied  to  the  head  and  nucha,  and  a  hot  mustard 
foot-bath  followed  by  sinapisms  to  the  nucha.  On  the  following  day, 
March  8,  she  was  partly  conscious,  when  aroused,  but  immediately  relapsed 
into  sleep,  head  retracted,  bowels  constipated ;  pulse  136  ;  temperature  102°  ; 
vomited  occasionally.  It  was  thought  proper,  on  account  of  the  extreme 
stupor,  to  apply  one  leech  to  each  temple,  and  the  bites  trickled  slowly 
nearly  five  hours.  The  other  treatment  was  continued.  On  the  9th  the 
pulse  was  180,  so  feeble  that  it  was  counted  with  difficulty;  temperature 
101J°.  The  patient  was  evidently  sinking.  It  was  necessary  to  order 
whiskey  in  teaspoonful  doses  every  two  hours,  with  beef  tea  and  other 
most  nutritious  drinks.  Evening,  pulse  172,  still  feeble.  March  10,  pulse 
180,  barely  perceptible;  great  hypersesthesia ;  axillary  temperature  100°; 
axes  of  eyes  directed  downward.  After  this  the  patient  gradually  rallied 
for  a  time,  the  pulse  becoming  stronger  and  less  frequent,  but  death  finally 
occurred  after  nine  weeks  in  a  state  of  extreme  emaciation  and  exhaustion. 
Slight  convulsions  occurred  in  the  last  hours. 

It  is  seen  that  in  the  above  case,  which  may  be  regarded  as  typical,  the 
patient  passed  into  a  state  of  extreme  prostration  after  the  application  of 
the  leeches,  so  that  for  three  days  1  did  not  believe  that  she  would  live 
from  hour  to  hour,  and  death  occurred  after  an  illness  of  nine  weeks, 
apparently  from  sheer  exhaustion.  Experience  like  this,  which  corresponds 
with  that  of  most  other  observers,  shows  the  necessity  of  preserving  the 
blood  and  thereby  the  strength,  however  urgent  the  initial  symptoms,  inas- 
much as  cerebro-spinal  fever  in  its  subsequent  course  is  attended  by  such 
marked  asthenia.  On  May  3,  1878,  a  boy  of  ten  years  was  admitted  into 
one  of  our  best  hospitals,  in  the  service  of  a  prominent  New  York  physician. 
It  was  stated  that  he  had  been  four  days  sick  with  cerebro-spinal  fever,  and 
among  other  characteristic  symptoms  he  had  had  delirium  every  night  and 
on  May  2  delirium  in  the  daytime,  which  had  abated  considerably  after 
free  epistaxis.  In  the  hospital  the  application  of  ten  leeches  along  the 
spine  was  ordered,  but  it  does  not  appear  to  have  diminished  the  delirium 
or  any  other  symptom,  and  on  the  folloAviug  day  the  pulse  was  so  frequent 


CEREBRO-SPINAL   FEVER.  551 

and  feeble  that  active  stimulation  by  brandy  was  resorted  to.  He  had  three 
strong  convulsions  on  May  13,  Avliich  were  relieved  by  ice  to  the  head  and 
nape  of  neck,  and  by  six  minims  of  Magendie's  solution.  Severe  pains 
occurred  at  times  in  the  back  and  limbs,  and  on  the  29th,  one  month  after 
the  commencement  of  the  disease,  the  same  pain  frequently  recurring,  twelve 
leeches  were  ordered  to  be  applied  to  the  spine.  On  June  2  the  limbs  were 
flexed  and  quite  stiff,  and  the  effort  to  move  them  was  attended  by  great 
pain.  The  pain  in  the  back  was  also  more  constant,  and  in  consequence 
sixteen  leeches  were  applied  to  the  spine.  The  next  day  there  was  no  pain, 
but  the  patient  was  very  stupid.  On  June  6  the  records  state  that  he  was 
obviously  losing  strength  day  by  day,  that  his  emaciation  was  extreme  and 
his  ansemia  very  marked.  But  he  had  great  vitality,  and,  although  he  had 
strabismus,  bed-sores,  incontinence  of  urine  and  fseces,  and  extreme  prostra- 
sion,  he  lingered  till  August  1.  At  the  autopsy,  "body  a  skeleton;  brain, 
dura  mater,  and  pia  mater  appear  normal,  except  a  little  thickening  of 
latter  at  base  of  brain  ;  ventricles  much  enlarged  and  full  of  clear  serum  ; 
surface  of  walls  of  ventricles  looks  normal,  but  is  soft ;  spinal  cord  and 
membranes  appear  normal  to  the  naked  eye."  No  disease  was  discovered 
in  other  organs,  except  that  the  liver  appeared  congested  and  the  kidneys 
pale.  It  can  scarcely  be  doubted  that,  although  some  temporary  relief  from 
the  pain  may  have  resulted  to  this  patient  by  the  repeated  application  of 
leeches,  which  diminished  the  meningeal  hyperaemia,  yet  his  chances  for 
ultimate  recovery  would  have  been  far  better  without  such  depletion. 
Therefore  the  histories  of  cases  show  that  the  result  of  abstraction  of  blood 
has  been  unsatisfactory,  on  account  of  the  asthenic  nature  and  protracted 
course  of  cerebro-spinal  fever,  and  it  should  never  be  recommended  as  a 
remedial  agent. 

Some  benefit  is  apparently  derived  from  the  application  of  stimulating 
and  moderately  irritating  lotions  along  the  spine.  A  liniment  consisting 
of  equal  parts  of  camphorated  oil  and  turpentine  briskly  applied  by  friction 
with  flannel  up  and  down  the  spine  till  redness  is  produced  appears  to  cause 
some  alleviation  of  the  suffering,  and  it  does  not  conflict  with  the  use  of 
the  ice-bag.  Dr.  William  H.  Sutton,  of  Dallas,  Texas,  has  published  the 
following  interesting  case,  showing  the  benefit  from  stimulating  and  irritant 
applications  over  the  spine  made  in  an  unusual  manner.  A  child,  aged 
three  and  one-half  years,  had  been  three  weeks  under  treatment,  througli 
error  of  diagnosis,  for  supposed  continued  fever.  When  Dr.  Sutton  assumed 
charge  of  the  case,  November  20,  1877,  tlic  ])upils  were  greatly  dilated  and 
insensible  to  light;  features  pallid  and  pinched;  pulse  130;  temperature 
103°  F. ;  })atient  totally  unconscious.  November  21,  morning  temperature 
105°,  pulse  140;  evening  temporaturc  101]^°,  pulse  120.  November  22, 
morning  temperature  106^°,  pulse  160;  restless;  evening  temperature 
105J°,  pulse  120  ;  had  not  slept,  except  for  moments,  for  nearly  two  weeks. 
A  strip  of  flannel  saturated  with  turpentine  was  placed  over  the  spine  from 
the  neck  to  the  sacrum,  and  a  hot  sniootliing-iron  was  run  up  and  down  it, 


552  CEREBRO-SPINAL    FEVER. 

and  eight  drops  of  the  fluid  extract  of  ergot  were  given  every  three  hours. 
Dr.  Sutton  adds^  "  The  father  stated  to  me  that  as  soon  as  the  apphcation 
was  finished  the  child  fell  asleep,  and  slept  several  hours, — the  first  for 
two  weeks, — and  the  fever  rapidly  declined.  From  this  time  he  began  to 
improve,  and  gradually  and  fully  recovered."  The  use  of  irritating  appli- 
cations over  the  spine  in  the  treatment  of  cerebro-spinal  fever  has  been  long 
and  favorably  known,  but  the  mode  of  applying  it  practised  in  the  above 
case  is  novel. 

Internal  Treatment. — It  will  aid  in  the  selection  of  the  proper  reme- 
dies to  recall  to  mind  the  pathological  state  which  Ave  know  to  be  present 
from  the  many  autopsies  which  have  been  recorded.  We  have  seen  that  the 
largest  mortality,  and  consequently  the  most  dangerous  period,  is  in  the  first 
days,  when  there  is  intense  suddenly-developed  inflammatory  congestion  of 
the  meninges,  with  more  or  less  secondary  hyperasmia  of  the  underlying 
brain  and  spinal  cord,  producing  great  headache,  delirium,  or  somnolence, 
with  exaggerated  reflex  irritability  of  the  spinal  cord,  so  that  eclampsia  is  a 
common  and  fatal  complication. 

Fortunately,  a  remedy  has  been  discovered  in  modern  times,  the  bromide 
of  potassium,  which  acts  promptly  and  efficiently.  It  can  be  safely  admin- 
istered in  large  and  frequent  doses  to  the  youngest  child.  It  is  quickly 
eliminated  from  the  system  through  the  kidneys  and  other  emunctories  in 
children,  so  as  to  prevent  the  occurrence  of  bromism,  at  least  to  the  extent 
of  causing  any  unpleasant  consequences.  It  causes  contraction  of  the 
minute  vessels  of  the  nervous  centres  so  as  to  diminish  the  hypersemia,  as 
shown  by  the  experiments  and  observations  of  Dr.  Putnam-Jacobi  and 
others,  and  at  the  same  time  it  diminishes,  in  a  marked  degree,  the  reflex 
irritability  of  the  spinal  cord,  two  most  beneficial  and  important  effects  of 
its  use  in  this  disease.  Many  children  by  its  timely  employment  are  saved 
from  the  dangers  of  eclampsia,  and  by  its  sedative  effect  on  the  nervous 
system  and  contractile  action  on  the  capillaries  it  probably  diminishes  the 
intensity  of  the  inflammation  and  the  amount  of  exudation.  I  usually  pre- 
scribe it,  as  recommended  by  Dr.  Squibb^  dissolved  in  simple  cold  water.  In 
ordinary  cases  not  attended  by  eclampsia  or  marked  symptoms  which  show 
that  eclampsia  is  threatening,  I  generally  prescribe  at  my  first  visit  about 
four  grains  every  two  hours  to  a  child  of  two  years  wlio  has  the  usual  rest- 
lessness and  apparent  headache,  and  six  grains  to  a  child  of  five  years.  If 
eclampsia  occur,  the  bromide  should  be  given  more  frequently,  as  every  five 
or  ten  minutes,  till  it  ceases.  It  is  important  to  be  able  to  determine  when 
the  quantity  of  the  bromide  administered  should  l>e  diminished,  and  when 
its  use  should  be  discontinued.  I  have  very  rarely  observed  bromism  in 
children,  and  never  to  the  extent  of  doing  any  serious  harm,  though  for 
many  years  I  have  administered  it  in  lai'ge  and  frequent  doses  whenever  the 
occasion  seemed  to  require  it ;  but  the  symptoms  of  bromism  cannot  readily 
be  discriminated  from  those  wliich  may  result  from  cerebro-spinal  fever, 
Buch  as  muscular  weakness,  dilated  pupils,  with  perhaps  impaired  vision, 


te*' 


CEREBEO-SPINAL    FEVER.  553 

unsteady  gait,  nausea  or  vomiting,  and  abdominal  pains.  If  the  case  pro- 
gress favorably,  frequent  and  large  doses  should,  in  my  opinion,  be  given 
only  in  the  first  week,  after  which  this  agent  should  be  given  at  longer  in- 
tervals, or  in  smaller  doses.  But  during  exacerbations,  which  are  liable  to 
occur  from  time  to  time  till  the  patient  is  well  on  the  M^ay  to  recovery,  the 
use  of  the  bromide  in  full  doses  is  again  indicated  till  the  urgent  symptoms 
begin  to  abate. 

Antipyrin  promises  also  to  be  another  useful  remedy  in  this  disease, 
from  its  well-known  action  in  relieving  headache,  reducing  fever,  and  pro- 
curing sleep.  It  may  be  administered  with  the  bromide.  It  appears  to  be 
a  very  useful  adjuvant  to  the  bromide  during  the  first  week,  when  the  tem- 
perature is  most  elevated  and  the  headache  severe.  At  a  later  stage^  when 
asthenic  symptoms  are  more  pronounced,  its  use  appears  to  be  contra-indi- 
cated, unless  in  exceptional  instances. 

Ergot  is  another  very  important  remedy.  It  is  scarcely  less  useful  than 
the  bromide,  from  its  action  in  contracting  the  arterioles  and  diminishing 
the  flow  of  arterial  blood.  The  fluid  extract,  tincture,  or  wine  of  secale 
cornutum  can  be  employed,  or  its  active  principle  ergotin.  In  New  York 
City,  Squibb's  fluid  extract  has  been  more  used  than  any  other  preparation. 
I  have  commonly  prescribed  it  except  for  patients  old  enough  to  take  ergo- 
tin  in  the  pill.  The  doses  employed  by  diflerent  physicians  vary  greatly. 
Dr.  William  A.  Thomson,  Professor  of  Materia  Medica  in  the  New  York 
University,  has  prescribed,  so  far  as  I  am  aware,  the  largest  doses  in  the 
treatment  of  this  disease, — to  wit,  one  teaspoonful  of  the  flui<l  extract  of 
secale  cornutum  every  three  hours,  to  a  boy  of  ten  years  in  Roosevelt  Hos- 
pital in  1878,  with  apparent  benefit  as  regards  the  meningeal  hyperajmia, 
although  the  case  was  fatal  after  the  lapse  of  several  mouths  from  asthenia. 
The  alkaloid  ergotin,  to  which  the  beneficial  effects  of  the  secale  cornutum 
are  due,  may  be  given  in  the  pill  or  in  solution.  In  case  of  much  irri- 
tability of  the  stomach  it  can  be  employed  hypodermically,  dissolved  in 
water  with  glycerin.  The  efficacy  of  this  agent  is  most  marked  during 
the  first  and  second  weeks,  when  the  congestion  of  the  nervous  centres  is 
greatest.  At  a  more  advanced  stage,  when  there  is  less  congestion  and  the 
danger  arises  from  the  inflammatory  products  and  structural  changes,  the 
time  for  the  use  of  ergot  is  past,  or  if  it  is  still  of  some  service  it  is  less 
needed  than  at  first  and  should  be  given  less  frequently. 

The  severe  headache  and  restlessness  which  attend  many  cases  require 
the  occasional  use  of  an  opiate,  or  the  hydrate  of  chloral.  Chloral  in  proper 
dose  never  fiiils  to  give  quiet  sleep,  and  it  is  supjiosod  by  some  who  have 
studied  its  therapeutic  action  that  it  diminishes  the  cerebral  circulation.  It 
is  therefore  a  useful  adjuvant  to  the  bromide.  Five  grains  usually  suffice 
for  a  child  of  six  to  eight  years.  Cldoral  is  especially  useful  in  cases  at- 
tended by  eclampsia,  or  by  symptoms  which  threaten  eclampsia,  since  it  acts 
promptly  and  decidedly  in  diminishing  reflex  irritability.  Formerly  it  was 
considered  injudicious  and  unsafe  to  prescribe  opiates  in  meningeal  inflam- 


554  CEEEBRO-SPIXAL   FEVEE. 

mation^  since  it  was  supposed  that  they  increased  the  liability  to  coma,  but 
experience  shows  that  they  are  sometimes  very  useful  in  this  disease  when 
administered  in  small  or  moderate  doses,  and  without  the  risk  which  was 
once  supposed  to  be  incurred  by  their  use.  The  thirty-second  part  of  a 
grain  of  morphia  administered  at  intervals  of  some  hours  was  sufficient  to 
relieve  the  suffering  of  one  of  my  patients  at  the  age  of  six  years. 

Quinia  apparently  does  not  exert  any  marked  controlling  effect  on  the 
course  of  cerebro-spinal  fever  or  its  symptoms,  although  the  paroxysmal 
character  of  the  severe  pains  in  many  patients  suggests  the  use  of  this  agent 
as  an  antiperiodic.  It  was  frequently  prescribed  by  New  York  physicians 
in  the  epidemic  of  1872,  but  I  believe  that  the  opinion  was  unanimous  that 
it  was  not  the  proper  remedy.  I  have  prescribed  it  in  large  and  small  doses, 
in  one  instance  giving  fifteen  grains  to  a  child  of  thirteen  years,  but  do  not 
know  that  I  have  derived  any  benefit  from  its  use  in  this  malady. 

When  the  acute  stage  has  abated,  measures  designed  to  remove  the 
serum  which  sometimes  remains,  constituting  a  hydrocephalus,  are  indicated. 
For  this  purpose  the  iodide  of  potassium  is  probably  more  useful  than  any 
other  agent.  It  is  administered  by  some  physicians  early,  along  with  the 
bromide,  as  they  have  been  in  the  habit  of  treating  other  forms  of  menin- 
gitis. I  have  prescribed  it  with  the  bromide,  and  alone  when  the  bromide 
was  discontinued,  but  whether  it  produces  any  marked  sorbefacient  effect  in 
this  disease  seems  to  me  doubtful. 

The  result  depends  to  a  great  extent  on  the  nursing.  The  skill  of  the 
physician  may  be  thwarted  and  the  life  of  the  patient  lost  by  inefficient 
nursing.  No  other  disease  more  urgently  requires  kind,  intelligent,  and 
constant  attendance  night  and  day  on  the  part  of  the  nurses.  Not  only 
should  the  medicines  and  nutriment  be  given  punctually  and  regularly, 
but  the  great  restlessness  of  the  patient  in  the  first  days  requires  constant 
readjusting  of  the  ice-bags,  and  during  the  long  period  of  convalescence 
the  utmost  care  is  required  to  remove  at  once  the  excretions  in  order  to 
prevent  bed-sores,  and  to  give  the  proper  amount  and  kind  of  nutriment  to 
prevent  the  emaciation  and  weakness  from  which  many  perish. 

The  diet,  from  the  beginning  to  the  end  of  the  malady,  should  be  the 
most  nutritious,  and  such  as  is  easily  digested.  It  is  necessary  to  give  it 
in  the  liquid  form,  unless  in  mild  cases  in  which  the  appetite  may  not  be 
entirely  lost.  It  is  proper  to  aid  the  digestion  by  pepsin  preparations. 
Nutritive  enemata,  consisting  of  beef  tea,  or  one  of  the  extracts  of  beef,  milk, 
and  brandy,  aid  in  averting  the  fatal  prostration  in  protracted  cases.  After 
the  acute  stage  has  passed  and  the  meningeal  hyperremia  has  abated,  the 
alcoholic  compounds  in  moderate  doses,  which  in  the  beginning  would  be 
very  injurious,  may  now  be  useful,  administered  regularly  by  the  mouth. 
The  room  should  be  dark,  well  ventilated,  and  quiet.  All  sympathizing 
friends  who  are  not  required  in  the  nursing  should  be  excluded.  I  know 
no  other  disease  in  which  this  is  so  necessary,  for  mental  excitement  may 
produce  dangerous  aggravation  of  symptoms. 


SCARLET   FEVER. 

By  SAMUEL  C.  BUSEY,  M.D.,  LL.D. 


Definition. — Scarlet  fever  is  an  infectious  disease,  due  to  a  specific 
contagion,  and  characterized  by  a  peculiar  exauthem,  more  or  less  diffused 
over  the  entire  surface,  an  angina  of  variable  intensity,  and  a  fever,  which 
may  be  appreciable  only  with  the  thermometer  or  so  intense  as-  speedily  to 
destroy  life.  It  is  irregular  in  form,  intensity,  and  prevalence.  These 
diversities  are  exhibited  in  individual  cases,  in  the  constitution  of  epi- 
demics, and  in  the  morbid  process  in  the  organs  which  may  be  involved. 
Its  epidemicity  and  contagiousness  are  established,  yet  the  intensity  of  the 
contagion  is  so  variable  and  individual  susceptibility  and  immunity  are  so 
inconstant  that  those  who  may  escape  a  prevalent  and  virulent  epidemic 
may  be  seized,  subsequently,  during  an  epidemic  of  lesser  prevalence  and 
malignity,  and  in  the  same  epidemic  individual  cases  will,  without  apparent 
cause,  vary  from  the  lowest  to  the  highest  grade  of  intensity.  The  diifer- 
ence  in  the  susceptibility  of  persons  and  the  variability  of  tlie  poison  in 
virulence  and  diffusion  are  more  markedly  exhibited  in  this  than  in  any 
other  of  the  exanthematous  affections. 

Synonymes. — Scarlatina  ;  Scarlet  rash. 

History. — Until  Sydenham  established  the  unity  and  specific  nature  of 
scarlet  fever  it  had  been  considered  a  variety  of  measles,  diiferiug  only  in 
the  form  of  the  exauthem.  During  the  prevalence  of  the  epidemic  in  Lon- 
don from  1661  to  1665  the  scarlatinal  eruption  was  carefully  studied  and 
its  distinctive  characters  and  differentiation  were  definitely  established.  To 
what  extent  it  had  prevailed  previous  to  that  period  cannot  be  ascertained, 
but  it  is  generally  believed  to  have  appeared  in  mild  epidemics,  limited  to 
circumscribed  regions,  for  a  very  long  time  anterior, — pcrhaj)s  quite  as  early 
as  measles.  How,  when,  or  where  it  originated  are  questions  which  cannot 
be  answered.  During  the  past  two  hundred  years  its  course,  })rogress, 
prevalence,  and  epidemic  character  have  been  carefully  recorded  and  studied. 
This  later  history  justifies  the  conclusion  that  it  has  continuously  increased 
in  prevalence,  extending  over  larger  areas  and  invading  widely-sej)arated 
countries,  and  that  with  the  more  frequently  recurring  and  more  widely 
spread  epidemics  it  has  assumed  more  dangerous  forms.  At  the  present 
time  it  is  the  most  prevalent  and  fatal  of  the  exanthematous  maladies. 

555 


556  SCARLET    FEVER. 

Its  greater  prevalence  is  undoubtedly  due  to  the  rapid  increase  in 
population ;  and  its  wider  dissemination  and  invasion  of  remote  regions 
and  countries  are  attributable  to  the  increased  facilities  of  intercommuni- 
cation.    The  first  epidemic  in  this  country  occurred  in  1735. 

Etiology. — Scarlet  fever  is  due  to  a  specific  poison  capable  of  repro- 
ducing itself.  That  such  a  contagion  exists^  possessing  the  power  of  in- 
fecting unprotected  persons  with  a  disease  similar  in  all  its  essential  char- 
acteristics, and  that  every  such  case  is  the  result  of  such  infection,  cannot 
be  doubted.  It  is  true  that  cases  occasionally  occur  independent  of  any 
epidemic,  and,  apparently,  of  any  contagious  element ;  but  such  cases,  like 
those  occurring  under  circumstances  readily  explained,  are  due  to  infection 
with  the  scarlatinous  poison.  The  failure  to  establish  the  origin  of  such 
cases  and  to  connect  them  with  the  specific  contagion  is  partly  due  to  defec- 
tive methods  of  investigation,  but  mainly  to  the  special  qualities  of  the 
contagion,  which  characterize  it  as  a  volatile,  diffusible,  portable,  minutely 
divisible,  and  tenacious  poison,  possessing  a  vitality  and  latency  which 
permit  its  transportation  to  great  distances.  The  further  fact  that  the 
contagion  of  such  sporadic  cases  will  always  reproduce  the  disease  in  un- 
protected persons  seems  conclusive  against  their  spontaneous  origin. 

The  nature  of  the  contagion  has  not  been  determined.  Experimental 
and  clinical  observation  point  to  the  existence  of  a  scarlatinal  microbe,  but 
such  an  organism  has  not  been  isolated  or  demonstrated.  That  it  is  a  con- 
tagium  vivum  ^  seems  indisputable ;  for  it  is  inconceivable  that  a  poison 
of  spontaneous  origin  could  possess  such  special  and  pecuHar  properties, 
capable  of  reproducing  a  disease  which  would  afford  immunity  from  subse- 
quent invasion  and  infection.^ 

Its  volatility  is  established  by  its  minute  divisibility  and  diffusibility  in 
the  atmosphere,  its  rapid  transference  from  person  to  person  without  direct 
contact  or  close  proximity,  and  its  wide-spread  prevalence  among  unpro- 
tected persons  in  the  same  or  neighboring  communities. 

The  evidence  in  favor  of  its  portability  is  conclusive.  It  may  be  con- 
veyed by  the  clothing,  furniture,  toys,  flowers,  letters,  locks  of  hair,  and 
food  from  the  sick-room.  Any  article  of  wearing-apparel,  either  of  the:  sick 
person,  physician,  or  nurse  in  attendance,  or  of  any  other  person  who  may 
be  exposed  to  the  direct  contagion,  may  convey  it.  During  such  conveyance 
its  latent  vitality  will  remain  unimpaired  for  a  considerable  time.  The 
wearing  of  the  clothing  of  the  sick,  occupancy  of  the  sick-room,  dusting, 


^  It  appears  to,  have  been  established  that  a  virus  may  retain  its  pathogenetic  power  after 
being  deprived  of  living  micro-organisms.  Chauveau  supposed  he  had  proved  this  in  1880; 
but  Pasteur  claims  that  it  has  only  been  recently  demonstrated  in  his  laboratory.  The  fact 
is,  however,  that  Salmon  and  Smith  in  1885  made  the  decisive  demonstration  which  settled 
the  question. 

^  Richardson  believes  "  that  the  disease  is  caused  by  the  development  of  a  chemical 
body,  which  by  its  presence  gives  rise  to  the  sjanptoms,  and  by  its  ultimate  elimination 
frees  the  sj^stem  from  them  all  except  those  which  are  secondary." 


SCAELET   FEVER.  557 

beating,  and  cleaning  the  clothing  of  the  sick,  and  even  a  visit  to  the  house 
of  a  scarlatinous  patient,  have  frequently  infected  susceptible  persons.  It 
may  also  be  communicated  by  domestic  animals.  It  is  even  believed  that 
the  horse,  dog,  cat,  cow,  and  swine  may  contract  the  disease,  and  thus 
become  sources  of  direct  contagion.  It  may  be  disseminated  by  contami- 
nated drinking-water,  and  in  later  years  has  been  quite  frequently  commu- 
nicated by  infected  milk.  Three  kinds  of  milk  epidemics  are  recognized  by 
Klein,  of  which  examples  may  be  found  in  the  literature  of  recent  epidemics 
in  England.  In  one  kind  the  infective  material  is  communicated  to  the 
milk  by  the  exposure  of  either  the  milk  or  the  milk-cans  to  a  patient 
during  the  desquamative  stage ;  in  the  second  kind,  by  the  conveyance  of 
the  poison  to  the  milk  from  an  infected  cow ;  and  in  the  third  kind,  by 
the  direct  poisoning  of  the  milk  of  a  cow  suffering  with  the  disease.  The 
most  common  mode  of  infection  is,  however,  from  direct  contact  with  a 
scarlatinous  patient. 

The  "  Heudon  outbreak"  of  scarlet  fever  in  London,  in  December,  1885, 
was  associated  with  the  distribution  of  the  milk  from  a  herd  in  Hendon  that 
was  affected  with  an  infectious  and  contagious  disease  communicable  by 
inoculation  to  healthy  cows  and  to  man.  Klein  discovered  in  the  discharge 
from  the  ulcers  on  the  udders  of  the  affected  cows  a  micrococcus  which  he 
believes  is  identical  with  a  micro-organism  which  he  has  found  in  the  blood 
of  human  scarlet-fever  patients.  Edington,  Thin,  and  others,  who  have 
pursued  a  similar  line  of  experiment  and  investigation,  have  failed  to  verify 
the  conclusion  of  Klein  that  the  Hendon  disease  was  scarlet  fever.  The 
streptococcus  isolated  and  cultivated  by  Klein  is  associated  with  an  eruptive 
disease  of  the  udders  and  teats  of  cattle,  but  it  has  not  been  proved  that 
this  disease  is  scarlet  fever. 

The  extraordinary  tenacity  and  vitality  of  the  scarlatinal  contagion  are 
shown  by  the  various  modes  of  conveyance,  propagation,  and  infection,  but 
the  duration  of  its  vitality  has  not  been  ascertained.  Richardson  reports 
that  five  months  after  the  first  case  occurred  children  became  infected  when 
they  occupied  a  room  under  the  infected  straw  roof  of  a  house ;  and  it  is 
stated  that  Hildenbrand's  coat  retained  its  contagiousness  for  one  year  and  a 
half  Numerous  recorded  observations  indicate  the  inertness  of  the  ordinary 
means  of  purification  and  cleanliness,  and  that  continuous  and  energetic 
ventilation  but  imperfectly  accomplishes  the  removal  of  the  poison. 

The  contagiousness  of  scarlatina  is  conclusively  proved  by  the  communi- 
cability  of  the  disease  to  a  healtliy  person  by  inoculation.  A^arious  experi- 
ments have  been  performed  with  the  view  of  producing  an  attenuated  virus 
which  might  be  employed  to  secure  immunity  from  the  more  fatal  forms, 
but  the  generated  disease  has  proved  even  more  dangerous  than  that  con- 
tracted in  the  ordinary  mode.  The  disease  has  been  produced  by  inocula- 
tion with  the  blood,  epidermic  scales,  and  serum  from  cutaneous  vesicles, 
and  the  persons  so  inoculated  have  not  contracted  the  disease  subsequently 
when  exposed  to  the  infection.     It  may  also  be  communicated  by  the  pul- 


558  SCARLET   FEVER. 

monary  and  cutaneous  exhalations,  by  the  nasal  and  pharyngeal  secretions, 
and  by  the  urine.  These  experiments  and  clinical  observations  show  that 
the  blood  is  the  essential  seat  of  the  contagion,  and  that  it  is  disseminated 
throughout  the  tissues,  secretions,  and  excretions  of  the  body. 

The  contao;ion  is  so  volatile  and  intense  that  the  briefest  contact  with  a 
scarlatinous  patient  or  exposure  to  the  atmosphere  of  the  sick-room  may  be 
sufficient  for  infection.  In  fact,  the  receipt  of  a  letter  from  a  long  distance, 
written  in  the  room  of  such  a  patient,  may  communicate  the  disease  to  sus- 
ceptible children.  A  third  person  pausing  for  a  moment  in  the  room  may 
convey  the  contagion  for  a  distance  and  infect  susceptible  persons  for  weeks 
after.  The  poison  may,  however,  be  diluted  and  rendered  innocuous  by 
thorough  and  persistent  ventilation  of  the  sick-room.  Well-directed  venti- 
lation, and  isolation  of  the  patient,  may  limit  the  spread  of  the  disease  in 
a  household.  Some  maintain  that  the  spreading  of  the  disease  may  be 
effectually  arrested  by  isolation  of  the  patient,  disinfection  of  the  sick-room 
and  clothing  of  the  patient,  inunction  of  the  body  with  some  disinfecting 
material,  and  scrupulous  cleanliness.  Whether  or  not  the  poison  can  be  de- 
stroyed by  such  means  is  questionable,  but  that  its  intensity  and  diffusibility 
can  be  thus  diminished  is  beyond  dispute.  The  accepted  belief  is  that  the 
poison  can  be  destroyed  only  by  heat,  and,  that  a  temperature  nearly  up  to 
212°  F.  is  necessary. 

The  period  of  most  intense  contagiousness  and  the  duration  of  capacity 
for  infection  have  not  been  positively  settled.  Some  contend  that  the  stage 
of  desquamation,  others  that  during  the  bloom  of  the  eruption,  is  the  most 
contagious  period.  The  only  fact  universally  admitted  is  that  with  restora- 
tion to  health  the  contagiousness  declines ;  but  it  certainly  does  not  cease 
until  desquamation  has  been  completed,  and  it  is  known  to  have  remained 
attached  to  dropsical  patients.  The  period  of  infectivity  must  then  neces- 
sarily vary  with  the  patient.  Some  will  desquamate  more  rapidly  than 
others ;  some  will  suffer  from  dropsy  or  other  sequelae,  while  others  will 
escape.  With  the  termination  of  desquamation,  completion  of  convalescence, 
and  restoration  to  health,  infectivity  will  certainly  have  ceased. 

The  varying  predisposition,  susceptibility,  and  immunity  of  individuals 
and  families  are  as  remarkable  as  they  are  inexplicable.  In  a  family  of 
children  one  or  more  may  escape  or  suffer  but  a  mild  attack,  whilst  the 
remaining  members  may,  without  apparent  cause,  exhibit  the  most  intense 
susceptibility.  Families  residing  in  close  proximity,  perhaps  in  adjoining 
houses,  and  subject  alike  to  the  infection,  may  be  very  differently  influenced. 
In  one  the  most  aggravated  form  of  the  disease  may  prevail,  and  the  other 
will  be  protected  by  a  special  immunity.  This  absence  of  susceptibility  may 
continue  throughout  life,  or  only  during  the  prevailing  epidemic,  or  it  may 
continue  during  residence  in  one  locality  and  disappear  upon  removal  to 
another  in  the  same  city  or  to  some  distant  village  or  city.  Predisposition 
may  be  increased  or  diminished  by  locality.  Rapid  and  fatal  cases  indicate 
extraordinary  susceptibility. 


SCAELET   FEVER.  559 

A  population  long  exemjit  from  scarlet  fever  does  not  necessarily  exhibit 
very  marked  susceptibility  when  invaded  by  an  epidemic.  If  such  invasion 
is  long  continued,  the  susceptibility  seems  to  increase,  and  individuals  and 
families  that  have  escaped  previous  epidemics  may  exhibit  susceptibility  in 
its  most  aggravated  forms. 

It  quite  frequently  occurs  that  persons  who  have  escaped  the  disease,  or 
who  have  had  a  mild  or  severe  attack,  will  upon  every  subsequent  ex- 
posure to  the  direct  contagion  suiFer  more  or  less  from  a  sore  throat.  This 
form  of  angina  may  recur  with  every  exposure,  or  it  may  cease  after  one  or 
more  attacks. 

Social  position  and  external  circumstances  influence  the  mortality,  but 
do  not  seem  to  affect  the  predisposition.  The  death-rate  increases  Avith 
poverty  and  diminishes  with  affluence.  This  difference  is  undoubtedly  due 
to  the  condition  of  life  rather  than  to  any  difference  in  constitution.  Among 
the  well-to-do,  the  modifying  influence  of  ventilation,  diffusion  and  dilution 
of  the  poison,  more  efficient  care,  nursing,  feeding,  and  medical  attendance 
is  very  markedly  shown  in  the  diminished  mortality. 

Age  exerts  a  very  decided  influence.  No  age  is  exempt.  Children  have 
been  born  with  scarlet  fever,  and  newly-born  infants  are  occasionally  at- 
tacked, but  during  the  first  year  the  susceptibility  is  not  very  marked.  It 
is  increased  during  the  second  year,  but  between  two  and  seven  years  it  is 
most  intense.^  After  the  tenth  year  the  liability  is  greatly  diminished, 
and  more  so  after  the  fifteenth.  Only  about  1.75  per  cent,  of  cases  occur  in 
adults  over  twenty-five  years  of  age.  These  facts  point  very  clearly  to  the 
value  of  isolation.  If  children  can  be  protected  during  the  first  ten  years 
of  life,  the  chances  of  escape  are  greatly  enhanced,  and  the  danger  is  greatly 
lessened. 

Sex  and  race  do  not  influence  the  predisposition.  Previous  condition  of 
health  is  a  doubtful  factor.  Conditions  of  soil  seem  occasionally  to  favor 
the  prevalence  of  the  disease,  but  residence  in  the  country  or  in  cities  does 
not  show  any  marked  difference.  Occupation  is  a  doubtful  clement.  Very 
many  unprotected  persons  whose  employment  brings  them  in  contact  with 
affected  persons  contract  the  disease,  but  this  cannot  be  ascribed  to  the  occu- 
pation except  in  so  far  as  it  may  expose  them  to  the  contagion. 

Epidemics  of  scarlet  fever  occur  most  often  in  the  autumn,  and  in 
successive  order  of  frequency  during  winter,  spring,  and  summer.  The 
condition  of  the  weather  does  not  influence  the  epidemics.  Changeable, 
cold,  and  moist  weather  d(8es  not  aggravate  them.  In  fact,  tliey  seem  to 
be  independent  of  atmospheric  conditions.     Altitude  is  witliout  influence. 

Pregnancy  increases  the  predisposition  of  the  unprotected,  but  not  so 
markedly  as  the  lying-in  and  the  nursing.  The  wounded  and  those  who 
have  undergone  operation  seem  to  acquire  increased  susceptibility. 

'  The  rarity  of  the  disease  under  two  years  is  denied  by  some.  Others  assert  that  the 
most  common  age  is  about  the  third  or  fourth  year. 


560  SCAELET   FEVER. 

The  prevalence  of  epidemics  of  scarlet  fever  is  mainly  dependent  upon 
personal  intercourse.  All  other  conditions  and  elements  are  of  minor 
importance.  Locality,  condition  of  the  subsoil,  season,  density  of  popu- 
lation, and  circumstances  of  life  may  increase  or  lessen  the  predisposition, 
but  without  personal  intercourse  and  the  direct  conveyance  of  the  contagion 
from  the  aifected  to  the  unprotected  the  spread  of  the  disease  in  any 
community  would  be  circumscribed,  and  in  most  instances  limited  to  com- 
paratively few  of  those  susceptible  to  it.  In  view  of  this  fact,  immediate 
isolation  of  the  sick  should  be  imperative,  and  non-intercourse  should  be 
established  and  maintained  until  the  period  of  desquamation  has  been  com- 
pleted and  health  restored.  Epidemics  of  scarlet  fever  usually  begin  with 
a  few  scattered  cases,  and  not  infrequently,  such  cases  being  of  a  mild  type, 
no  restrictions  are  imposed  beyond  those  voluntarily  assumed  by  the  patient. 
Intercourse  with  other  children  is  permitted,  and  the  patient  is  usually 
returned  to  the  school  to  disseminate  the  disease  throughout  the  community. 
A  mild  and  apparently  sporadic  case  is  no  guarantee  against  a  wide-spread, 
virulent,  and  fatal  epidemic.  The  susceptible  in  any  community  cannot  be 
considered  safe  until  the  epidemic  has  entirely  disappeared.  Its  subsidence 
and  disappearance  are  usually  very  slow.  The  epidemic  may  have  lost 
its  force  and  virulence,  but  the  single  cases  occurring  at  localities  distant 
from  one  another  may  continue  and  prolong  the  infectious  influence  until 
the  subjects  are  exhausted. 

A  study  of  the  history  of  the  epidemics  of  scarlet  fever  during  the 
past  two  and  a  half  centuries  has  suggested  the  theory  of  periodic  recur- 
rence. Whilst  this  is  apparently  true  in  some  localities,  the  exceptions 
have  been  too  numerous  to  permit  the  acceptance  of  the  law  of  periodicity. 
In  some  cities  it  has  become  endemic.  In  fact,  in  many  populous  cities 
the  disease  is  probably  always  present.  Occasionally  it  has  become  pan- 
demic, spreading  over  vast  areas  of  country  and" continuing  through  a 
protracted  prevalence. 

Epidemics  of  scarlet  fever  frequently  follow  in  the  wake  of  epidemics 
of  measles.  This  fact  does  not  estai^lish  any  relation  of  cause  and  eifect 
between  the  two  diseases,  but  favors  the  theory  that  measles  in  some  inex- 
plicable manner  increases  the  susceptibility  of  unprotected  individuals  and 
thus  prepares  the  field  for  the  rapid  dissemination  of  the  poison  of  scarlet 
fever. 

Prevention. — There  is  no  effectual  method  of  protecting  the  susceptible 
from  the  contagion  of  scarlet  fever.  Much  can  be  accomplislied  in  limiting 
the  prevalence  of  the  disease  by  prompt  and  efficient  isolation  of  the  sick, 
and  by  non-intercourse.  The  intensity  of  the  poison  may  be  diminished 
by  ventilation,  diiFasion,  and  dilution.  It  is  also  highly  probable  tliat  its 
mortality  may  be  greatly  diminished  by  the  rigid  enforcement  of  hygiene, 
both  domiciliary  and  personal. 

All  experiments  to  secure  protection  by  the  internal  administration  of 
drugs  have  failed.     For  a  time  many,  especially  laymen,  harbored  the  con-- 


SCARLET   FEVER.  561 

ceit  that  the  administration  of  belladonna  in  minute  doses  would  afford  pro- 
tection ;  but  the  theory  has  long  since  been  exploded.  Of  late  years  the 
employment  of  antiseptic  gargles  and  inunctions  has  been  advocated  by  some. 
Jamieson  maintains  that  the  exhalations  from  the  mouth  and  throat  and 
the  particles  of  cast-off  cuticle  are  the  sources  of  infection,  and  insists  that 
the  contagion  may  be  destroyed  by  frequent  applications  to  the  mouth  and 
throat  of  a  strong  solution  of  boracic  acid  in  glycerin.  The  skin,  including 
the  scalp,  should  be  thoroughly  bathed  daily  with  warm  water,  and  twice 
daily  the  entire  surface  of  the  body  should  be  anointed  with  an  ointment 
composed  of  carbolic  acid  gr.  xxx,  thymol  gr.  x,  vaseline  3ij  and  simple 
ointment  3i ;  or  the  following  salve :  "resorcin  1,  lanoline  6,  and  ol.  sesame 
2  parts.  This  is  rubbed  into  the  skin  to  hasten  desquamation  and  to 
destroy  the  specific  organism."  Brown  uses  a  five-per-cent.  carbolized  oil 
inunction  all  over  the  body,  except  on  the  face,  where  olive  oil  is  used. 
This  is  done  daily  for  six  or  eight  weeks,  followed  by  a  warm  bath.  He 
claims  that  sequelse  are  averted.  Long  anoints  with  a  carbolized  inunction, 
and  gives  daily  baths  as  soon  as  the  patient's  condition  will  permit.  Wig- 
glesworth  employs  carbolic  acid  internally,  rendered  liquid  by  ten  per  cent, 
of  water.  Three  to  six  minims  are  given  every  two  hours  day  and  night 
during  the  first  three  days  and  continued  at  longer  intervals  during  the  four 
or  five  succeeding  days  until  the  urine  is  deeply  discolored.  He  gives  one 
minim  three  times  a  day  to  everybody  in  the  dwelling,  and  claims  complete 
protection.  The  reports  seem  to  establish  the  value  of  these  methods  of 
prophylaxis.  It  is  undoubtedly  true  that  frequent  bathing  and  inunction 
during  the  period  of  desquamation  will  effectually  prevent  the  diffusion  of 
the  cast-off  particles  of  the  epidermis  in  the  surrounding  atmosphere,  and 
thereby  limit  to  a  very  considerable  extent  the  dissemination  of  the  poison ; 
but  it  is  not  believed  that  the  vitality  of  the  poison  is  lessened.  Walford 
claims  that  arsenic  given  during  the  incubative  stage  will  either  prevent  or 
greatly  modify  the  disease.  He  employs  the  liquor  arsenicalis  in  as  large 
dose  as  the  age  of  the  child  will  permit,  in  combination  with  sulphurous 
acid  and  syrup  of  poppy.  The  dose  should  be  given  daily  for  several  days, 
and  then  less  frequently. 

Separation  aud  disinfection  are  the  most  effectual  prophylaxes.  The 
discharges  of  the  patient  and  all  vessels  employed  in  the  sick-room  should 
be  thoroughly  disinfected.  The  clothing  worn  by  the  patient,  the  bed-linen, 
and  other  clothing  should  either  be  destroyed  or  be  submitted  to  some  cer- 
tain disinfecting  process.  The  mattress  should  be  burned.  After  the 
patient  is  well  and  has  returned  to  the  fiunily  circle,  tlie  room  should  be 
subjected  to  an  equally  effective  process  of  cleansing  and  disinfection.  No 
unprotected  person  should  be  permitted  to  occupy  it  for  a  reasonable  period 
thereafter. 

The  prevalence  and  mortality  of  scarlet  fever  demand  the  rigid  enforce- 
ment of  every  practicable  method  of  prevention. 

Incubation. — The  period  of  incubation  varies.     In  the  vast  majority  of 

Vol.  I.,  -otj 


562  SCARLET    FEVER. 

cases  it  varies  from  tAvo  to  eight  clays.  There  are,  however,  many  excep- 
tions to  this  general  law.  In  occasional  instances  the  disease  has  developed 
a  few  hours  after  the  first  and  only  exposure ;  in  other  instances,  far  more 
numerous  than  those  of  brief  incubation,  it  has  been  delayed  for  several 
weeks.  It  is  never  safe  or  wise  to  pronounce  a  child  who  may  have  been 
exposed  to  the  contagion  free  from  the  danger  of  an  attack  until  several 
weeks,  at  least  three,  have  elapsed  after  the  date  of  last  exposure. .  In  many 
of  the  cases  of  delayed  incubation  it  may  be  that  a  second  or  a  third  exjDO- 
sure  has  occurred,  and  the  period  of  incubation  in  such  cases  would  date 
from  the  last.  In  this  as  in  many  other  particulars  scarlet  fever  presents 
very  many  anomalous  variations,  which  demand  unusual  alertness  on  the 
part  of  the  medical  adviser. 

Immunity. — Reference  has  been  made  to  the  peculiarities  of  constitu- 
tion and  variations  in  the  susceptibility  of  individuals  and  families,  through 
which  some  seem  to  have  inherited  and  others  acquired  an  immunity  which 
continued  throughout  life  or  vanished  under  changed  conditions  of  life. 
Immunity  may  be  acquired  by  age.  The  disease  rarely  occurs  more  than 
once  in  the  same  individual.  Occasional  instances  of  a  second,  a  third,  and 
even  a  fourth  attack  have  been  reported.  It  is  a  common  but  a  mistaken 
belief  among  laymen  that  second  and  third  attacks  are  fi-equent.  Physi- 
cians sometimes  pronounce  cases  of  roseola  and  erythema  to  be  mild  attacks 
of  scarlatina,  and,  when  the  mistake  is  recognized,  fail  to  correct  the  diag- 
nosis. Then,  again,  mistakes  are  made,  and  parents  are  greatly  surprised 
Avhen  another  physician,  usually  in  a  different  city,  ascribes  the  illness  of 
their  child  to  an  attack  of  scarlet  fever.  The  wa^iter  during  a  considerable 
experience  has  never  seen  a  second  or  subsequent  attack,  but  he  has  very 
frequently  encountered  the  assertion  of  second  and  third  attacks.  Why 
the  susceptibility  is  not  completely  destroyed  by  a  first  attack  is  as  inexpli- 
cable as  the  fact  that  a  single  attack  usually  affords  complete  immunity  for 
life.  By  a  second  attack  is  meant  a  new  case  occurring  after  a  shorter  or 
longer  interval,  without  any  connection  with  the  first  attack,  and  after  a 
subsequent  exposure  to  the  contagion.  Suet  cases  must  be  distinguished 
from  the  cases  of  relapse  wliich  follow  immediately  in  the  wake  of  the  first 
attack,  and  also  from  the  cases  of  pseudo-relapse,  which  are  characterized 
by  the  recurrence  of  the  exanthem  during  the  second  or  third  week  of  the 
disease. 

The  survival  of  susceptibility  is  most  frequently  a  family  inheritance. 
In  some  cases  it  seems  to  be  due  to  the  incompleteness  of  the  first  attack, 
and  in  other  and  rarer  instances  changed  conditions  of  life  seem  to  have 
revived  the  susceptibility. 

Pathology. — The  special  characteristics  of  the  contagion  of  scarlet 
fever  have  been  set  forth  in  the  preceding  sections.  Beyond  this  but  little 
is  known  in  regard  to  the  nature  of  the  disease.  Recent  experiments  and 
investigations  by  Klein,  Edington,  Jamiesou,  and  others  point  very  dis- 
tinctly to  the  existence  of  an  organism  peculiar  to  scarlet  fever.    A  ninnber  . 


SCARLET    FEVER.  563 

of  organisms  have  been  discovered  in  the  blood  and  desquamation,  and 
some  of  them  have  been  isolated  and  cultivated.  The  indications  are  that 
the  bacillus  scarlatinse,  which  consists  of  "  rods  measuring  0.4  m.  in  thick- 
ness and  1.2  m.  to  1.4  m.  in  length,  most  usually  forming  excessively  long- 
pointed  and  curved  filaments,"  is  the  specific  cause  of  scarlet  fever,^  But 
control  experiments  of  sufficient  magnitude  have  not  been  made  to  establish 
the  fact. 

Pathological  Anatomy. — The  morbid  anatomy  in  scarlet  fever  consists 
mainly  in  the  changes  which  take  place  in  the  integument,  subcutaneous 
connective  tissue,  and  mucous  membrane  of  the  oral  and  nasal  cavities  and 
throat.  The  changes  which  are  found  in  the  viscera  refer  more  particularly 
to  the  complications  and  sequelae.  The  skin  is  hypersemic,  and  the  surface 
is  more  or  less  covered  with  an  exauthem,  which  consists  of  numerous 
and  closely-aggregated  points,  slightly  red  in  the  beginning,  but  rapidly 
increasing  in  redness,  sometimes  to  a  brilliant  scarlet  color.  They  are  sel- 
dom larger  than  a  pin's  head,  and  may  be  separated  by  pale  points  of  skin. 
They  may  be,  and  most  usually  are,  so  crowded  together  as  to  present  to 
the  naked  eye  a  uniform  scarlet  redness  of  marked  intensity.  These  points 
may  be  fl^at  or  slightly  elevated,  are  usually  circular  in  form,  but  may  be 
elongated.  Marked  confluence  with  vivid  redness  denotes  increased  hyper- 
semia.  In  mild  cases  with  moderate  hypersemia  the  points  remain  isolated 
and  disappear  with  desquamation. 

The  exauthem  usually  maintains  its  maximum  development  for  one  or 
t\vo  days,  rarely  less  than  one  day,  and  then  gradually  fades,  to  disappear 
with  the  beginning  of  desquamation. 

The  subcutaneous  cellular  tissue  is  but  slightly  affected  in  mild  cases. 
The  infiltration  and  exudation  are  limited  to  the  superficial  layers,  but  in 
severe  cases  they  may  be  greatly  increased  and  extend  to  the  subcutaneous 
cellular  tissue.  Exudations  of  blood  may  also  take  place  in  the  layers  of 
the  skin  and  in  the  sub-integumental  tissue.  In  consequence  of  the  hyper- 
aemia  of  the  skin  and  the  exudation  into  the  rete  Maljiighii,  there  takes  place 
a  rapid  new  formation  of  epidermis  and  consequent  exfoliation.  The  des- 
quamation may  be  either  branny  or  lamellar,  and  may  recur  several  times, 
dependent  upon  the  nature  of  the  epidermis  and  the  intensity  of  the  exau- 
them. After  the  completion  of  the  desquamation  the  skin  returns  to  its 
normal  condition,  except  in  very  rare  instances.  After  a  relapse  the  process 
of  desquamation  may  be  repeated. 

The  changes  in  the  organs  of  the  tliroat  and  the  mucous  membrane  of 
the  oral  cavity  and  pliarynx  vary.  It  may  be  a  simple  turgesccnce,  witli 
moderate  swelling  of  the  uvula,  palatine  arches,  and  tonsils,  and  increased 
secretion ;  or  it  may  be  a  much  more  extensive  inflammation,  involving  the 
])osterior  pharyngeal  wall  and  the  structure  of  the  tonsils,  and  extending 
throughout  the  mucous  membrane  of  the  mouth  and  the  lining  membrane 


'  Shakespeare,  Ann.  Univ.  Med.  Sci.,  vol.  v.  p.  4Go  et  seq. 


564  SCAELET    FEVER. 

of  the  nasal  cavity.  The  tonsils  may  be  greatly  enlarged ;  sometimes  ab- 
scesses form  in  them.  Follicular  abscesses  are  quite  often  observed  on  dif- 
ferent parts  of  the  inflamed  mucous  membrane,  most  frequently  on  the  soft 
palate.  In  some  cases  the  turgescence  is  so  intense  as  to  impart  a  livid  color 
to  the  parts,  and  the  oedema  of  the  soft  parts  is  so  great  as  to  interfere  with 
deglutition.  In  more  severe  forms  of  scarlatinous  angina  the  submucous  cel- 
lular tissue  may  become  involved  in  the  inflammatory  process.  This  may 
be  limited  to  small  areas,  or  it  may  extend  to  the  post-pharyngeal  and 
laryngeal  regions,  or  externally  to  the  neck  and  to  the  parotid  and  submax- 
illary glands.  The  swelling  outside  about  the  neck,  jaws,  and  temples  is 
sometimes  very  considerable,  and  may  result  in  very  extensive  abscesses. 
In  such  cases  the  parenchymatous  inflammation  of  the  tonsils  progresses 
very  rapidly  to  the  formation  of  large  abscesses.  Gangrene  with  extensive 
sloughing  may  follow.  This  destruction  may  be  limited  to  the  tonsils,  or 
may  extend  in  any  direction  to  the  parts  involved  in  the  inflammation. 

There  is  no  longer  any  doubt  that  scarlet  fever  may  be  associated  with 
the  formation  of  a  membrane  in  the  throat  and  upper  air-passages  similar  to 
diphtheritic  exudation.  In  some  cases  the  membrane  is  diphtheritic;  in 
others  it  is  a  scarlatinal  affection.  In  the  latter  class  of  cases  it  appears 
between  the  third  and  sixth  days,  rarely  invades  the  larynx,  but  may  extend 
into  the  posterior  nares.  The  cervical  glands  may  enlarge  and  suppurate, 
but  this  form  is  never  followed  by  paralysis.  The  exudation  may  be  a  soft, 
white,  pultaceous,  easily-detached  deposit,  may  consist  of  layers,  or  may  be  a 
well-formed  membrane,  attended  with  dysphagia,  swelling  of  the  cervical 
glands,  and  infiltration  of  the  cellular  tissue  of  the  neck,  and  may  invade 
the  nasal  cavities  and  ears.  True  diphtheria  does  not  usually  appear  before 
the  second  week,  and  is  a  much  more  serious  comj^lication.^  It  may  com- 
plicate the  mildest  as  well  as  the  severe  forms  of  scarlatina,  and  may  assume 
the  form  and  extent  either  of  an  ordinary  case  of  diphtheria,  or  of  the  most 
malignant  type.  In  all  cases  the  course  of  the  fever  is  aggravated  by  this 
complication.  It  is  probably  due  to  a  secondary  infection  with  the  germs 
of  true  diphtheria. 

In  rare  instances  the  brain  and  its  membranes  are  cono-ested.  The  in- 
testinal  and  mesenteric  glands  may  be  enlarged.  Some  have  contended  that 
the  gastro-intestinal  mucous  membrane  is  inflamed  and  subjected  to  an  ex- 
foliation of  epithelial  cells.  The  spleen  may  be  enlarged  and  softened.  In 
fatal  cases  complicated  with  catarrh  of  the  stomach  and  alimentary  tract, 
bronchitis,  pneumonia,  pleurisy,  peritonitis,  endocarditis,  or  pericarditis,  the 
ordinary  changes  incident  to  such  inflammations  will  be  found. 

The  kidneys  quite  often-  present  evidences  of  derangement.  Some  recent 
authors  consider  renal  catarrh  a  necessary  accompaniment  of  scarlet  fever  ; 

^  The  duality  of  scarlatinal  diphtheria  and  true  diphtheria  is  not  admitted  by  all  ob- 
servers. Some  maintain  their  identity.  Weigert  and  Heubner  claim  to  have  demonstrated 
the  anatomical  identity  of  scarlatinal  and  ordinary  diphtheria ;  but  the  etiological  and 
clinical  differences  have  not  been  established. 


SCARLET   FEVEE.  565 

but  this  view  has  not  been  generally  accepted.  The  changes  are  not  uni- 
form. The  organs  may  be  simply  congested,  and  changes  more  or  less 
marked  mav  be  found  in  the  glomeruli,  arterioles,  and  convoluted  tubes. 
There  may  be  proliferation  of  the  nuclei  in  the  Malpighian  tufts,  degenera- 
tion of  the  intima  of  the  capillaries,  swelling  and  fatty  degeneration  of  the 
epithelium  of  the  convoluted  tubes,  infiltration  of  the  interstitial  tissue,  and 
filling  of  the  tubes  with  hyaline  casts.  In  other  but  rarer  instances  the 
morbid  appearances  are  more  marked,  and  indicate  later  stages  of  the  in- 
flammatory process.  The  tissue-changes  usually  found  are  those  of  renal 
catarrh  in  its  primary  stage.  In  fatal  cases  of  scarlatinal  nephritis  of  long 
duration  the  tissue-alterations  are  more  pronounced. 

Forms. — Scarlet  fever  occurs  in  such  a  variety  of  forms,  and  the  com- 
plications are  so  numerous,  that  it  is  impossible  to  arrange  a  classification 
sufficiently  comprehensive  to  present  them  in  a  definite  manner.  The  earlier 
authors  described  the  disease  under  the  subdivisions  of  scarlatina  simplex, 
scarlatina  auginosa,  and  scarlatina  maligna ;  but  later  writers  have  gener- 
ally adopted  the  classification  of  regular,  irregular,  and  malignant,  which 
will  be  followed  in  this  chapter. 

Symptomatology. — Regular  Form.  The  regular  form  is  characterized 
by  a  well-marked  exanthem,  angina,  and  more  or  less  fever.  It  may  begin 
suddenly,  or  be  preceded  by  a  day  or  two  of  indefinite  indisposition,  during 
which  time  the  patient  will  complain  of  headache,  with  general  malaise 
and  loss  of  appetite.  The  tongue  will  be  slightly  coated.  The  bowels  are 
usually  constipated ;  occasionally  there  may  be  some  looseness.  In  some 
cases  there  will  be  marked  sluggishness,  and  in  others  fretfulness  with  loss 
of  sleep.  Most  frequently  the  disease  begins  suddenly  with  a  chill,  vomit- 
ing, a  convulsion,  or  a  high  fever  associated  with  the  usual  phenomena  of 
high  febrile  action, — headache,  frequent  pulse,  flushed  face,  thirst,  sparkling 
eyes,  anorexia,  twitching  and  starting,  and  perhaps  delirium  or  stupor. 
The  vomiting  may  be  persistent,  but  usually  it  is  not  troublesome  except  in 
serious  cases.  A  slight  diarrhoea  may  supervene.  These  symptoms  con- 
tinue without  abatement,  and  sometimes  are  increased,  until  the  appearance 
of  the  eruption,  which  may  occur  within  a  few  hours  or  be  delayed  one, 
two,  or  three  days, — not  often,  however,  later  than  twenty-four  hours.  The 
rash  appears  first  about  the  neck,  chest,  and  shoulders  in  indistinct  points, 
increases  rapidly  in  redness,  and  extends  over  the  trunk  and  extremities, 
reaching  its  maximum  development  in  rare  cases  during  the  first  day,  but 
most  usually  during  the  second,  and  in  some  cases  not  before  the  third  or 
fourth  day.  When  the  development  is  slow  the  confluence  is  more  marked. 
When  at  its  maximum  the  entire  body  is  covered,  the  skin  being  uniformly 
red,  hot,  and  dry,  and  sometimes  tense,  swollen,  very  sensitive  and  cedema- 
tous,  especially  about  the  face  and  eyes.  Sudamina  may  also  appear,  and 
in  some  localities  extravasations  may  take  place.  The  rash  does  not  always 
become  confluent,  l>ut  frequently  remains  distinctly  punctate.  The  degree 
of  confluence  and  intensity  of  color  are  very  variable.     In  some  epidemics 


566  SCARLET    FEVER. 

these  conditions  are  much  more  marked  than  in  others,  and  in  different 
cases  in  the  same  epidemic  there  are  great  variations.  In  some  cases  the 
burning  and  intensely  red  and  hot  skin  denote  an  uiifavorable  prognosis. 
During  the  development  of  the  exanthem  the  other  symptoms  remain 
unchanged  or  increase,  and  during  the  period  of  its  full  development  the 
accompanying  symptoms  and  conditions  usually  reach  their  maximum 
intensity,  to  subside  with  its  gradual  disappearance. 

The  throat-symptoms  begin  with  the  onset  of  the  disease  and  progress 
with  the  development  of  the  exanthem,  but  it  does  not  follow  that  an 
intense  exanthem  or  a  very  high  fever,  or  both  combined,  necessarily  indi- 
cate a  severe  angina.  In  some  cases  the  throat-affection,  in  others  the  con- 
stitutional conditions,  predominate.  A  moderate  exanthem  may  exist  with 
a  severe  angina,  and  an  intense  and  conJfluent  exanthem  may  exist  with  a 
moderate  angina.  But  as  a  rule  the  throat-affection,  whether  mild  or  severe, 
will  increase  during  the  periods  of  development  and  maximum  intensity  of 
the  exanthem.  With  the  fading  and  gradual  disappearance  of  the  rash  the 
throat-affection  usually  subsides.  In  many  cases,  and  in  some  epidemics, 
the  throat-affection  is  insignificant,  but  as  a  rule  the  changes  in  the  mucous 
membrane  of  the  oral  cavity  and  pharynx  are  sufficiently  characteristic  to 
be  readily  distinguished.  In  the  beginning  the  tongue  is  reddened  at  the 
tip  and  coated  white.  The  enlarged  jDapilla^  project  through  the  coating. 
In  a  few  days  the  coating  disappears  and  the  surface  assumes  the  character- 
istic strawberry  appearance,  deeply  red,  with  thickly-studded,  enlarged,  and 
shining  papillse.  The  lips  are  dry  and  crack  at  the  angles.  Niven  says 
the  breath  is  peculiarly  sweet,  almost  aromatic,  in  the  early  stage  of  the 
disease.  When  the  angina  is  severe,  and  more  especially  when  ulceration 
occurs,  the  breath  is  foul,  and  fetid  if  suppuration  and  sloughing  take 
place. 

Sudden  and  marked  elevation  of  the  temperature,"  with  corresponding 
rapidity  of  the  pulse,  is  one  of  the  most  common  initial  and  characteristic 
phenomena  of  scarlet  fever.  At  the  onset  the  fev^er  may  reach  102°  F. 
and  rapidly  rise  during  the  first  day  to  105°- or  106°  F.  In  some  cases  it 
may  reach  this  and  even  a  higher  elevation  in  a  few  hours.  In  a  majority 
of  cases  it  will  either  continue  during  the  period  of  development  and 
maximum  intensity  of  the  exanthem  to  range  between  102°  and  104°  F., 
or  gradually  rise  during  each  succeeding  day  until  the  exanthem  has 
reached  its  maturity,  and  then  lessen  daily  with  the  gradual  disappearance 
of  the  rash,  until  the  normal  is  reached  with  the  beginning  of  desquama- 
tion. The  course  of  the  fever  is  marked  by  remissions  and  exacerbations. 
In  very  mild  cases  there  may  be  distinct  intermissions.  In  this  form  the 
temperature  does  not  often  exceed  106°  F.,  and  this  highest  point  is  usually 
reached  during  the  period  of  maximum  intensity  of  the  rash.  With  the 
rise  and  fall  of  the  fever  the  scarlet  color  of  the  rash  varies,  increasing 
with  the  elevations  and  lessening  with  the  remissions.  During  the  period 
of  high  fever  there  is  usually  active  delirium,  in  some  cases  stupor,  and  in 


SCARLET    FEVER.  567 

others  twitching,  jerking,  jactitation,  tossing  about  the  bed,  moaning,  and 
occasionally  screaming  as  if  in  pain.  The  effects  of  high  temperature  are 
very  different.  Some  patients  will  bear  continuous  high  temperature  with- 
out any  cerebral  or  nervous  disturbances,  while  others  will  exhibit  the  most 
alarming  perturbations  under  a  much  lower  temperature.  The  amount  and 
intensity  of  the  poison  and  power  of  resistance  may  have  much  to  do  with 
the  degree  and  extent  of  the  pyrexial  phenomena.  Defervescence  is  slow 
and  gradual,  with  increasing  remissions  and  shortening  exacerbations.  If 
the  normal  is  not  reached  with  the  beginning  of  desquamation,  some  com- 
plication may  be  suspected. 

The  pulse  ranges  high  from  the  beginning,  and  continues  so  w- ith  corre- 
sponding increase  in  frequency  with  the  rise  of  the  temperature,  sometimes 
reaching  160,  or  more,  per  minute.  It  diminishes  in  rapidity,  but  not 
correspondingly,  with  the  fall  of  the  temjDcrature.  Usually  it  continues 
fast  until  convalescence  is  established. 

During  the  continuance  of  the  fever  the  urine  is  scanty  and  high- 
colored.  Total  suppression  is  rare,  but  in  high  grades  of  pyrexia  it  may 
occur.  Marked  diminution  of  the  quantity  is  ominous,  and  indicates  renal 
complication.  Careful  observation  will  frequently  detect  evidences  of  renal 
catarrh  in  the  early  stages  of  the  disease,  and  sometimes  at  the  very  begin- 
ning. Epithelial  debris,  mucous  casts,  and  blood-corpuscles,  with  or  without 
albumen,  may  indicate  an  insignificant  catarrh,  but  if  such  conditions  be 
overlooked  or  neglected  the  graver  forms  of  scarlatinal  nephritis  may  rapidly 
develoj)  and  assume  a  threatening  aspect. 

The  eruption  fades  and  disappears  on  the  different  parts  of  the  body  in 
the  order  of  its  appearance.  Desquamation  may  begin  as  early  as  the  third, 
but  usually  not  before  the  fifth,  day  ;  it  sometimes  is  delayed  for  a  week,  and 
in  very  rare  cases  for  a  longer  period.  It  usually  begins  about  the  neck  or 
between  the  fingers  in  furfuraceous  scales ;  on  other  parts  of  the  body  it 
peels  off  in  lamellae.  It  is  peeled  off  the  palmar  and  plantar  surfaces  in 
long  strips.  The  character  and  extent  of  the  exfoliations  depend  greatly 
upon  the  intensity  of  the  exanthem  and  the  nature  of  the  skin.  When  the 
rash  is  mild  and  the  skin  soft  and  delicate,  the  exfoliation  is  branny  and 
moderate ;  when  severe,  it  is  lamellar  and  very  abundant.  In  some  a 
second,  and  in  occasional  instances  a  third,  desquamation  takes  ]:)laee.  The 
process  continues  for  a  Aveek  or  ten  days,  and  wath  its  completion  conva- 
lescence is  usually  established.  The  skin  is  soft  and  clean,  the  throat- 
affection  has  subsided,  the  tongue  has  resumed  its  normal  appearance,  the 
bowels  and  urinary  secretion  are  healthy,  the  appetite  has  returned,  and 
the  patient  solicits  release  from  confinement  and  isolation.  The  patient  is 
not,  however,  free  from  danger  even  when  convalescence  has  been  estab- 
lished. Some  one  of  its  numerous  complications  or  sequelse  may  uuex- 
})ectedly  interrupt  the  progress  of  recovery.  It  is  not  safe  to  discharge  a 
patient  from  observation  and  control  until  six  or  eight  wrecks  have  elapsed. 

Such  is  a  brief  description  of  the  ordinary  course  of  the  regular  form 


568  SCARLET    FEVER. 

of  the  disease.  But  there  are  very  many  exceptions  to  this  general  rule. 
Trivial  complications  aggravate  the  symptoms,  prolong  the  course,  and  delay 
and  protract  convalescence.  The  graver  complications  increase  the  suffering 
and  endanger  the  life  of  the  patient.  The  course  of  the  disease  is  so  vari- 
able and  so  easily  influenced  by  intercurrent  conditions  and  irregularities  of 
the  usual  phenomena  that  it  is  not  possible  always  to  anticipate  unfavorable 
changes  or  complications.     A  guarded  prognosis  should  be  the  rule. 

Irregular  Fo7'm.  The  irregular  form  of  scarlet  fever  is  most  frequently 
caused  by  some  pre-existing  or  coexisting  disease,  and  the  irregularities  may 
refer  to  the  febrile  phenomena,  extent  and  intensity  of  the  exanthem,  nature 
and  degree  of  the  local  affections,  constitutional  peculiarity,  or  circumstances 
of  life.  The  febrile  phenomena  are  very  variable.  Total  absence  is  very 
rare,  but  moderate  fever  throughout  the  course  of  the  disease  is  quite 
common.  In  many  cases  the  fever  continues  moderate  until  some  compli- 
cation supervenes,  and  then  a  dangerous  explosion  ensues ;  in  other  cases 
the  fever  persists  without  apparent  cause  after  the  disappearance  of  even  a 
moderate  rash  and  complete  recovery  of  the  throat-affection  ;  and  in  others 
its  course  is  irregular,  with  marked  remissions,  and  sometimes  intermissions, 
succeeded  by  exaggerated  exacerbations.  In  fact,  the  irregularities  are  at 
times  as  surprising  as  they  are  inexplicable,  but  usually  the  sudden  exacer- 
bations may  be  traced  to  some  local  affection  which  has  just  begun,  or  to 
some  intercurrent  affection  which  has  been  aggravated.  Oftentimes  they 
are  due  to  some  indiscretion  of  the  patient  or  nurse.  Sometimes  the  irreg- 
ular course  of  the  fever  is  due  to  irregularities  in  the  development  and 
progress  of  the  throat-affection ;  in  other  cases,  to  the  intensity  of  the  infec- 
tion and  to  blood-poisoning.  Intercurrent  nervous  attacks  are  quite  often 
due  to  irregularities  in  the  course  of  the  fever. 

Variations  in  extent,  intensity,  and  duration  of  the  exanthem  are  common 
in  the  irregular  form.  It  may  be  so  indistinct  as  to  be  scarcely  recognizable, 
or  limited  to  circumscribed  regions,  as  in  the  joint-flexures,  or  appear  and 
disappear  in  a  brief  period,  or  not  appear  at  all,  or  be  delayed  in  appear- 
ance, and  may  vary  in  extent  and  intensity  from  a  mild  and  discrete  punc- 
tate rash  to  an  intensely  hypersemic  and  confluent  eruption,  attended  with 
a  tense,  swollen,  hot,  and  burning  skin,  exudations,  and  extravasations. 
Delayed  eruption  with  high  fever  is  a  very  grave  condition.  When  the 
course  of  the  disease  is  modified  by  a  pre-existing  entero-colitis  the  rash 
is  delayed ;  and  it  is  usually  modified  by  intercurrent  attacks  of  intestinal 
disturbances.  The  danger  of  these  irregularities  mainly  refers  to  the  sup- 
pression and  intensity  of  the  exanthem. 

Irregularities  of  the  angina  are  very  frequent.  Instead  of  declining 
with  the  disappearance  of  the  rash,  it  may  become  worse.  Suppuration  and 
gangrene  may  take  place.  Diphtheria  may  set  in  at  any  time,  either  during 
the  continuance  of  the  angina  or  after  it  has  subsided.  The  implication  of 
the  lymphatic  and  glandular  structures  in  close  proximity  may  persist  and 
progress  to  the  formation  of  abscesses. 


SCARLET   FEVER.  569 

The  regular  may  be  transformed  into  the  irregular  form  at  any  stage  by 
the  development  or  aggravation  of  a  pre-existing  local  affection.  It  quite 
often  happens  that  a  case  will  pursue  a  regular  course  for  a  time  and  then 
suddenly  assume  an  irregular  and  graver  form.  In  rare  instances  this  will 
occur  independently  of  any  local  affection,  and  is  probably  due  to  some 
constitutional  peculiarity. 

Malignant  Form.  This  form  of  scarlet  fever  is,  fortunately,  not  so 
common  as  the  others.  In  some  epidemics  more  cases  occur  than  in  others. 
It  refers  especially  to  the  combination  of  dangerous  nervous  phenomena 
with  hyperpyrexia.  Its  beginning  is  explosive.  The  initial  symptoms  are 
intense  headache,  high  fever,  delirium,  sometimes  coma,  which  continue 
without  abatement  for  one,  two,  or  perhaps  four  days,  when  death  takes 
place.  A  case  may  begin  with  a  convulsion,  followed  by  coma  and  death 
within  twenty-four  hours,  before  the  appearance  of  the  rash.  In  some 
cases  the  type  of  malignancy  is  due  to  early  and  grave  renal  complications. 
Delirium,  excitement,  mania,  jactitation,  convulsions,  coma,  are  the  ordinary 
phenomena,  and  death  the  usual  result,  of  this  form.  In  some  cases  it  is 
ascribed  to  the  delay  of  the  exanthem ;  in  many,  to  some  pre-existing  dis- 
ease ;  in  others,  to  the  virulence  of  the  contagion  ;  and  in  some,  probably,  to 
an  intensified  predisj^osition. 

Complications  and  Sequelae. — The  complications  and  sequelae  of  scar- 
let fever  are  too  numerous  to  be  considered  here  in  extenso.  To  some  only  a 
brief  reference  can  be  made.  The  more  common  and  graver  conditions  will 
be  more  fully  discussed.  Complications  may  occur  in  any  form  and  in  any 
case.     They  are  more  frequent  and  serious  in  the  malignant  form. 

In  the  section  on  pathological  anatomy  reference  has  been  made  to  the 
graver  forms  of  angina  and  tonsillar  inflammation  and  to  the  suppurative 
and  gangrenous  conditions  which  may  ensue.  Aggravated  angina,  attended 
with  ulceration  and  sloughing,  is  a  very  frequent,  serious,  and  sometimes 
fatal  complication.  In  such  cases  the  inflammation  usually  extends  to  the 
glandular  structures  and  connective  tissue  about  the  neck,  which,  as  a  rule, 
progresses  to  suppuration,  and  perhaps  to  sloughing,  with  extensive  de- 
struction of  tissue.  When  the  external  inflammation  is  not  directly  con- 
nected with  the  throat-aflfection,  or  is  independent  of  any  angina,  it  usually 
terminates  by  resolution,  unless  associated  with  a  low  vitality  and  great 
exhaustion.     In  rare  cases  cancrum  oris  occurs. 

Few  cases  escape  a  mild  coryza.  Occasionally  it  proves  serious  and 
extends  along  the  Eustachian  tube  into  the  tympanum  and  sets  up  a  painful 
and  troublesome  otitis.  If  the  nasal  discliarge  should  be  fetid,  diphtheria 
may  be  suspected.  Diphtheria  is  usually  a  fatal  comj^lication.  When  it 
occurs  as  a  sequel,  recovery  may  be  anticipated. 

Bronchitis  and  pneumonia  are  not  so  frequent  as  inflammations  of  the 
serous  membranes.  Pleurisy,  peritonitis,  pericarditis,  and  eiidocarditis  are 
rare  but  grave  complications.  They  usually  set  in  during  the  second  week 
of  the  disease.    Pleurisy  and  pericarditis  are  generally  associated  with  joint- 


570  SCARLET    FEVER. 

inflammations,  which  ordinarily  follow  the  course  of  rheumatism.    Purulent 
arthritis  is  rare. 

Disturbances  of  the  alimentary  tract  are  quite  common.  Vomiting  in 
the  beginning  of  the  disease  is  not  serious,  but  when  persistent  or  recurring 
durino-  the  progress  of  the  disease  produces  rapid  exhaustion  and  emaciation. 
Diarrhoea  is  not  often  severe,  and  is  usually  associated  with  vomiting.  Fol- 
licular inflammation  and  entero-colitis  are  much  more  serious  but  not  fre- 
quent complications.  When  the  stools  are  frequent,  large,  and  bloody,  with 
colicky  pains  and  tenesmus,  collapse  may  speedily  occur. 

A  mild  conjunctivitis  is  quite  common  during  the  eruptive  stage.  More 
serious  and  protracted  ophthalmias  occur  during  the  later  stages,  and  some- 
times lead  to  grave  corneal  troubles. 

Otitis  may  be  a  complication  or  a  sequel.  The  lining  membrane  of  the 
Eustachian  tubes  is  in  direct  continuity  with  the  mucous  membrane  of  the 
pharynx  and  continuously  exposed  to  an  extension  of  the  inflammatory 
process  present  in  the  latter  region.  Ear-troubles  usually  begin  during 
the  later  stages  or  convalescence  of  the  disease,  with  earache.  The  lining 
membrane  of  one  or  both  tubes  becomes  inflamed  and  swollen,  so  that  the 
products  of  the  inflamed  membrane  are  pent  up.  The  effusion  increases, 
becomes  purulent,  fills  the  tympanic  cavity,  distends  the  drum,  and  may 
penetrate  into  the  mastoid  cells.  The  pain  produced  by  the  accumulation 
and  distention  is  very  acute.  After  a  variable  period  of  intense  suffering, 
the  drum  bursts,  and  a  copious  discharge  of  pus  takes  place  through  the 
external  meatus.  In  many  cases  recovery  follows  the  perforation  of  the 
drum  and  discharge  of  the  accumulated  pus.  The  aperture  heals  without 
any  serious  impairment  of  hearing.  Not  so,  however,  in  a  few  unfortu- 
nate cases.  Ulceration  of  the  mucous  membrane  and  necrosis  of  the  bony 
structure  may  follow.  The  aperture  may  be  enlarged  by  complete  destruc- 
tion of  the  drum,  and  the  ossicles,  becoming  detached,  may  be  discharged. 
In  such  cases  the  hearing  will  be  seriously  impaired,  if  not  totally  de- 
stroyed. The  inflammation  may  extend  to  the  meninges,  followed  by  con- 
vulsions and  death.  In  other  rarer  instances  the  ear-complication  becomes 
chronic,  terminating  finally  in  total  deafness,  and  perhaps  in  death. 

Convulsions  occurring  at  the  outset  of  the  disease  are  not  necessarily  an 
alarming  symptom,  but  when  recurring  or  occurring  during  the  progress  of 
the  disease  are  a  very  fatal  complication.  J.  Lewis  Smith  asserts  that  con- 
vulsions occurring  after  the  complete  development  of  the  exanthem  are  uni- 
formly fatal.  This  may  be  true  when  caused  by  cerebral  congestion  or  the 
scarlatinous  poison  ;  but  ursemic  convulsions  are  not  necessarily  fatal. 

Nervous  disturbances  of  variable  character,  motor  and  sensory,  are  not 
infrequent.  Hemiplegia,  paraplegia,  and  paralyses  of  single  nerves  have 
been  observed.  Neuralgise,  hypersesthetic  and  anaesthetic  conditions,  epi- 
lepsy and  hysteria,  and  a  variety  of  mental  disturbances,  have  followed 
scarlet  fever. 

Nephritis. — Nephritis  may  appear  as  either  a  complication  or  a  sequel 


SCARLET   FEVER.  571 

of  scarlet  fever,  and  is  as  often  associated  with,  the  mild  as  with  the  severe 
forms.  Some  recent  authors  maintain  that  renal  derangement  is  present  in 
everv  case ;  but  this  extreme  view  cannot  be  admitted.  It  is,  however,  far 
more  frequent  than  is  generally  believed.  It  is  more  constantly  present  in 
some  epidemics  than  in  others,  and  may  begin  with  the  beginning  or  at  any 
stage  of  the  disease,  but  most  frequently  the  first  symptoms  are  not  observed 
before  the  latter  half  of  the  first  or  during  the  second  week.  As  a  sequel 
it  may  not  appear  for  several  weeks  after  convalescence.  No  patient  ought 
to  be  considered  safe  until  six  weeks  have  elapsed.  In  some  cases  it  is  a 
febrile  phenomenon,  but  in  most  cases  it  is  an  effect  of  the  scarlatinal  poison, 
and  in  other  instances  it  is  probably  the  result  of  indiscretion  in  diet  or  of 
improper  exposure.  It  may  appear  as  a  mild  albuminuria  with  moderate 
diminution  of  the  amount  of  urine  and  gradually  increase  from  day  to  day, 
or  it  may  set  in  suddenly  with  intense  headache,  stupor,  and  convulsions, 
followed  by  coma  and  death.  In  fact,  it  may  be  said  to  be  as  insidious  in 
its  onset,  as  irregular  in  its  course,  and  as  uncertain  in  its  result  as  the 
disease  which  it  so  frequently  complicates  and  aggravates. 

Scarlatinous  nephritis  may  or  may  not  be  a  dangerous  complication. 
The  danger  lies  mainly  in  the  failure  to  discover  its  presence  until  grave 
symptoms  appear.  Careful  observation  of  the  quantity  and  specific  gravity 
of  the  urine  should  be  made  daily,  and  chemical  and  microscopical  exami- 
nation sufficiently  often  to  discover  the  early  symptoms  of  simple  renal 
catarrh.  A  diminution  in  the  quantity  of  urine  is  usually  the  first  symp- 
tom. The  albumen  may  be  slight.  Dropsy  is  usually  later,  but  may  be  one 
of  the  early  symptoms.  It  may  begin  as  a  slight  oedema  about  the  eyes  and 
quickly  invade  the  serous  cavities.  If  the  early  symptoms  of  a  mild  renal 
catarrh  be  overlooked  or  neglected,  the  complication  may  very  speedily 
become  more  serious  than  the  original  disease.  The  urinary  secretion  may 
be  totally  suppressed  or  very  scanty,  highly  albuminous,  with  an  abundant 
deposit  containing  hyaline,  epithelial,  and  granular  casts,  with  epithelial 
cells  and  blood-corpuscles  in  varying  quantities.  In  such  cases  the  course 
will  be  marked  by  rapid  increase  of  the  dropsy,  more  or  less  headache, 
sudden  elevation  or  accession  of  fever,  vomiting  more  or  less  persistent, 
and,  finally,  convulsions,  either  partial  or  unilateral,  clonic  or  tonic,  and 
perhaps  recurring  in  rapid  succession,  followed  by  coma  and  death. 

Scarlatinal  nephritis  is  not  necessarily,  even  in  its  graver  forms,  a  fatal 
Cfjmplication.  If  recognized  in  the  beginning  it  usually  yields  to  prompt 
and  appropriate  treatment,  but  when  not  discovered  until  late  it  becomes  a 
very  grave  disorder ;  but  no  case  ought  to  be  dismissed  as  liopeless  until  the 
evidences  of  renal  degeneration  beyond  restoration  are  manifest. 

Diagnosis. — In  a  majority  of  cases,  when  first  seen  by  the  physician 
the  diagnosis  may  be  made  at  a  glance.  A  characteristic  exanthcm  and 
angina,  or  either  separately,  with  a  moderate  or  a  high  fever,  will  be  suffi- 
cient. The  prevalence  of  the  disease,  or  the  fact  of  exposure  of  a  suscep- 
tible person  to  the  contagion,  is  always  suggestive,  and  frequently,  in  cases 


572  SCARLET    FEVER. 

of  doubt,  is  sufficient  to  establish  the  nature  of  the  malady.  Failures  in  diag- 
nosis do  not  often  occur  in  the  regular  form.  The  difficulties  mainly  refer 
to  the  irregular  and  malignant  forms,  and  in  such  case's  the  circumstances  of 
prevalence  and  exposure  to  the  contagion  constitute  important  elements.  If 
either  or  both  of  these  facts  are  established,  a  provisional  diagnosis  may  be 
made  under  a  great  variety  of  symptomatic  conditions  before  the  appearance 
of  the  exanthem  or  the  development  of  the  characteristic  angina.  The  sub- 
sequent history  would  speedily  verify  its  correctness.  Previous  exposure 
of  a  susceptible  person  within  a  reasonable  period  of  time  would  establish 
the  diagnosis,  before  the  appearance  of  the  rash,  in  a  person  taken  suddenly, 
or  after  several  days  of  indisposition,  with  a  chill  or  a  convulsion,  with 
more  or  less  fever  and  a  mild  angina,  which  might  be  nothing  more  than  a 
slight  tenderness  and  redness  of  the  throat.  The  circumstance  of  prevalence 
or  exposure  would  be  even  more  important  in  cases  beginning  with  a  chill, 
a  convulsion,  or  severe  vomiting,  followed  by  more  or  less  fever ;  in  cases 
beginning  with  a  slight  angina  with  moderate  fever ;  or  in  cases  beginning 
with  an  indistinct  rash,  without  either  fever  or  angina,  or  Avith  a  high  or 
moderate  fever  without  any  of  the  usual  accompanying  phenomena.  In  all 
such  cases  the  appearance  of  the  characteristic  exanthem  or  the  development 
of  the  anginose  conditions  woiild  establish  the  diagnosis.  In  some  such 
cases  a  roseola  or  erythema,  due  to  intestinal  troubles,  may  complicate  the 
diagnosis,  but  the  delay  of  a  day  or  two  will  usually  remove  the  doubt.  In 
scarlet  fever  the  symptoms  are  more  serious  and  persistent,  and  the  peculiar 
condition  of  the  tongue,  more  or  less  marked,  is  present.  Erythema  is  not 
so  widely  diffiised,  spreads  in  an  irregular  manner,  and  is  absent  from  the 
extremities,  neck,  and  portions  of  the  chest.  Roseola  is  usually  unattended 
with  fever  or  acceleration  of  the  pulse.  There  are  no  joint  or  glandular 
swellings,  and  the  rash  is  more  likely  to  appear  in  circumscribed  spots,  and 
resembles  measles. 

When  the  doubt  arises  from  scantiness  of  the  exanthem,  the  angina  will 
rarely  be  absent,  and  the  tongue  will  present  its  usual  characteristic  appear- 
ance. In  most  cases  there  will  be  more  or  less  swelling  of  the  cervical 
glands.  In  some  such  cases  the  diagnosis  cannot  be  made  until  desquama- 
tion occurs,  or,  perhaps,  symptoms  of  nephritis  appear. 

The  condition  of  the  tongue,  with  an  eruption,  and  the  occurrence  of 
cervical  lymphadenitis  or  a  mild  form  of  nephritis,  may  occasionally  consti- 
tute the  entire  picture.  The  absence  of  the  scarlatinal  eruption  from  the 
region  of  the  mouth  is  often  a  valuable  differential  symptom. 

Rheumatic  conditions  or  a  nephritis  with  a  scarlatinal  tongue,  desqua- 
mation, and  swelling  of  the  cervical  glands  will  establish  the  diagnosis. 

A  miliary  eruption,  with  or  without  sudamina,  may  be  differentiated  by 
the  absence  of  the  ano-ina,  glandular  enlaro-ements,  and  characteristic  tou2:ue. 
It  is  never  so  generally  diffused  over  the  whole  body. 

Erysipelas  is  distinguished  by  the  punctate  character  of  the  scarlatinal 
rash  and  the  vesicular  formations  with  oedema  of  the  connective  tissue  in 


SCAELET   FEVER.  573 

erysipelas.     lu  scarlet  fever  desquamation  may  occur  in  places  where  there 
was  no  eruption ;  in  erysipelas  it  is  always  limited  to  the  affected  part. 

It  is  sometimes  very  difficult  to  distinguish  scarlet  fever  from  rubeola 
and  measles.  In  rubeola  the  rash  appears  as  early  on  the  face  as  on  the 
neck  and  trunk,  and  is  short  in  duration.  The  scarlet  tongue  is  absent,  and 
the  inflammation,  if  present,  is  more  generally  diffused  throughout  the  oral 
cavity  and  pharynx. 

Measles  must  be  distinguished  by  the  history,  the  prodromal  stage,  the 
coryza,  the  later  appearance  of  the  eruption,  the  course  and  character  of 
the  fever,  peculiarities  of  the  exanthem,  and  the  absence  of  the  special 
characteristics  of  scarlet  fever. 

In  malignant  forms  without  an  eruption,  the  diagnosis  can  be  made  only 
bv  the  intensity  of  the  fever  and  coexisting  severe  nervous  disturbances 
without  other  assignable  cause.  The  prevalence  of  an  epidemic  or  the  fact 
of  exposure  of  the  patient  to  the  contagion  will  be  an  important  aid. 

In  very  many  cases  of  the  irregular  forms  of  scarlet  fever  the  diagnosis  * 
will  be  perplexing,  but  a  careful  study  of  the  history  of  the  case  and  close 
and  intelligent  observation  of  the  symptoms  will  almost  always  enable  the 
physician  to  reach  a  correct  diagnosis.  Sometimes  there  may  be  a  delay  of 
a  day  or  two ;  but  few,  if  any,  cases  occur  which  do  not  during  their  course 
jjresent  phenomena  sufficiently  characteristic  to  settle  the  diagnosis  defi- 
nitely. 

Scarlatinous  dropsy  is  easily  distinguished  by  its  occurrence  in  children 
during  or  subsequent  to  an  attack  of  the  fever,  its  acute  course,  and  its 
usual  beginning  about  the  face  and  subsequent  effusion  into  the  serous 
cavities.  When  occurring  late  during  convalescence  there  will  be  present 
the  evidence  or  history  of  desquamation,  and  probably  existing  glandular 
enlargements. 

Prognosis. — The  prognosis  of  scarlet  fever  is  as  indefinable  as  the 
general  course  and  progress  of  the  disease.  In  the  ordinary  regular  form 
it  is  favorable,  but  the  variations  are  so  numerous  and  the  liability  to  com- 
plications is  so  constant  that  the  mildest  case  may  be  suddenly  transformed 
into  one  of  maximum  gravity.  The  most  trivial  complication  may  quickly 
change  the  whole  picture.  Constitutional  peculiarities,  epidemic  influences, 
circumstances  of  life,  intensity  of  the  poison,  season,  location,  density  of 
population,  pre-existing  disease,  age,  nursing  and  care,  and  diet,  are  im- 
portant considerations,  and  often  factors  decisively  determining  a  favorable 
or  an  unfavorable  prognosis.  Hyperpyrexia,  with  a  temperature  rapidly 
rising  to  or  continuing  above  105°  F.,  with  or  without  the  usual  nervous 
disturbances,  a  fever  persisting  after  the  beginning  of  desquamation,  or 
failing  to  decline  with  the  fading  of  the  exanthem,  or  marked  by  acute 
exacerbations,  is  unfavorable.  All  nervous  disturbances  and  all  inflam- 
matory complications  iiuM'oase  the  danger  of  the  disease.  Some  are  more 
serious  than  others.  Gangrenous  angina  very  often,  and  diphtheritic  con- 
ditions more  frequently,  prove  fatal.     Death  is  almost  invariably  the  result 


574  SCARLET    FEVER. 

when  the  diphtheria  extends  to  the  larynx  and  nose.  Intense  coryza, 
extensive  suppuration  of  the  structures  about  the  neck,  typhoid  conditions, 
early  appearance  of  nephritic  disturbances,  intense  albuminuria,  scanty 
urine,  early  appearance  and  persistence  of  dropsical  conditions,  effusion 
into  the  serous  cavities,  severe  and  continuous  vomiting,  dysentery,  severe 
eye-  and  ear-aifections,  and  intense  infection,  are  unfavorable,  and  the  more 
so  in  proportion  to  the  degree  and  extent,  and  to  the  strength  and  condition 
of  the  patient.  Pyaemia  and  septicaemia  are  usually  fatal.  Continuous 
delirium  and  recurring  convulsions  are  very  grave  symptoros,  and  coma  is 
ordinarily  the  sign  of  speedy  death.  Paralytic  complications  are  serious, 
but  not  necessarily  fatal.  An  intense  exauthem,  with  a  high  fever  and  a 
rapid  pulse,  is  very  grave,  and  more  so  when  associated  wdth  extravasation 
of  blood.  Abundant  hemorrhagic  extravasations,  haematuria,  and  evidences 
of  the  hemorrhagic  diathesis,  however  mild  the  associated  phenomena  may 
be,  must  be  accepted  as  signs  of  an  unfavorable  prognosis. 

No  one  can  assert,  either  at  the  beginning  or  during  the  progress  of  any 
case  of  scarlet  fever,  that  it  will  run  a  regular  course  and  terminate  in 
complete  restoration  of  health.  So  long  as  the  regular  form  pursues  the 
ordinary  course,  and  the  stages  of  invasion,  development,  maximum  in- 
tensity, and  decline  of  the  exauthem,  desquamation,  and  convalescence, 
are  uninterrupted,  the  prognosis  will  continuously  improve  from  period  to 
period,  and  one  can,  as  these  successive  stages  run  their  com'se  favorably, 
more  confidently,  though  always  guardedly,  give  assurance  of  ultimate  and 
complete  recovery.  But  even  then  it  must  not  be  forgotten  that  sequelae 
are  not  infrequent,  and  that  the  patient  must  at  least  be  held  as  an  invalid 
until  sufficient  time  has  elapsed  to  justify  the  positive  assurance  of  cure. 

Mortality. — Scarlet  fever  is  the  most  fatal  of  the  exanthematous  dis- 
eases. The  mortality  varies  with  epidemics  and  the  circumstances  of  life. 
In  some  epidemics  it  has  reached  ten  per  cent.  It  is  more  fatal  in  cities 
than  in  the  country,  and  in  hospitals  than  in  private  practice.  In  the 
regular  form  death  is  usually  due  to  some  complication. 

Treatment. — The  expectant  and  symptomatic  methods  of  treatment 
yield  the  best  results.  Various  attempts  have  been  made  to  formulate  a 
specific  treatment  for  scarlet  fever,  but  as  yet  they  have  proved  to  be  of 
little  or  no  value.  Recently  Illingworth  has  stated  that  biniodide  of  mer- 
cury is  a  specific.  Clement  Duke  gives  it  in  doses  varying  from  one-half 
to  one-twenty-fourth  of  a  grain,  and  maintains  that  it  arrests  fever  and  pre- 
vents desquamation.  Shakhovsky  asserts  that  salicylic  acid  will  prevent  all 
complications,  such  as  uraemia,  dropsy,  diphtheria,  anginas,  and  lymphade- 
nitis, and  will  remove  them  when  present.  He  employs  the  following  for- 
mula: R  Acid,  salicylic,  gr.  xv;  aquae  destill.  fervid.,  5ii;  syrup,  aurantii.  Si. 
From  one  to  four  teaspoonfuls  every  hour  during  the  daytime,  and  every 
two  hours  by  night.  To  prevent  relapses,  the  mixture  must  be  continued 
at  longer  intervals  for  several  days  after  defervescence.  He  says  that  he 
has  succeeded  with  this  method  in  a  large  number  of  cases  of  malignant 


SCARLET    FEVER.  575 

type.  It  is,  however,  useless  wheu  resorted  to  late,  or  when  there  is  present 
severe  chronic  disease.  Moderate  cases  of  the  regular  form  need  but  little 
medicine,  and  the  very  mild  cases  none.  Isolation,  confinement  to  bed  in  a 
properly-heated  and  well-ventilated  room,  a  simple  or  fluid  diet,  and  proper 
care  of  the  bowels  may  be  all  that  is  needed.  When  two  or  more  are  sick 
in  the  same  house,  separate  apartments  should  be  provided,  and  cleanliness 
and  disinfection  should  be  rigidly  enforced.  The  person  of  the  patient 
should  be  kept  clean,  the  bed-linen  should  be  changed  daily,  and  all  un- 
necessary hangings  and  furniture  should  be  removed  from  the  sick-room. 
Every  care  should  be  taken  to  prevent  the  dissemination  of  the  contagion. 
It  is  as  much  the  duty  of  the  physician  to  direct  and  supervise  the  methods 
of  prevention  as  it  is  the  duty  of  the  nurse  to  execute  his  orders. 

If  constipation  exists,  an  enema  or  some  mild  aperient  may  be  given. 
Irritating  and  drastic  cathartics  should  be  avoided.  Moderate  diarrhoea 
may  need  nothing  more  than  a  restricted  diet.  If  attended  with  intestinal 
inflammation  and  colicky  pain,  cold  abdomiaal  compresses  may  be  found 
very  useful,  with  such  internal  medication  as  is  usually  applicable  in  entero- 
colitis and  dysenteric  conditions.  Vomiting  in  the  beginning  will  usually 
cease  with  complete  evacuation  of  the  stomach ;  but  when  persistent,  pellets 
of  ice,  carbonic-acid  water,  lime-water,  either  alone  or  with  milk  in  vary- 
ing proportions,  in  small  quantities  at  short  intervals,  will  prove  service- 
able. Lime-water  with  creasote  is  very  valuable  in  irritable  conditions  of 
the  stomach.  Vomiting  recurring  during  the  progress  of  the  disease  is 
usually  associated  with  some  grave  complication,  and  is  best  relieved  by 
such  treatment  as  the  intercurrent  affection  may  demand. 

Restlessness,  sleeplessness,  and  other  mild  nervous  disturbances  will 
frequently  yield  promptly  to  bromide  of  potassium.  Convulsions,  especially 
in  the  early  stage,  may  also  be  controlled  by  it.  The  cerebral  and  nervous 
disturbances  are  so  generally  associated  with  the  febrile  condition  that  their 
proper  treatment  refers  to  the  management  of  the  temperature,  and  such 
measures  as  will  reduce  the  fever  will  effectually  control  them. 

Fever  is  the  most  constant  symptom  demanding  treatment.  When  the 
temperature  ranges  below  102°  F.,  and  is  unattended  with  nervous  pertur- 
bation, but  little  more  than  a  placebo  of  the  liquid  acetate  of  ammonium  is 
needed.  Water  should  be  allowed  in  reasonable  quantity ;  unnecessary  bed- 
clothing  should  be  removed ;  and  tlje  temperature  of  the  room  should  not, 
as  a  rule,  exceed  65°  F.  When  the  patient's  temperature  ranges  above  102° 
F.,  and  especially  when  associated  with  other  symptoms  resulting  therefrom, 
moi-e  effective  measures  should  be  resorted  to.  Quinine  is  a  very  vahi- 
ablc  drug  in  all  grades  of  fever  demanding  energetic  treatment,  and  may  be 
given  in  such  doses  at  short  or  long  intervals  as  the  age  of  the  patient  and 
the  range  of  the  temperature  will  suggest.  In  liyperpyrcxia  larger  doses  at 
shorter  intervals  will  be  required.  Quinine,  preferably  the  hydrochlorate,  in 
tonic  doses,  is  also  very  valuable  in  all  conditions  of  exhaustion,  especially 
so  in  suppurative  complications  and  in  slow  and  protracted  convalescence. 


576  SCARLET    FEVER. 

It  may  be  given  either  by  the  mouth  or  in  the  form  of  rectal  suppositories. 
Antifebrin  and  antipyrin  are  very  efficient  and  certain  agents  to  produce 
rapid  and  decided  lessening  of  the  temperature,  but  are  not  always  safe. 
Antipyrin  is  a  very  popular  antipyretic,  and  is  especially  indicated  in  those 
cases  of  hyperpyrexia  where  the  temperature  is  above  105°  F.  and  at- 
tended with  grave  cerebral  and  nervous  symptoms.  It  should  be  given 
with  great  care  and  not  in  large  doses.  It  is  better  to  repeat  several  small 
doses  than  to  give  one  large  dose ;  and  when  given,  the  physician  should 
make  a  timely  visit  to  observe  the  eifect,  and  not  allow  any  dose  to  be 
repeated  without  such  observation  as  may  enable  him  to  decide  upon  its 
advisability.  If  collapse  should  follow  or  be  threatened,  some  alcoholic 
stimulant  will  be  necessary.  Small  doses  of  antipyrin  are  sometimes  admis- 
sible in  cases  of  moderate  fever  with  high  nervous  excitement  and  delirium, 
but  usually  in  such  cases  the  fever  can  be  controlled  by  some  milder  diapho- 
retic, as  quinine  or  salicylate  of  sodium. 

The  reduction  of  the  temperature  by  the  abstraction  of  heat  is  a  very 
popular  and  efficient  method  of  treating  scarlet  fever.  This  is  accomplished 
by  the  employment  of  cold  water,  in  the  form  of  cold  aifusion,  sponging, 
cold  or  graduated  bath,  bathing  of  the  head,  face,  and  extremities,  the 
cold  pack  of  Currie,  or  the  iced  coil  to  the  head.  When  the  temperature 
does  not  exceed  102°  F.,  it  is  not  necessary  to  resort  to  this  method,  but  in 
many  cases  of  moderate  fever  great  relief  and  comfort  will  be  obtained  by 
fi^equeut  sponging  of  the  head  and  face,  the  effect  of  which  may  be  increased 
by  the  addition  of  bay  rum  to  the  water,  which  promotes  evaporation,  and, 
consequently,  the  rapid  dissipation  of  heat.  When  the  temperature  rises 
above  103°  F.,  and  more  especially  in  the  hyperpyretic  conditions,  wdth 
a  temperature  above  104°  and  perhaps  reaching  106°  or  107°  F.,  some  one 
of  the  more  efficient  methods  of  the  application  of  cold  water  must  be  em- 
ployed, such  as  cold  sponging  of  the  entire  body  frequently  repeated,  Ziems- 
sen's  graduated  bath,  by  immersing  the  patient  in  water  at  90°  F.  and  grad- 
ually reducing  it  to  80°,  the  cold  pack  of  Currie,  or  the  application  of  the 
ice-coil  to  the  head.  The  writer  has  found  the  last  the  most  efficient  and 
rapid  method  of  reducing  very  high  temperatures.  It  is  perfectly  manage- 
able, and  easily  regulated  by  adjusting  the  coil  of  rubber  tubing  about  the 
head,  Avith  the  reservoir  filled  with  water  at  such  temperature  as  may  be 
deemed  necessary,  and  at  such  a  height  above  the  patient  as  will  produce  a 
rapid  or  slower  current  as  may  be  desired.  The  colder  the  water  and  the 
more  rapid  the  current  through  the  tubing,  the  more  rapid  the  abstraction 
of  heat.  This  method  has  accomplished  satisfactory  results  in  cases  where 
antipyrin  had  proved  dangerous  because  of  the  collapse,  following  its  use. 
It  may  be  necessary  in  some  cases  to  associate  these  methods  of  rapid  re- 
duction of  temperature  with  alcoholic  stimulants  to  avoid  exhaustion.  If 
heart-failure  is  threatened,  alcohol,  digitalis,  quinine,  and  the  carbonate  of 
ammonium  may  be  demanded. 

In  all  conditions  of  exhaustion,  whether  caused  by  continuous  high  tern- 


SCARLET   FEVER.  577 

perature  or  bv  other  grave  complications, — and  a  protracted  convales- 
cence must  be  considered  a  complication, — stimulants  are  necessary.  In 
addition,  quinine  in  tonic  doses  and  digitalis  are  valuable  adjuvants.  Digi- 
talis is  oftentimes  not  only  necessary  but  imperatively  demanded,  and  may 
be  given  in  verv  decided  doses.  The  carbonate  of  ammonium  would  be 
contra-indicated  in  cases  complicated  with  stomachal  or  intestinal  disturb- 
ances. Alcohol  in  some  form  and  digitalis  are  the  most  available  remedies 
in  conditions  indicating  the  employment  of  cardiac  stimulants  and  tonics. 

The  condition  of  the  throat  demands  special  attention.  Very  mild 
anginse  need  but  little  treatment,  but  it  is  never  safe  to  neglect  even  the 
mildest  forms  of  throat-affections.  In  such  cases  pellets  of  ice,  frequent 
draughts  of  carbonic-acid  water,  gargles  of  the  chlorate  of  potassium,  or 
powders  of  the  chlorate  and  white  sugar  placed  on  the  tongue  and  allowed 
to  be  dissolved  in  the  saliva,  may  be  all  that  will  be  needed.  In  the  severer 
and  graver  forms  spraying  will  prove  the  most  effective  method  of  treat- 
ment. The  fluid  may  be  either  a  simple  solution  of  the  chlorate  of  potas- 
sium, or  such  solution  to  which  carbolic  acid,  glycerin,  and  tincture  of  the 
chloride  of  iron  have  been  added.  A  spraying  fluid  composed  of  water, 
glycerin,  chlorate  of  potassium,  and  tincture  of  the  chloride  of  iron,  in  such 
proportions  as  the  case  may  demand,  has  proved  the  most  generally  appli- 
cable and  efficient  treatment.  It  is  necessary  to  repeat  the  spraying  every 
one,  tsvo,  or  three  hours,  according  to  the  condition  of  the  throat.  Gan- 
grenous and  ulcerative  anginse  are  to  be  treated  with  disinfecting  and  de- 
odorizing gargles  and  sprays.  Sometimes  cauterization  of  the  ulcerated 
surfaces  will  be  required.  When  complicated  with  infiltration  and  swelling 
of  the  glands  and  connective  tissue  about  the  neck,  cold  compresses  will  be 
sei-viceable  during  the  early,  and  warm  fomentations  or  poultices  during  the 
later,  stages.  As  soon  as  suppuration  can  be  detected,  it  should  be  evacuated 
by  a  free  incision.  In  diphtheritic  and  nasal  complications  the  treatment 
should  conform  to  the  plan  ordinarily  in  use  in  those  diseases. 

The  internal  administration  of  the  chlorate  of  potassium,  either  alone 
or  in  combination  with  the  tincture  of  the  chloride  of  iron,  is  a  routine 
practice  of  undoubted  value  in  very  many  cases  of  scarlet  fever.  The 
potassium  salt  must  not,  however,  be  pushed  too  far,  or  given  in  too  large 
quantity,  for  fear  of  its  injurious  effect  upon  the  kidneys. 

Eye-  and  ear-troubles  must  be  treated  as  similar  affections  would  be 
under  ordinary  circumstances. 

The  inflammatory  complications  do  not  require  any  special  treatment 
l^eyond  that  which  similar  conditions  would  require  as  original  or  primary 
diseases.  It  must  always  be  borne  in  mind,  however,  that  such  affections 
occurring  as  complications  of  scarlet  fever  are  always  more  serious  than 
when  attacking  a  subject  otherwise  healthy.  He  is  most  successful  in  the 
management  of  such  cases  who  is  most  alert  in  the  recognition  of  the 
earliest  symptoms  of  such  intercurrent  maladies  and  equally  prompt  in 
the  application  of  such  treatment  as  the  extent  of  the  disease  may  require. 

Vol.  I.— 37 


578  SCARLET    FEVER. 

In  bronchial  and  pulmonary  complications  the  air  of  the  room  should  be 
kept  pure. 

Rheumatism  is  usually  mild,  and  needs  nothing  more  than  complete 
rest  of  the  affected  joint  and  the  application  of  some  anodyne  liniment. 
Synovitis  will  demand  the  treatment  usual  in  such  cases. 

As  a  rule,  the  exanthem  needs  no  further  attention  than  some  applica- 
tion to  allay  the  itching.  Sponging  with  tepid  water  will  frequently  meet 
this  indication  and  afford  great  relief  to  the  patient,  while  at  the  same  time 
it  will,  in  a  measure,  lessen  the  fever.  Some  one  of  the  inunctions  before 
referred  to  may  be  employed.  Some  maintain  that  inunctions  diminish 
the  temperature  of  the  body,  and  with  this  view,  in  former  years,  the  daily 
anointing  of  the  entire  body  with  lard  was  advised  and  highly  extolled. 
Vaseline,  cacao  butter,  or  pure  glycerin  is  much  neater,  and  equally  effective 
in  relieving  the  burning  and  itching.  In  cases  where  the  exanthem  is 
delayed,  partially  develops,  or  fades  too  soon,  a  warm  bath,  hot  or  warm 
douches,  hot  poultices  containing  mustard,  or  cold  affusion  followed  by 
warm  wrappings,  may  be  employed.  If  such  irregularities  of  the  exan- 
them are  attended  with  grave  symptoms,  the  most  energetic  applications 
will  be  necessary,  together  with  the  internal  administration  of  ammonia 
and  antifebrile  medicines. 

Nephritis  demands  special  care.  It  cannot  be  said  that  every  death 
attributable  to  this  complication  is  due  to  the  neglect  of  the  medical 
attendant,  but  it  is  true  in  much  the  larger  number  of  cases.  All  cases  in 
which  marked  diminution  in  the  quantity  of  urine  occurs,  whether  or  not 
attended  with  any  other  symptom  of  renal  disturbance,  demand  prompt 
attention.  If  simply  a  febrile  phenomenon,  the  reduction  of  the  tempera- 
ture and  increased  allowance  of  fluid  may  suffice.  Flushing  of  the  kidney 
by  increasing  the  consumption  of  some  pure  drinking-water,  such  as  the 
Poland,  is  not  only  valuable  as  a  remedial  measure,  but  will  also  to  some 
extent  prove  preventive  of  renal  complication  by  dilution  of  the  concen- 
trated urinary  filtration. 

The  danger  of  scarlatinal  nephritis  lies  mainly  in  the  failure  or  arrest 
of  the  emunctory  function  of  the  kidneys,  and,  consequently,  in  ursemic 
toxaemia.  The  indications,  therefore,  for  treatment  must  refer  to  the  pro- 
motion of  elimination  by  diaphoresis,  catharsis,  and  diuresis.  Diaphoresis 
may  be  promoted  by  steam,  hot-water,  or  hot-air  baths.  The  first  may  be 
accomplished  by  enveloping  the  patient  under  cover  with  steam  conveyed 
by  rubber  tubing  from  a  generator,  or  by  placing  around  the  patient  hot  bot- 
tles or  bricks  wrapped  in  moist  cloths ;  the  hot-water  bath,  by  immersing 
the  patient  in  water  at  the  temperature  of  90°  F.  and  gradually  raising 
it  to  105°  or  110°  F. ;  and  the  hot-air  bath,  by  packing  about  the  patient, 
under  cover,  bottles  filled  witli  hot  water,  care  being  taken  to  avoid  direct 
contact  of  the  bottles  with  the  skin.  These  baths  may  be  repeated  at 
longer  or  shorter  intervals,  as  circumstances  may  require.  Free  diaphoresis 
is  the  most  effective  method  of  elimination  in  cases  of  imperative  urgency, 


SCARLET    FEVER.  579 

when  the  renal  function  is  nearly  or  totally  suppressed.  In  such  cases  the 
hypodermatic  use  of  the  hydrochlorate  of  pilocarpine,  or  the  internal  em- 
ployment of  the  fluid  or  solid  extract  of  jaboraudi,  becomes  a  yaluable  and 
often  necessary  adjuvant.  In  addition  to  the  diaphoretic  measure,  prompt 
attention  should  be  given  to  the  bowels,  and,  unless  some  contra-indication 
is  present,  free  catharsis  should  be  induced.  A  saline  purgative  may  be 
sufficient,  but  usually  the  comj)ound  jalap  powder,  in  decided  doses,  will 
be  preferable  and  more  effective.  In  cases  of  great  urgency,  podophylliu, 
croton  oil,  or  elaterium  may  be  given.  Loomis  insists  that  a  full  dose  of 
calomel  will  prove  very  valuable  in  cases  attended  with  considerable  effusion. 
It  not  infrequently  happens  that  after  a  fi-ee  sweating  and  purgation  the 
quantity  of  urine  increases  very  rapidly  :  nevertheless,  it  is  not  wise  to 
omit  such  measures  as  may  aid  in  speedy  restoration  of  the  renal  function. 
Hot  poultices  may  be  applied  to  the  back.  Common  experience  points  to 
acetate  of  potassium  and  digitalis  as  the  most  efficient  diuretics, — the  latter 
especially  so  when  there  is  present  any  condition  of  the  heart  indicating  its 
use.  They  may  or  may  not  be  given  in  combination,  and  should  be  given 
in  doses  at  such  intervals  as  the  urgency  of  the  symptoms  may  demand. 
The  inftision  of  digitalis  is  the  most  reliable  preparation.  If  the  effusion 
in  the  pleural  or  abdominal  cavity  is  serious,  paracentesis  must  be  performed. 
The  withdrawal  of  a  portion  of  the  liquid  will  usually  promote  the  rapid 
absorption  of  the  remaining  portion.  In  the  later  stages  of  scarlatinal 
nephritis  iron  and  quinine  become  most  valuable  remedies.  The  tincture 
of  the  chloride  of  iron,  in  the  form  either  of  Basham's  mixture  or  the  mis- 
tura  ferri  et  ammonii  acetatis,  is  especially  beneficial  in  the  later  and  anaemic 
condition.  Ursemic  convulsions  should  be  treated  by  brisk  purging  and 
copious  sweating,  together  with  the  employment  of  efficient  diuretics.  The 
bromide  of  potassium,  chloral  hydrate,  chloroform  by  inhalation,  or  the 
sulphate  of  morphia  hypodermatically,  may  be  employed  to  control  the  con- 
vulsions for  the  time  being.  Illingworth  advises  venesection.  In  drop- 
sical conditions  jalap  is  the  best  purgative,  and  iron  is  the  essential  tonic. 

The  diet  should  be  fluid,  preferably  milk,  light  broths,  and  soups. 
Farinaceous  foods  may  be  allowed  in  limited  quantity  after  the  acute  stage 
has  passed.  A  rigid  but  proper  dietary  should  be  adhered  to  until  the 
disappearance  of  the  renal  complication.  The  patient  should  be  confined 
to  the  house,  and  perhaps  to  the  sick-chamber,  and  all  exposure  of  the 
])erson  to  sudden  and  inclement  clianges  of  weather  should  be  avoided. 
Chronic  cases  should  be  treated  as  cases  of  Bright's  disease. 

The  general  management  of  scarlet  fever  after  the  disease  has  run  its 
ordinary  course,  terminating  with  the  completion  of  desquamation,  refers  to 
the  treatment  of  the  complications  and  sequelae,  the  nutrition  of  the  patient, 
and  the  employment  of  such  tonics,  especially  iron  and  quinine,  and  pcrliaps 
alcoholic  stimulants,  as  may  be  necessary  to  support  the  patient  and  obviate 
fatal  exhaustion. 


DIPHTHERIA. 

By  J.   LEWIS    SMITH,   M.D. 


Diphtheria  is  one  of  the  most  dreaded,  one  of  the  most  fatal,  and 
unfortunately  one  of  the  most  common  maladies  of  childhood.  It  is  be- 
lieved to  be  produced  by  a  micro-organism.  It  is  characterized  by  the 
occurrence  of  a  grayish-white  pellicle  upon  the  mucous  surface,  or  the  skin 
deprived  of  its  protecting  epithelium.  The  specific  principle  is  ordinarily 
received  by  the  inspiration  of  infected  air,  but  it  is  sometimes  received  by 
direct  contact  of  infected  matter  with  one  of  the  surfaces  not  lying  in  the 
respiratoiy  tract. 

Diphtheria  is  a  disease  of  antiquity.  M.  Sanne  mentions  the  following 
names  by  which  it  has  been  known  in  diiferent  countries  and  at  different 
periods :  ulcus  Syriaoum,  ulcus  ^gyptiacum,  garrotillo,  morbus  suffocans, 
affectus  strangulatorius,  pestilentis  gutturis  afPectio,  pedancho  maligna,  an- 
gina maligna,  anginosa  passio,  mal  de  gorge  gangreneux,  ulcere  gangreneux, 
angina  polyposa,  angine  maligne,  croup,  diphtheritis,  diphtheria.  These 
terms  expressing  the  prominent  characteristics  of  diphtheria  render  it  prob- 
able that  this  was  the  disease  alluded  to. 

It  is  impossible  to  state  or  form  a  probable  conjecture  in  regard  to  the 
time  when  diphtheria  originated,  but  its  origin  probably  antedated  the 
Christian  era.  According  to  Aurelianus,  Asclepiades,  who  lived  one  hun- 
dred years  before  Christ,  scarified  the  tonsils,  and  performed  laryngotomy 
for  the  relief  of  respiration,  and  it  is  supposed  that  he  treated  cases  of 
membranous  croup,  and  probably  diphtheria.  Areteeus,  a  Greek  physician 
of  Cappadocia  at  the  commencement  of  the  Christian  era,  gave  in  writings 
still  extant  a  clear  and  accurate  description  of  mild  and  severe  diphtheria. 
After  describing  what  he  designates  ulcers  upon  the  tonsils  "covered  with 
a  white,  livid,  or  black  concrete  product,"  he  adds,  "  If  the  malady  invades 
the  chest  by  the  trachea,  it  causes  suffocation  on  the  same  day.  Children 
up  to  the  age  of  puberty  are  most  exposed  to  this  disease."  He  gives,  also, 
a  graphic  and  truthful  description  of  the  suffering  of  the  child  when  the 
disease  extends  to  the  larynx  and  croup  results.  Galen,  in  the  second 
century,  apparently  alludes  to  diphtheria,  when  he  describes  a  fatal  disease 
prevalent  at  his  time,  in  which  fragments  of  "membranous  tunic"  are  ex- 
pelled. He  states  that  he  is  able  to  determine  by  the  manner  in  which  the 
580 


DIPHTHERIA.  581 

fragments  are  expelled,  by  coughing  or  spitting  (hawking),  whether  they 
are  detached  from  the  larynx  or  the  pharynx.  Coelius  Alirelianus,  a  Latin 
physician,  who  is  supposed  by  some  to  have  lived  in  the  second  century 
and  by  others  as  late  as  the  fifth  century,  describes  a  grave  angina  in  which 
the  symptoms  which  sometimes  arise  correspond  with  those  in  diphtheritic 
croup  and  diphtheritic  paralysis  as  observed  at  the  present  time.  In  the 
fifth  century  Aetius  of  Amida  described  a  disease  accompanied  by  "  crusty 
and  pestilential  ulcers"  sometimes  having  a  whitish  and  in  other  instances 
an  ashy  or  rusty  color,  and  not  preceded  by  a  discharge.  Aetius  alludes  to 
the  hoarseness  which  he  says  sometimes  supervenes,  and  is  a  source  of 
danger  up  to  the  seventh  day. 

From  the  close  of  the  fifth  century  until  the  sixteenth  the  record  of 
diphtheria  is  broken.  It  is  probable  that  during  the  long  period  embraced 
in  the  Dark  Ages,  every  decade  witnessed  epidemics  of  this  fatal  disease, 
but  if  they  were  observed  and  recorded  the  records  were  lost,  the  literature 
of  diphtheria  sharing  the  fate  of  general  literature  during  this  time  of 
intellectual  darkness. 

In  the  sixteenth  century  epidemics  of  diphtheria  occurred  in  various 
parts  of  Europe,  and  clear  and  unmistakable  descriptions  of  them  have  been 
preserved.  From  the  sixteenth  century  until  the  present  time,  diphtheria 
has  continued  to  be  one  of  the  most  frequent  and  fatal  of  the  epidemic  dis- 
eases upon  the  European  continent,  and  it  is  apparently  permanently  estab- 
lished in  its  great  cities. 

It  is  a  remarkable  fact  that  those  pestilential  diseases  which  desolate 
families  and  communities  in  modern  times  originated  in  the  Eastern  hemi- 
sphere, chiefly  in  Asia  or  Africa,  and  extended  to  the  Western  nations 
through  commerce  or  navigation.  The  aborigines  of  America  had  in  their 
primitive  state  no  ailments,  so  far  as  we  can  ascertain,  except  such  as 
occurred  from  vicissitudes  of  temperature  or  were  incident  to  age  and  their 
wild  and  exposed  nomadic  life.  Pernicious  to  them  was  the  discovery  of 
America  by  Europeans  for  various  reasons,  but  especially  because  it  led  to 
the  introduction  of  the  contagious  and  pestilential  maladies.  The  cruel  and 
rapacious  gold-hunters  under  Cortez  introduced  small-pox  into  Mexico,  and 
for  ages  afterwards  throughout  Central  America  heaps  of  skeletons  of  those 
who  perished  of  this  disease  were  found  in  shaded  and  out-of-the-way  local- 
ities where  they  had  been  taken  by  their  friends.  Adventurers  from  the 
Old  World  introduced  the  eruptive  fevers,  and  the  loathsome  contagious 
diseases  of  vice  and  immorality,  into  the  islands  and  upon  the  continent  of 
North  America.  The  medicine-men  of  the  Indians  liad  by  their  incanta- 
tions gained  great  repute  in  the  management  of  the  diseases  with  which  they 
were  familiar  in  tlieir  wild  life  in  the  forests,  but  they  were  unable  to  cope 
with  the  new  diseases  which  the  vessels  of  the  foreigner  liad  l)r()Uo;ht  to  this 
Western  world. 

Of  all  tlie  diseases  which  America  has  received  from  Europe,  the  one 
most  dreaded,  because  of  its  highly  contagious  character,  the  great  mortality 


582  DIPHTHERIA. 

which  attends  it,  and  the  extreme  suifering  which  certain  forms  of  it  pro- 
duce, is  diphtheria.  It  is  to  be,  from  appearance,  above  all  other  maladies 
the  scourge  of  America  in  the  future.  It  is  probable  that  the  first  casies  of 
diphtheria  in  America  occurred  in  or  near  Boston.  Josselyn  made  two  voy- 
ages to  New  England  in  1638  and  1663,  remaining  eight  years  in  this  coun- 
try after  his  second  arrival.  He  states  that  the  Europeans  residing  in  New 
England  are  greatly  afflicted  by  a  disease  "  which  hath  proved  mortal  to 
some  in  a  very  short  time,  quinsies  and  impostumations  of  the  almonds, 
with  great  distempers  of  colds."  ^  At  Roxbury,  Massachusetts,  in  1659, 
three  children  in  a  family  were  attacked  by  the  "  malady  of  bladders  in  the 
windpipe,"  all  dying  within  two  weeks.^ 

At  the  close  of  the  seventeenth  century  and  in  the  first  half  of  the 
eighteenth  century  epidemics  of  diphtheria  occurred  in  various  parts  of 
New  England.  At  Kingston,  New  Hampshire,  in  March,  1735,  a  child 
died  of  three  days'  sickness  of  a  throat-aifection.  A  week  subsequently, 
three  children  in  another  family,  four  miles  distant  from  the  first  case,  also 
died  of  a  three  days'  sickness.  The  malady  continued  to  spread,  and  the 
first  forty  cases  all  perished.  They  died  of  a  disease  located  in  the  throat, 
neck,  and  air-passages,  attended  in  many  of  them  by  swelling  of  the  cheek 
or  neck.  The  disease  from  Kingston  spread  to  other  townships,  but  in  its 
subsequent  course  it  was  milder  than  at  first.  We  recognize  in  this  name- 
less disease  the  characteristics  of  diphtheria. 

In  August,  1735,  in  Boston,  a  child  had  a  disease  of  the  fauces  at- 
tended by  white  spots.  In  the  following  month  several  similar  cases  oc- 
curred in  different  parts  of  Boston.  In  October  of  the  same  year  a  young 
man,  lately  arrived  from  Exeter,  New  Hampshire,  where  a  brother  had 
died  of  this  new  disease,  himself  sickened  with  it,  in  a  more  severe  form 
than  had  yet  occurred  in  Boston.  Diphtheria  thus  established  in  Boston 
was  epidemic  during  the  following  winter  and  spring  months.  At  the 
height  of  the  epidemic,  in  the  second  week  of  March,  1736,  the  burials 
increased  from  an  average  of  ten  to  twenty-four,  through  the  prevalence 
and  severity  of  the  new  disease.  Two  years  later, — 1738, — a  monograph 
appeared  from  the  pen  of  I.  Dickinson,  A.M.,  Boston,  bearing  the  title, 
"Observations  on  that  Terrible  Disease  vulgarly  called  the  Throat  Dis- 
temper, with  Advices  as  to  the  Method  of  Cure,  in  a  letter  to  a  friend." 
The  writer  of  this  epistle,  though  a  clergyman,  appears  to  have  been  a  close 
observer.  He  probably,  as  was  not  unusual  at  that  period,  practised  both 
as  physician  and  clergyman.  Dickinson's  graphic  description  shows  that 
the  disease  in  his  day  presented  the  same  characteristics  as  at  present. 

Diphtheria  thus  established  in  eastern  New  England  spread  westward 
through  the  intercourse  of  the  inhabitants,  reaching  New  York  in  about 
two  years.     Dr.  Cadwallader  Golden,  writing  in  1753,  had  already  carefully 


1  Wm.  Veazie,  Boston,  1865. 

2  Historical  Researches  of  Dr.  Elsworth  Eliot. 


DIPHTHERIA.  583 

observed  diphtheria.  He  remarks,  "  When  the  disease  first  appeared  it 
was  treated  in  the  usual  way  for  a  common  angina,  and  no  plague  was 
more  destructive.  .  .  .  The  orifices  made  by  the  lancet  in  bleeding,  and  the 
adjacent  parts,  were  apt  to  become  diseased ;  so  likewise  the  places  where 
blisters  were  applied."  He  recognized  the  fact,  now  well  known,  that  in 
rare  instances  the  throat  remains  unaffected,  while  the  diphtheritic  inflam- 
mation and  exudate  appear  upon  other  surfaces  :  "  A  girl  about  ten  years 
of  age,  while  the  throat-distemper  was  prevaihng,  had  sores  on  her  private 
parts,  like  those  on  the  tonsils  of  others,  but  no  symptom  of  the  disorder 
appeared  in  her  throat."  Dr.  Jacob  Ogden,  wanting  from  Jamaica,  Long 
Island,  in  1769,  and  again  in  1774,^  described  diphtheria  as  it  occurred  in 
his  practice  and  in  the  adjacent  townships.  He  recommended  the  use  of 
senega  and  calomel.  But  the  American  physician  of  this  period  whose 
writings  contributed  most  to  a  correct  understanding  of  diphtheria  was 
Samuel  Bard,  of  New  York  (1771).  He  possessed  a  mind  admirably 
qualified  for  scientific  investigations,  and  especially  for  study  of  an  obscure 
disease,  basing  his  opinions  upon  accurate  clinical  examinations.  A  recent 
appreciative  reviewer.  Dr.  John  C.  Peters,  says,  "Bard's  article  is  among 
the  calmest,  wisest,  and  most  accurate  that  has  ever  been  written  on  diph- 
theria, both  before  and  since  his  time."  He  recognized  the  fact  that  the 
various  forms  of  diphtheritic  inflammation  were  identical  in  nature,  and, 
however  differing  in  appearances,  had  the  same  underlying  cause. 

In  the  first  half  of  the  present  century  diphtheria  was  regarded  as  a  very 
important  disease  in  Europe,  and  was  made  the  subject  of  investigation  by 
the  most  renowned  clinical  teachers,  among  whom  we  may  mention  Jurine 
(1807),  Bretonneau  (1821),  Bourgeoise  (1823),  Gendron  (1825),  Billard 
(1826),  Bland  (1827),  Blanquin  (1828),  Broussais  (1829),  Trousseau  (1830), 
Cheyne  (1833),  Fricout  and  Burley  (1836),  Boudet  (1842),  Guersant  and 
Blache  (1844),  Moland  (1845),  Damot  (1846),  and  Heine  (1849).  During 
this  half-century,  ending  with  1850,  which  witnessed  such  an  augmentation 
of  the  literature  of  diphtheria  in  Europe,  this  disease  attracted  but  little 
attention  in  America.  It  appears  to  have  been  much  less  prevalent  on  this 
continent  than  in  the  Old  World.  It  may  have  occurred  in  small  epidemics 
in  various  localities  from  the  time  of  Dr.  Bard  until  1850,  but  they  attracted 
so  little  notice  from  American  physicians  that  no  monograph  or  communi- 
cation to  medical  journals  relating  to  diphtheria,  which  was  worthy  of 
preservation,  appeared  during  this  long  period. 

Since  1850,  epidemics  of  diphtheria  have  occurred  in  numerous  localities 
in  North  America,  not  only  in  the  cities  with  their  sewers  and  crowded 
tenement-houses  rendering  the  air  impure,  but  also  in  the  sparsely-settled 
and  mountainous  sections,  where  no  impurities  in  the  air  exist.  But  diph- 
theria is  most  prevalent  and  fatal  in  the  cities.  During  the  last  quarter- 
century  it  has  become  established  in  most  of  the  larger  cities  in  the  Northern 

^  See  Medical  Keport,  vol.  v.,  1802. 


584  DIPHTHEEIA. 

and  Western  States  from  the  Atlantic  to  the  Pacific  coast,  along  the  line  of 
commerce  and  travel.  The  permanent  establishment  of  diphtheria  in  the 
centres  of  trade  and  travel,  and  the  fact  that  many  have  this  subtle  malady 
in  so  mild  a  form  that  they  are  not  aware  of  it  and  mingle  with  others  in 
places  of  resort,  iuevdtably  tend  to  disseminate  the  disease  throughout  the 
country.  Hence  in  rural  localities  intervening  between  the  cities  outbreaks 
of  diphtheria  of  unknown  origin  are  common,  in  at  least  all  the  eastern, 
northern,  central,  and  western  portions  of  the  United  States  and  in  Canada. 
Consequently  in  the  last  two  decades  in  America  diphtheria  has  been  the ' 
subject  of  discussion  at  numerous  meetings  of  medical  societies,  many  cases 
of  interest  have  been  reported,  and  histories  of  epidemics  and  statistics  of 
treatment  have  been  published  in  the  medical  journals.  Therefore  the 
American  literature  of  diphtheria  is  abundant  and  rapidly  accumulating, 
and  to  the  genius  and  perseverance  of  an  American  (O'Dwyer)  the  world 
is  indebted  for  the  means  of  combating  more  successfully  than  in  former 
times  the  most  painful,  most  dreaded,  and  most  fatal  form  of  diphtheritic 
inflammation. 

In  Europe,  diphtheria  is  established  in  the  centres  of  medical  education, 
as  Paris,  Berlin,  London,  and  more  recently  Vienna.  It  has  in  these  cities 
and  in  smaller  cities  and  towns,  where  it  has  occurred,  been  the  subject  of 
much  discussion  and  investigation.  In  Europe,  therefore,  as  well  as  in 
America,  the  literature  of  diphtheria  has  been  greatly  increased  during  the 
last  decade,  by  reports  of  cases,  histories  of  epidemics,  and  statistics  of 
treatment.  In  six  consecutive  months  in  1888  the  deaths  from  diphtheria 
in  ten  of  the  principal  cities  of  Europe  were  as  follow^s  : 


Deaths.  Population. 

Paris 1047  2,260,945 

London 852-  4,282,921 

Berlin 523  1,414,980 

St.  Petersburg     ...      341  928,016 

Vienna 251  1,212,232 


Deaths.  Population. 

Buda-Pesth 207  442,787 

Copenhagen 210  300,000 

Christiania 196  135,600 

Prague 161  300,828 

Amsterdam 136  390,016 

Bull.  Gen.  de  Ther.,  October  30,  1888. 


In  Madrid,  with  a  population  increasing  from  136,663  in  1880  to 
157,965  in  1885,  the  deaths  from  diphtheria  during  the  six  years  ending 
with  1885  were  as  follows  : 


In  1880 242 

"  1881 799 

"  1882 587 


In  1883 1027 

"  1884 1079 

"  1885 1350 

La  Hif/ienc,  October,  1888. 


Among  the  American  physicians  who  liave  recently  advanced  our  knowl- 
edge of  diphtheria  are  Drs.  Curtis  and  Satterthwaite,  of  New  York,  in  their 
Report  on  the  Pathology  of  Diphtheria  made  to  the  New  York  Board  of 
Health,  Drs.  Wood  and  Formad,  of  Pliiladelphia,  in  their  ]\Iemoir  on  the 
Nature  of  Diphtheria,  prepared  for  and  published  by  the  National  Board  of 
Health  in  1882,  and  Dr.  A.  Jacobi,  in  his  treatise  on  diphtheria  (W.  Wood 


DIPHTHEEIA.  585 

&  Co.,  1880).  In  Europe  during  the  same  period  interesting  and  instructive 
monographs  have  been  published  by  Peters,  Birch-Hirschfeld,  Rosenbach, 
Leyden,  Wagner,  Fiirbringer,  Fischl,  Weigert,  Meyer,  and  others. 

Etiology. — During  the  last  twenty  years  numerous  experiments  and 
microscopic  examinations  have  been  made  in  order  to  elucidate  the  cause 
and  nature  of  diphtheria.  Each  year  of  investigation  has  strengthened  the 
belief  that  the  cause  is  a  microbe,  but  it  is  still  a  matter  of  doubt  which 
microbe  is  the  causal  agent,  or  whether  there  may  not  be  more  than  one 
species  of  bacteria  which  by  their  action  upon  and  in  the  tissues  produce 
diphtheria. 

Between  the  years  1868  and  1873,  many  of  the  leading  pathologists  of 
Europe  believed  that  the  cause  of  diphtheria  had  been  discovered, — that  it 
was  the  micrococcus  or  spherical  bacterium.  During  the  decade  commencing 
with  1868  no  subject  in  pathology  attracted  so  much  attention  as  the  rela- 
tion of  the  micrococcus  to  diphtheria.  Oertel  (1868)  discovered  micrococci 
in  the  diphtheritic  pseudo-membrane  and  in  the  blood,  lymphatic  vessels, 
and  kidneys  in  severe  diphtheria,  appearing  as  "  point-like,  dark-contoured, 
round  or  oval  little  bodies,  isolated  and  in  zoogloea."  In  later  investi- 
gations (1874)  he  found  a  larger  or  smaller  number  of  the  bacterium 
termo  accompanying  the  micrococcus,  and  he  expresses  more  firmly  the 
belief  that  micrococci  lodging  on  the  mucous  surface  cause  the  dijahtheritic 
inflammation.  He  produced  croup  in  rabbits  by  applying  ammonia,  and 
found  few  or  no  micrococci  in  the  false  membrane,  and  never  in  the  blood 
or  internal  organs.  He  inoculated  the  trachea  of  rabbits,  pigeons,  and 
chickens  with  the  diphtheritic  membrane,  and  produced  local  lesions  appar- 
ently identical  with  those  of  diphtheria  in  man,  and  the  blood  of  the  ani- 
mals subjected  to  the  experiment  contained  micrococci  in  abundance.  Nas- 
silof  ^  states  as  the  result  of  his  observations  that  fungi,  not  designating  the 
species,  are  always  present  in  diphtheritic  membranes  and  precede  their 
development,  and  that  they  penetrate  the  tissues  by  the  blood-vessels  and 
lymphatics  before  any  observable  change  occurs  in  the  tissues.  Therefore 
he  believes  that  they  cause  the  diphtheritic  inflammation.  Hueter  and  Tom- 
masi  inserted  particles  of  the  diphtheritic  membrane  in  the  back  of  the 
rabbit.  Death  occurred  in  forty  hours.  Micrococci  were  found  at  the  seat 
of  the  injury,  and,  before  death,  in  the  blood  of  the  animal.  Similar  experi- 
ments and  observations  made  by  otlier  pathologists  of  renown  strengthened 
the  belief  that  the  cause  of  diphtheria  liad  at  last  been  discovered  in  the 
micrococcus.  Cohn  (1872  and  1873)  classified  this  organism,  which  had 
now  assumed  great  importance,  with  the  scliizophytes,  tribe  sphsero-bacteria, 
and  he  designated  it  micrococcus  dipJdhenticus. 

On  the  other  hand,  Eberth  (1872)  and  Klebs  (1871)  expressed  the 
opinion  that  the  diphtheritic  micrococci  are  the  same  as  septic  micrococci. 
Senator  (1874)  states  that  other  diseases  of  the  mouth  and  pharynx  are 


^  Vircbow's  Archiv,  1870. 


586  DIPHTHERIA. 

accompanied  by  the  same  micrococci  as  those  in  diphtheria.  They  are  also, 
he  savs,  found  in  the  mucus  between  the  teeth,  and  in  normal  urine,  and  the 
micrococci  of  diphtheria  do  not  differ  in  cultures  from  those  occurring  in 
other  conditions.  Billroth  (1874)  also  dissented  from  the  opinion  that  mi- 
crococci caused  diphtheria.  He  made  the  broad  statement  that  "the  so- 
called  pathogenic  bacteria  of  diseases  are  positively  identical  with  those 
found  in  putrefying  dead  tissues."  Therefore  the  theory  that  micrococci 
alighting  upon  one  of  the  surfaces  caused  diphtheria  met  vnih  strong  oppo- 
sition soon  after  it  was  announced,  and,  as  time  went  on,  facts  and  observa- 
tions which  militated  against  it  multiplied. 

In  1877,  Drs.  Curtis  and  Satterthwaite  were  employed  by  the  New  York 
Health  Board  to  investigate  the  etiology  and  pathology  of  diphtheria. 
After  many  experiments,  they  reported  "that  the  bacteria  of  diphtheritic 
membranes  do  not  differ  in  optical  or  chemical  behavior  from  those  found 
in  putrescent  but  non-diphtheritic  animal  material."  They  also  found  that 
"scrapings  from  the  upper  surface  of  a  somewhat  furred  tongue  from  a 
healthy  person"  cause,  when  inserted  in  the  cellular  tissue  of  the  rabbit,  an 
effect  exactly  similar  to  that  produced  by  inoculations  with  diphtheritic 
membrane.  Putrid  Cohn's  fluid  (an  aqueous  solution  of  ammonic  tartrate, 
potassic  and  calcic  phosphates,  and  magnesic  sulphate)  also  caused  the  same 
result.  They  were  enabled,  after  many  carefully-conducted  experiments,  to 
enunciate  the  following  propositions :  "  Thorough  trituration  of  proven 
virulent  diphtheritic  membrane  and  tongue-scrapings  with  a  high  per- 
centage of  salicylic  acid  fails  not  only  to  remove,  but  even  markedly  to 
modify,  the  intensity  of  the  infectious  quality  of  those  substances.  Hence, 
since  salicylic  acid  in  even  a  minute  percentage  is  capable  of  permanently 
suspending  the  vital  activity  of  bacteria,  the  inference  is  that  the  infectious 
quality  of  diphtheritic  membrane  upon  the  system  of  the  rabbit  is  not  cor- 
related to  the  vital  activity  of  the  bacteria  present  in  such  membrane." 
Therefore  if,  as  is  probable,  the  agent  in  the  pseudo-membrane  which  causes 
the  noxious  effects  in  the  inoculated  rabbit  be  the  same  as  that  which  causes 
diphtheria  in  man,  it  follows  "that  there  is  no  theoretical  ground  for  assuming 
that  preventing  the  bacteria  of  a  diphtheritic  patch  from  making  their  way 
through  the  underlying  mucous  membrane  iinll,  per  se,  prevent  general  dipth- 
theritic  infection  of  the  system.'' 

These  important  observations  and  opinions,  expressed  by  Curtis  and 
Satterthwaite  in  1877,  evidently  prepared  the  way  for  the  theory  that  the 
bacteria  themselves  are  not  the  cause  or  the  infectious  principle  of  diph- 
theria, but  chemical  substances  or  ptomaines,  produced  by  the  agency  of 
the  bacteria,  maybe. 

In  1882,  Drs.  Wood  and  Formad,  employed  by  the  National  Board  of 
Health  to  investigate  the  nature  of  diphtheria,  after  many  microscopic  ex- 
aminations and  experiments,  declared  their  belief  that  the  micrococcus  diph- 
theriticus  and  m.  septicus,  inasmuch  as  they  responded  alike  to  optical, 
chemical,  and  vital  tests,  are  identical.     They  found  the  same  micrococcus 


DIPHTHERIA.  587 

in  the  unliealtliy  pus  of  erysipelatous  cellulitis,  and  in  twenty-one  instances 
in  which  death  resulted  from  inoculations  with  this  pus  they  found  the  same 
micrococci  in  the  blood  of  the  victims.  The  blood  of  twenty-two  cases  of 
erysipelas  was  examined  for  micrococci,  with  the  following  result :  "  In 
thirteen  of  these  the  organisms  were  found  in  the  blood,  whilst  in  the 
other  nine  there  were  none.  Of  measles,  twenty-nine  cases  were  studied  : 
in  six  only  were  micrococci  detected,  whilst  in  eight  cases  of  rdtheln  or 
German  measles  there  were  no  organisms.  We  have  also  investigated  four 
cases  of  malignant  fatal  scarlet  fever,  in  all  of  which  we  found  the  blood 
a  few  hours  before  death  loaded  with  micrococci,  both  free  attacking  the 
white  corpuscles,  and  in  zoogloea  masses,  and  in  one  of  which  micrococci 
emboli  were  abundant  in  the  kidneys.  We  have  also  studied  four  cases 
of  ^puerperal  fever,'  probably  septic  metritis,  in  all  of  which  micrococci 
existed  in  the  blood  before  death." 

It  soon  became  apparent  to  pathologists,  from  experiments  and  observa- 
tions like  the  above,  that  the  so-called  micrococcus  diphtheriticus  is  not 
peculiar  to  diphtheria,  that  it  occurs  in  all  pestilential  and  putrid  diseases, 
in  decomposing  animal  tissues  in  various  diseases,  and  even  upon  the  tongue 
and  gums  in  health.  Hence  it  was  necessary  to  look  elsewhere  for  the  cause 
of  diphtheria. 

In  1883,  Klebs  made  extended  and  thorough  examinations  of  the 
microbes  of  diphtheria,  and  formed  the  opinion  that  a  bacillus  which  he  had 
observed  in  the  pseudo-membrane  and  upon  the  inflamed  tissue  merited 
special  attention.  Subsequently  Loeifler  pursued  the  investig-ation,  and  the 
organism  known  as  the  Klebs-Loef&er  bacillus  became  a  prominent  object  of 
study  as  perhaps  the  causal  agent  in  diphtheria.  Loeffler,  in  the  published 
statement  of  his  investigations,  remarks  that  all  observers  have  found  bacteria 
in  the  diphtheritic  exudate,  micrococci  most  frequently,  existing  in  colonies, 
and  especially  abundant  in  superficial  portions  of  the  pseudo-membrane. 
At  times  bacteria  have  been  found  in  the  lymphatics  in  the  vicinity  of  the 
inflamed  tissues.  Every  diphtheritic  patch  contains  many  species  of  bac- 
teria which  have  been  cultivated ;  but,  as  they  have  not  been  isolated,  the 
specific  germ  of  diphtheria  has  not  been  determined.  The  rejection  of  the 
theory  that  micrococci  are  the  causal  agent  of  diphtheria,  on  the  ground  that 
they  occur,  presenting  the  same  optical,  chemical,  and  vital  characteristics, 
in  other  distinct  diseases  and  conditions,  led  to  a  more  careful  examination 
of  other  bacteria  present  in  the  diphtheritic  exudate  and  upon  and  in  the 
underlying  tissues.  The  bacillus  described  by  Klebs  and  later  by  Loeffler 
is  motionless,  partly  straight,  partly  curved,  of  the  length  of  the  tubercle- 
bacillus,  but  double  its  thickness.  It  is  abundant  in  the  pseudo-membrane, 
but  is  not  found  in  the  blood-vessels,  lymphatics,  or  internal  organs:  so  that 
its  pathogenic  action  must  be  localized  on  the  surface.  If  it  be  the  specific 
principle  or  germ  of  diphtheria,  it  must  act  by  producing  a  ptomaine  or 
chemical  poison  where  it  is  lodged,  which  poison  entering  the  lymphatics 
and  blood-vessels  causes  systemic  infection.     In  some  typical  cases  of  diph- 


588  DIPHTHERIA. 

theria  Loeffler  was  unable  to  find  the  bacillus,  which  of  course  militates 
against  the  theory  that  it  is  the  specific  germ ;  but  he  suggests  ihat  it  might 
have  died  and  been  eliminated  befi^re  the  death  of  the  patients.  Such  an 
explanation  seems  very  improbable;  it  is  making  a  stubborn  antagonistic 
fact  yield  to  a  theory ;  and  yet  without  such  an  explanation  we  must  look 
for  some  other  cause  of  diphtheria.  The  Klebs-Loeffler  bacillus  w^as  found 
by  Loeffler  in  the  exudate  in  thii-teen  cases  of  diphtheria,  and  cultures  to 
the  twenty-fifth  generation  inoculated  in  guinea-pigs  and  birds  caused  a 
whitish  exudation  at  the  point  of  inoculation, 

W.  Watson  Cheyne^  recognizes  the  importance  of  Klebs  and  Loeffler's 
researches,  and  thinks  it  probable  that  the  micro-organism  which  causes 
diphtheria  is  a  bacillus,  which  lodging  upon  the  surface  of  the  throat  is 
propagated  there.  Having  upon  the  mucous  membrane  a  favorable  nidus, 
it  not  only  lies  upon  but  penetrates  the  superficial  portion  of  the  mucous 
layer,  and  causes  the  exudation  of  fibrin.  The  pseudo-membrane  thus 
produced  consists,  according  to  Cheyne,  of  the  fibrinous  exudate  and  dead 
epithelial  cells.  As  the  bacilli  multiply  and  extend,  the  exudate  enlarges. 
Cheyne  believes  it  probable,  though  demonstration  is  lacking,  that  the 
bacilli  cause  very  poisonous  ptomaines,  which,  entering  the  lymphatics  and 
the  blood,  give  rise  to  systemic  infection  and  render  the  disease  constitu- 
tional. 

But  since  the  observations  of  Klebs,  Loeffler,  and  Cheyne,  the  bacillus 
which  they  consider  the  specific  principle  of  diphtheria  has  been  subjected 
to  a  more  thorough  examination,  with  the  result  of  apparently  demon- 
strating that  the  same  bacillus  occurs  in  non-diphtheritic  cases,  and  even  in 
healthy  persons,  as  well  as  in  diphtheria.  Thus,  Von  Hofmau-Wellenhof  ^ 
detected  this  bacillus  in  twenty-six  of  forty-five  cases  in  various  conditions 
of  the  buccal  and  faucial  surfaces.  He  discovered  it  in  seven  cases  of 
diphtheria,  in  three  of  measles,  in  six  of  nineteen  cases  of  scarlet  fever,  and 
in  four  of  eleven  normal  cases.  In  cultures  and  experimeiits,  the  bacilli 
from  different  sources  appeared  to  be  identical.  Therefore  in  the  light  of 
recent  investigations  the  Klebs-Loeffler  bacillus  has  no  more  significance  as 
a  cause  of  diphtheria  than  the  micrococcus  of  Oertel. 

Prof.  Oertel,  who  was  one  of  the  earliest  advocates  of  the  theory  of  the 
microbic  origin  of  diphtheria,  and  whose  monograph,  in  1868,  published  in 
"  Ziemssen's  Cyclopaedia,"  led  to  the  belief  in  the  profession  that  the  micro- 
coccus was  the  cause,  now  admits  that  the  theory  that  diphtheria  is  due  to 
the  action  of  bacteria,  though  plausible,  is  not  proved.  He  has  endeavored 
to  elucidate  the  pathogeny  of  the  disease  by  a  careful  and  minute  study  of 
its  anatomical  characters.^  After  an  elaborate  study  of  its  histology,  he 
remarks,  "  In  the  earliest-formed  membranes  many  varieties  of  microbes 

^'Brit.  Med.  .Jour. 

2  Wiener  Med.  Wochenschr.,  1888,  Nr.  3  und  4. 

'  Die  Pathogenese  d.  epidemi.?chen  Diphtherie,  uach  ihrer  histologischen  Begriindung, 
Leipzig,  1887. 


DIPHTHERIA.  589 

can  be  isolated ;  but  practically  there  are  two  chief  kinds, — chain-forming 
cocci  (streptococcus)  and  rod-shaped  bacteria  with  rounded  extremities 
(bacilli)."^ 

Oertel  remarks  that  in  the  septic  form  of  diphtheria  the  cocci  are 
abundant.  In  a  pseudo-membrane  of  twelve  hours'  continuance,  micrococci 
abounded  mostl}-  on  the  surface,  but  in  the  fibrinous  net-work  the  bacilli, 
often  in  colonies,  preponderated.  In  a  -specimen  of  1:sventy-four  hours' 
duration,  the  uj)per  surface  was  full  of  cocci,  and  between  them  were  bacilli. 
In  another  specimen  of  membrane  detached  after  six  days,  these  two  forms 
of  microbes  were  also  intermixed.  As  regards  the  tissues  and  organs,  the 
micrococci  and  bacilli  occurred  upon  the  mucous  membranes,  not  penetrating 
them  to  any  great  depth.  They  were  not  found  in  the  "  necrobiotic  foci," 
nor  were  they  observed  in  any  of  the  sections  of  the  kidneys,  which  were 
examined.  This  is  a  noteworthy  fact,  because  in  the  examinations  made 
between  1865  and  1871,  the  results  of  which  were  published  in  Oertel's 
article  in  "  Ziemssen's  Cyclopaedia,"  micrococci  were  found  in  the  kidneys. 
He  attributes  their  presence  in  the  kidneys  during  this  period  to  the  fact 
that  the  cases  under  observation  were  septic,  whereas  in  those  recently 
examined  septic  infection  was  not  common,  on  account,  he  thinks,  of  the 
employment  of  disinfecting  and  antiseptic  measures  in  place  of  the  escharotic 
treatment,  and  forcible  detachment  of  the  membrane,  in  use  during  the  time 
of  his  former  observations. 

The  purpose  of  Oertel  in  his  recent  investigations  has  been  to  ascertain, 
if  possible,  the  nature  of  the  diphtheritic  virus  by  a  close  and  minute  study 
of  the  lesions,  or  anatomical  changes,  which  it  produces.  It  appears  from 
his  examinations  that  the  primary  lesion  is  cell-change.  "Necrobiotic 
processes"  and  "  necrobiotic  areas"  commencing  in  the  cells  are  observed  in 
the  tonsils,  the  mucous  membrane  of  the  fauces,  uvula,  ejDiglottis,  larynx, 
trachea,  in  the  cervical,  submaxillary,  bronchial,  and  mesenteric  glands,  in 
the  spleen,  and  in  the  follicles  and  agminate  glands  in  the  intestines.  In 
different  cases  these  structural  changes  vary,  according  to  the  intensity  of 
the  virus  and  the  duration  of  its  action.  The  morbific  process  extends  by 
propagation  through  an  organ,  or  from  one  part  to  another,  the  virus  being 
carried  by  the  lymph-stream  or  blood,  disintegrating  products  being  the 
carrier. 

The  following  is  a  summary  of  Oertel's  views  in  regard  to  the  virus  of 
diphtheria.  They  express  all  that  is  at  present  known  of  the  etiology  of 
this  disease.  The  nature  of  the  virus,  says  Oertel,  is  still  obscure.  It  acts 
upon  cells,  causing  their  death  and  disintegration,  and  the  infected  particles 
convey  the  virus  to  other  cells.  The  virus  causes  hyaline  degeneration  in 
the  tissues.  The  hyaline  degeneration  in  the  walls  of  the  l)lood-vessels 
causes  tliem  to  rupture,  producing  hemorrhages.  The  unci|ual  amount  of 
hyaline  change  in  different  parts  of  the  vascular  apparatus  may  be  attrib- 

1  Londiin  Laiu'ot,  March  81,  1888. 


590  DIPHTHERIA. 

uted  to  difference  in  resisting  power,  or  unequal  exposure  to  the  infected 
blood.  Secondary  inflammatory  processes  in  the  lungs,  heart,  liver,  kid- 
neys, and  in  the  central  and  peripheral  nerve-tissues,  must  arise  from  the 
infectious  property  of  the  blood  circulating  in  them.  After  enumerating  at 
length  and  with  much  detail  the  results  of  his  examinations,  Oertel  expresses 
the  opinion  that  bacterial  organisms  cause  diphtheria,  and  that  they  produce 
this  result  not  by  their  direct  action,  but  by  producing  a  ptomaine  which 
infects  the  system  and  causes  the  disease  to  be  constitutional.  The  microbe 
itself  is  mostly  confined  to  the  surface,  whereas  the  action  of  the  virus  is 
"  wide-spread  and  deep."  The  most  eminent  pathologists  of  the  present  time 
do  not  express  any  more  positive  opinions  in  reference  to  the  specific  prin- 
ciple or  germ  of  diphtheria  than  is  contained  in  the  above  summary  of 
Oertel's  views. 

Dr.  Prudden  has  recently  made  systematic  studies  on  a  series  of  cases 
of  diphtheria  which  would  seem  to  indicate  that  a  streptococcus  which  is 
almost  constantly  present  in  the  pseudo-membrane  probably  stands  in  a 
causative  relation  to  the  disease.^ 

At  a  recent  meeting  of  the  London  Epidemiological  Society,  Dr.  M. 
W.  Taylor^  expressed  the  opinion  that  common  mould  might  sustain  a 
causal  relation  to  diphtheria.  The  walls  of  a  sleeping-apartment  became 
wet  and  sodden  on  July  12.  On  the  22d  a  fungus  appeared  on  the  plaster, 
and  in  the  beginning  of  August  the  three  children  who  occupied  the  room, 
and  who  had  not  been  exposed  in  any  other  way,  so  far  as  could  be  ascer- 
tained, sickened  with  diphtheria.  The  aspergillus  and  coprinus  grew  abun- 
dantly in  the  mould.  In  another  instance,  in  which  the  child  died  in  three 
days,  there  was  a  great  development  of  penicillum  moulds.  A  young  man 
had  diphtheria  severely  four  days  after  cleaning  out  a  pigeon-loft  where  the 
exuviae,  debris,  and  rotten  wood  were  covered  with  mould.  But  the  theory 
that  organisms  which  are  commonly  present  in  ordinary  mould  can  produce 
diphtheria  is  improbable,  for  mould  is  common  in  all  damp  localities,  where 
there  is  no  diphtheria  as  well  as  where  diphtheria  is  present.  We  shall  see 
in  our  remarks  on  the  propagation  of  diphtheria  that  there  can  be  little 
doubt  that  pigeons  and  other  feathered  animals  frequently  have  this  disease, 
and  in  the  instance  referred  to  by  Dr.  Taylor  it  is  probable  that  the  exuviae 
and  debris  in  the  pigeon-loft  had  been  infected  by  sick  pigeons.  The  specific 
principle  must  be  introduced  from  without,  but  if  it  obtain  a  lodgement  upon 
the  wet  and  mouldy  surface  of  any  filthy  accumulation  it  may  find  there  a 
nidus  favorable  for  its  development.  We  shall  see  that  the  fact  appears  to 
be  fully  established  that  the  diphtheritic  virus  is  frequently  propagated  in 
foul  and  damp  localities,  apart  from  the  animal  tissues  and  independently  of 
the  sick.  We  repeat,  therefore,  that  the  theory  in  reference  to  the  causation 
of  diphtheria  which  is  gaining  acceptance  throughout  the  world  is  that  it  is 
produced  by  a  microbe  or  microbes,  whose  action  is  chiefly  on  the  surface 

1  See  Amer.  Jour.  Med.  Sci.,  1889.  ^  Brit.  Med.  Jour. 


DIPHTHERIA. 


591 


or  at  no  great  depth,  and  that  blood-poisouing  occurs  maiuly  from  a 
ptomaine  or  ptomaines  produced  by  microbic  agency.  In  order  to  obtain  a 
knowledge  of  the  ptomaine,  chemistry  must  aid  microscopical  investigation. 

Mode  of  Propagation. — j^o  fact  is  better  established  than  that  diph- 
theria does  not  originate  de  novo.  Like  the  eruptive  fevers,  it  is  produced 
by  the  reception  in  or  upon  some  part  of  the  system  of  the  pre-existing 
specific  poison.  The  extreme  contagiousness  of  diphtheria  from  person  to 
person  is  well  known  :  a  moment's  exposure  to  the  breath  of  a  patient,  or  in 
the  infected  room  where  he  is  under  treatment  or  has  been  weeks  or  perhaps 
months  previously,  has  in  numberless  instances  communicated  the  disease. 
The  virus  adheres  tenaciously  to  objects  on  which  it  happens  to  alight.  The 
clothing  of  a  patient,  even  when  the  disease  is  in  its  mildest  form,  his  bed- 
ding, the  furniture  of  his  room,  and  the  objects  which  he  handles,  may  for 
weeks  afterwards  communicate  the  disease,  and  even  when  transported  to  a 
distance.  A  child  with  malignant  diphtheria  seen  by  me  in  consultation 
apparently  contracted  it  by  embracing  a  school-mate  who  was  in  the  street 
for  the  first  time  after  an  attack  of  diphtheria.  In  another  instance  a  child 
was  for  a  brief  period  in  a  room  where  diphtheria  had  occurred  two  months 
previously,  and  after  the  usual  incubative  period  sickened  with  the  disease. 

Although  diphtheria  is  often  contracted  in  the  manner  mentioned  above, 
— that  iSy  by  exposure  to  a  diphtheritic  patient,  or  to  a  room  or  some  object 
infected  by  such  patient, — there  is  another  mode  of  infection  common  in  the 
cities.  Dr.  Sternberg,  in  his  recent  Lomb  Prize  Essay,  published  by  the 
American  Public  Health  Association,  refers  to  the  fact  that  damp,  foul 
places,  such  as  sewers,  cellars,  ill-ventilated  spaces  under  floors,  where  the 
sun  never  enters  and  where  refuse  collects,  aflbrd  conditions  favorable  for 
the  development  and  propagation  of  the  diphtheritic  virus.  The  virus, 
whatever  its  nature,  once  received  may  be  propagated  in  such  a  place  for  an 
indefinite  time,  and,  ascending  in  the  vapors  which  arise  from  this  culture- 
bed,  it  is  liable  to  communicate  the  disease  to  any  one  who  inhales  it.  Thus, 
in  New  York  City  prior  to  1850,  although  foul  sewers  and  insanitary  con- 
ditions existed,  there  was  no  diphtheria,  but  in  the  decade  following  1850 
diphtheria  was  introduced.  Its  germ  made  its  way  into  the  sewers  under- 
ground ;  and  now  wherever  sewer-gas  escapes  into  the  domiciles  of  this  city 
it  carries  with  it  the  diphtheritic  virus.  The  amazing  vitality  and  power 
of  propagation  of  the  diphtheritic  poison  are  apparent  when  we  reflect  that  it 
permanently  infects  the  filthy  but  constantly-flowing  and  constantly-renewed 
currents  of  the  sewers  of  a  great  city.  In  all  the  wards  and  apparently  in 
every  street  in  New  York  City  children  are  constantly  fiilling  sick  with  this 
disease,  contracted  by  inhaling  sewer-gas,  which,  notwithstanding  "  sanitary 
plumbing,"  often  escapes  from  unsuspected  sources,  even  in  houses  con- 
structed with  all  the  modern  improvements.  It  is  chiefly  by  exposure  of 
children  to  infected  sewer-gas  whioli  ascends  from  this  widely-extending 
underground  culture-bed,  and  to  walking  cases  often  so  mild  that  there  is 
little  or  no  complaint  of  the  throat  or  impairment  of  the  general  health, 


592  DIPHTHERIA. 

that  this  disease  is  so  prevalent.  Most  of  the  contagious  diseases  of  chil- 
dren are  quickly  detected  by  characteristic  symptoms  or  appearances,  which 
the  most  ignorant  families  are  to  a  certain  extent  familiar  with,  but  mild 
diphtheria  possesses  so  few  subjective  symptoms  that  it  is  often  not  detected 
or  suspected,  even  in  intelligent  families  who  are  watchful  of  their  children. 
Children  with  mild  diphtheria  sit  among  other  children  in  the  schools,  in 
the  city  conveyances,  in  the  churches  and  dispensaries,  and  frequently  com- 
municate to  those  who  are  near  them  a  malignant  form  of  the  disease,  from 
which  the  unfortunate  victims  quickly  perish.  The  diphtheritic  virus  is  so 
subtle,  and  its  vitality  and  power  of  propagation  so  great,  that  when  it  is 
established  in  a  sewered  city  it  can  probably  never  be  stamped  out,  as 
cholera  and  yellow  fever  may  be,  by  measures,  however  stringent  and  active, 
employed  by  Health  Boards  or  by  legislative  enactments. 

Commonly  diphtheria  is  communicated  by  the  inhalation  of  infected 
air,  the  inhalation  of  air  containing  the  specific  principle,  whether  derived 
directly  from  a  patient  or  from  some  infected  inanimate  object,  as  the  walls 
of  a  room,  furniture,  apparel,  an  article  of  merchandise,  or  sewer-gas.  More 
rarely  diphtheria  is  communicated  by  direct  contact  with  some  infected  solid 
substance,  as  a  particle  of  the  diphtheritic  exudate,  muco-purulent  secretion 
from  an  infected  surface,  or  the  blood  of  a  patient.  A  considerable  number 
of  instances  has  been  reported  in  which  instruments  infected  by  use  upon 
a  patient,  and  not  properly  cleaned  and  disinfected  subsequently,  have  been 
the  means  of  communicating  the  disease.  In  these  instances  of  communi- 
cation by  direct  contact,  the  poison  is  received  either  upon  one  of  the  mucous 
surfaces  or  upon  the  skin  denuded  of  its  protecting  epidermis. 

Diphtheria  contracted  from  Animals. — Obsei-vations  are  accumulating 
which  show  that  diphtheria,  or  a  disease  closely  resembling  it,  occurs  among 
animals  and  is  sometimes  communicated  from  them  to  man.  The  feathered 
tribe  especially  appear  to  be  susceptible  to  this  disease.  On  the  island  of 
Skiathos,  oiF  the  northeastern  coast  of  Greece,  no  diphtheria  had  occurred 
during  at  least  thirty  years  previously  to  1884,  according  to  Dr.  Bild,  the 
medical  practitioner  of  the  island.  In  that  year  a  dozen  turkeys  were  in- 
troduced from  Salonica.  Two  of  tliem  were  sick  at  the  time,  and  died  soon 
afterwards ;  the  others  became  affected  subsequently,  and  of  the  whole  num- 
ber seven  died,  three  recovered,  and  two  were  sick  at  the  time  of  the  inquiry. 
The  two  had  a  pseudo-membrane  upon  the  larynx,  difficult  breathing,  and 
swelling  of  the  glands  of  the  neck.  As  further  evidence  that  the  disease 
was  true  diphtheria,  one  of  the  turkeys  that  had  survived  had  paralysis  of 
the  feet.  The  turkeys  were  in  a  garden  on  the  north  side  of  the  town,  and 
the  prevailing  winds  upon  the  island  are  from  the  north.  Wlien  this  sick- 
ness was  occurring  among  the  turkeys,  an  epidemic  of  diphtheria  com- 
menced in  the  houses  in  proximity  to  the  garden,  and  spread  through  the 
town.  It  lasted  five  months,  and  of  one  hundred  and  twenty-five  cases  in 
a  population  of  four  thousand,  thirty-six  died.  Diphtheria  was  from  this 
time  established  upon  the  island,  and  frequent  epidemics  of  it  have  occurred 


DIPHTHERIA.  593 

siuce.^  M.  Menzies^  states  that  diphtheria  is  common  among  the  poultry 
in  Italy,  in  which  country  the  flat  roofs  of  the  houses  aiford  a  resting- 
place  for  turkeys,  fowls,  pigeons,  and  rabbits,  and  their  evacuations  are 
carried  by  the  rain  into  the  cisterns  and  wells.  A  physician  at  Posilippo, 
near  Naples,  had  directed  his  servant  not  to  obtain  drinking-water  from 
the  well  next  to  his  house,  but  from  a  well  at  a  distance.  As  long  as  he 
obeyed  the  instruction  his  family  was  well ;  but,  yielding  to  his  indolence,  he 
finally  disobeyed  the  command  and  obtained  water  from  the  infected  well. 
Four  of  the  children,  who  drank  this  water,  soon  took  diphtheria  and  died. 
The  fifth  child,  who  did  not  drink  the  water,  escaped.  In  1878-79,  Nicati, 
of  Marseilles,  observed  cases  which  seemed  to  show  that  diphtheria  is  some- 
times contracted  from  fowls.^  The  Journal  de  Medeeine  de  Pans,  February 
19,  1888,  contains  an  instructive  paper  by  Dr.  Delthil  on  the  transmission 
of  diphtheria  from  animals  to  man,  in  which  a  considerable  number  of 
apparent  instances  is  related.  Dr.  F.  T.  Wheeler  *  states  that  while  in  a 
nesting  of  wild  pigeons  he  found  many  sick  with  a  pseudo-membranous  sore 
throat.  He  dissected  many  with  his  pocket-knife,  which  he  was  obliged  to 
throw  away  on  account  of  the  offensive  odor.  There  were  millions  of 
pigeons  in  the  nesting,  and  they  were  hunted  and  eaten  by  the  inhabitants. 
The  same  year  diphtheria  broke  out  in  a  most  malignant  form,  causing 
many  deaths  among  the  children.  Several  years  previously,  pigeons  nested 
in  the  same  locality,  or  near  by,  and  fully  half  of  the  children  living  in  the 
vicinity  had  diphtheria.  Dr.  George  Turner  ^  states  that  a  pigeon  was 
brought  to  him  for  dissection.  The  whole  of  its  windpipe  was  covered 
by  pseudo-membrane,  as  in  the  croup  of  a  child.  Pigeons  were  inoculated 
in  the  fauces  with  this  membrane,  and  a  similar  disease  was  produced,  which 
extended  to  their  eyes  through  the  nostrils.  An  epidemic  of  diphtheria 
occurred  in  the  village  of  Braughing,  Hertfordshire,  England,  the  first 
cases  appearing  on  a  farm  where  the  fowls  were  dying  of  a  disease  similar 
to  that  in  the  pigeon ;  and  on  other  farms  where  diphtheria  appeared  it  was 
preceded  by  a  similar  disease  in  the  fowls.  Dr.  Turner  also  mentions 
several  other  epidemics  of  diphtheria  in  different  localities,  where  the 
poultry,  turkeys,  pigeons,  and  in  one  locality  the  pheasants,  perished  of  a 
disease  attended  by  this  membranous  exudation.  At  Tougham  a  man 
bought  a  cliicken  at  a  low  price,  as  it  was  affected  by  the  prevailing  disease, 
and  cared  for  it  at  his  home.  Soon  after  diphtheria  broke  out  in  his  family, 
and  this  case  was  the  first  in  the  village.  Instances  are  also  cited  by  Dr. 
Turner  showing  that  cats,  sheep,  and  pigs  have  suffered  from  a  severe 
disease  of  the  throat,  probably  diphtheritic,  in  several  localities  where 
diphtheria  was  prevailing  among  children. 

According  to  the  observations  of  various  experimenters,  diphtheria  can 
be  transmitted  from  man  to  animals;  and,  if  this  be  true,  it  seems  probable 

1  Bulletin  Med.,  January  22,  1888.  «  Thesis,  Paris,  1881. 

'  Marseille  Med.,  1879,  p.  105.  *  American  Practitioner  and  News 

5  Journal  of  Laryngology  and  Rhinology. 
Vol.  L— as 


594 


DIPHTHERIA. 


that  it  can  likewise  be  transmitted  from  animals  to  man.  Trendelenburg 
inoculated  sixty-eight  rabbits,  introducing  diphtheritic  pseudo-membrane 
into  the  trachea  through  an  artificial  opening.  Eleven  of  the  rabbits  died 
with  the  symptoms  and  appearances  of  diphtheria.  In  control  experiments 
he  introduced  various  foreign  bodies  into  the  larynx  of  rabbits  and  was 
unable  to  produce  any  results  or  lesions  resembling  those  in  diphtheria. 
Oertel  performed  twelve  similar  experiments,  and  five  of  the  rabbits  died 
after  the  production  of  pseudo-membranes.  Zahn,  Gerhard,  Labadie- 
Lagrave,  Francotte,  and  Vulpian  obtained  similar  results  from  their  ex- 
periments. Such  observations  and  experiments  render  it  probable  that 
genuine  diphtheria,  equally  fatal  and  attended  by  the  same  anatomical  char- 
acters and  symptoms  as  in  man,  does  occur  in  birds,  whether  wild  or  domes- 
ticated, and  in  certain  quadrupeds,  as  the  rabbit.  Neverthless,  we  should 
add  that  certain  eminent  pathologists,  among  whom  we  may  mention  the 
honored  name  of  Virchow,  have  doubted  the  identity  of  animal  and  human 
diphtheria.  With  our  present  light  upon  the  subject,  it  is  evident  that,  since 
our  relations  to  the  domestic  animals  are  so  close,  if  they  are  sick  with  any 
disease  resembling  diphtheria  the  same  precautionary  measures  should  be 
taken  to  prevent  infection  of  the  family  as  in  human  diphtheria. 

Mr.  Cole,  a  veterinary  surgeon  of  Hinckley,  Australia,  published  in  the 
Australian  Veterinary  Journal,  February,  1882,  copied  into  the  New  York 
Medical  Record,  the  account  of  an  epidemic  of  diphtheria  that  was  appar- 
ently traced  to  the  milk  obtained  from  a  diseased  cow.  In  1879,  Mr.  W. 
H.  Power,  Health  Inspector,  investigated  an  outbreak  of  diphtheria,  and 
believed  that  he  traced  it  to  the  milk-supply.  The  cows  which  furnished 
the  milk  that  seemed  to  communicate  the  disease  had  what  the  veterinary 
surgeons  designate  "  garget,"  or  "  infectious  mammitis."  ^  Another  similar 
history  of  an  epidemic  is  related  by  the  same  journal  that  published  Mr. 
Power's  report.  Prof.  Damman,  of  the  Hanover  Veterinary_  School,  re- 
ported in  the  Deutsche  Zeitschrift  fur  Thiermedicin,  1877,  an  epidemic  of 
what  seemed  to  be  diphtheria  in  calves.  He  directed  the  attendant  to  make 
applications  to  the  mouths  and  throats  of  the  affected  calves.  This  was  on 
April  29.  On  May  5  the  attendant  became  sick,  complained  of  his  throat, 
and  was  confined  to  bed.  A  pseudo-membrane  appeared  on  his  tonsils, 
which  were  highly  inflamed ;  he  had  high  fever,  and  enlargement  of  both 
the  submaxillary  and  cervical  glands.  A  dairy-maid  who  now  took  charge 
of  the  calves  also  had  a  similar  but  less  severe  attack.  Milk  is  a  culture- 
medium  of  various  microbes,  and  that  it  may  be  the  medium  of  communi- 
cation of  diphtheria  as  well  as  of  scarlet  fever  seems  probable. 

The  fact  that  the  diphtheritic  virus  may  be  conveyed  long  distances  with- 
out losing  its  virulence  is  now  admitted  from  the  many  observations  that 
have  been  made.  Prof.  C.  W.  Earle,  of  Chicago,  read  before  the  Ninth 
International  Medical  Congress  an  interesting  statistical  paper  on  the  occur- 

1  Med.  Times  and  Gaz.,  .Jan.  1879. 


DIPHTHERIA. 


595 


rence  of  diphtheria,  often  severe  and  fatal,  in  sakibrious  rural  localities, 
free  from  sewage-gas  and  water-pollution,  in  the  newly-settled  and  moun- 
tainous States  and  Territories  of  the  Northwest.  Dr.  Earle's  statistics 
render  it  probable  that  the  diphtheritic  infection  is  transported  long  dis- 
tances to  these  localities,  being  carried  in  articles  of  clothing  and  merchan- 
dise. The  well-known  tenacious  adherence  of  the  virus  to  objects  renders 
it  highly  important  that  thorough  disinfection  should  be  employed  before 
articles  are  removed  from  an  infected  room. 

Age. — Trousseau  has  said  that  diphtheria  does  not  spare  any  age,  but 
is  most  common  between  the  ages  of  two  and  five  or  six  years.  Guersant 
believes  that  the  age  of  greatest  frequency  is  between  the  second  and  seventh 
years,  and  Barthez  and  Rilliet  agree  with  Guersant.  Bouillon-Lagrange  in 
sixty-three  cases  occurring  in  one  epidemic  treated — 


Under  2  years 14  cases. 

From    2  to    6      "  18     " 

"        6  to  12      "  10     " 

"      12  to  18      "  9     " 


From  18  to  30  years 15  cases. 

"      30  to  40      "  4     " 

"     40  to  50      "  1  case. 

Above  50      "  2  cases. 


According  to  M.  Barthez,  in  Sainte-Eug^nie  Hospital  during  twenty 
years  the  ages  of  the  diphtheritic  patients  were  as  follows,  adults  being  ex- 
cluded from  this  institution  : 


Under        1  year 81  cases. 

From  1  to  2  years 314     " 

"      2  to  3      " 319      " 

"      3  to  4      " 292      " 

"      4  to  5      " 200     " 

"      5  to  6      " 103      " 


From    6  to    7  years 59  cases. 

"        7  to    8      " 36     " 

"       8  to    9      " 24     " 

"        9  to  15      " 82     " 

"      15  to  17      " 2     " 


Louis  has  shown  that  diphtheria  may  occur  at  an  advanced  age ;  but  its 
occurrence  is  rare  over  the  age  of  forty  years,  and  very  rare  after  the  age  of 
sixty  years. 

Oertel  sa}'s,  "  In  the  first  half-year  the  infant  organism  seems  to  be  not 
at  all  susceptible  to  the  disease."  As  in  scarlet  fever,  so  in  diphtheria,  cases 
are  infrequent  under  the  age  of  six  months ;  but  a  considerable  number  of 
cases  are  on  record  showing  that  it  does  occur  even  in  the  newly-born.  Dr. 
A.  Jacobi  has  collated  the  following  cases  :  a  child  of  fourteen  days  treated 
by  Tigri,  one  of  fifteen  days  by  Bretonneau,  one  of  seventeen  days  by  Bednar, 
one  of  eight  days  by  Bouchut,  one  of  seven  days  by  Weikert,  several  cases  by 
Parrot,  and  eighteen  cases  observed  by  Sir^dey  in  the  Hopital  Lariboisiere 
in  the  spring  of  1877.  Dr.  Jacobi  adds,  "I  have  met  with  three  cases  of 
diphtheria  of  the  pharynx  and  larynx  in  the  newly-born  myself.  One  of 
these  became  sick  on  the  ninth  day  after  birtli,  and  died  on  the  thirteenth 
day ;  the  otlier  died  on  the  sixteenth  day  after  birth  ;  the  third  was  taken 
when  seven  days  old,  and  died  on  the  ninth  day."  ^ 

Certain  physicians  having  charge  of  maternity  wards  have  observed  a 


1  Treatise  on  Diphtheria,  W.  Wood  &  Co.,  New  York,  1880. 


596  DIPHTHERIA. 

disease  occurring  in  newly-born  infants  which  bears  some  resemblance  to 
diphtheria,  but  which,  if  it  be  true  diphtheria,  presents  anomalous  features. 
Thus,  Dr.  W.  S.  Bigelow  reports  in  the  Boston  Medical  and  Surgieal 
Journal  for  March  11,  1875,  ten  cases  occurring  between  September  and 
December,  1873,  in  the  Boston  Lying-in  Asylum,  all  fatal  but  two.  The 
prominent  symptoms  and  anatomical  characters  were  dark  hue  of  skiu, 
haematuria,  pseudo-membranous  exudation  upon  certain  mucous  surfaces, 
dark-green  stools,  spleen  enlarged  and  dark,  kidneys  engorged,  in  some  of 
the  cases  effusion  of  blood  into  the  pelves  of  the  kidneys  and  along  the 
urinary  tract.  Dr.  Bigelow  refers  to  what  appear  to  have  been  similar 
cases  in  one  of  the  European  asylums.  The  presence  of  pseudo-membranous 
exudations  on  the  mucous  surfaces,  and  renal  casts,  raises  the  suspicion  that 
the  disease  which  gave  such  strong  evidence  of  infectiousness  was  diph- 
theria. That,  so  far  as  appears  from  the  records,  the  mothers  remained 
well,  does  not  preclude  the  belief  that  the  disease  of  these  infants  had  a 
diphtheritic  origin ;  for  in  cases  which  we  will  presently  relate  the  mothers 
with  one  exception  remained  well,  although  their  infants  a  few  days  old 
undoubtedly  had  diphtheria. 

A  case  in  some  respects  similar  to  those  observed  by  Dr.  Bigelow  came 
under  my  notice.  Malignant  diphtheria  occurred  in  a  family  in  West  Fifty- 
Third  Street,  New  York,  in  October,  1880.  The  patient,  a  boy  often  years, 
died,  and  the  remaining  two  children,  as  soon  as  the  nature  of  the  malady 
was  apparent,  were  sent  from  the  house.  Nevertheless,  one  of  these,  precisely 
seven  days  after  the  removal,  was  attacked  by  diphtheria  of  the  hemorrhagic 
form,  and  died  in  less  than  a  week.  Blood  escaped  from  the  nostrils,  fauces, 
under  the  skin  in  numerous  places,  causing  purpuric  spots,  and  from  the 
kidneys  or  urinary  tract,  causing  hsematuria.  The  mother,  who  was  at  this 
time  in  the  sixth  month  of  pregnancy,  continued  greatly  depressed  by  the 
occurrence,  although  her  general  health  seemed  to  be  good.  Shehad  been  in 
constant  attendance  upon  her  children.  Her  infant  born  three  months  sub- 
sequently to  the  occurrence  of  diphtheria  in  her  family  (February  6,  1881) 
was  well  developed,  but  it  presented  a  similar  hemorrhagic  cachexia  to  that 
in  the  second  case  of  diphtheria.  Blood  escaped  from  the  vessels  under  the 
skin,  causing  blotches  and  prominences,  and  from  the  mucous  surfaces. 
The  bleeding  was  persistent  and  copious  from  the  umbilicus,  so  that  death 
occurred  in  less  than  a  week.  The  diphtheritic  virus  is  subtle  and  pene- 
trating, causing  the  specific  inflammation  in  the  uterine  walls  of  the  partu- 
rient woman,  even  when  her  fauces  are  not  aifected.  Nevertheless,  whether 
diphtheria  sustains  a  causal  relation  to  cases  like  the  above  is  uncertain,  and 
can  be  determined  only  by  more  numerous  observations. 

The  admitted  infrequency  of  diphtheria  in  the  newly-born,  and  the 
statement  by  some  writers  that  the  newly-born  have  an  immunity  from  it, 
induce  me  to  relate  the  following  cases,  in  which  the  diagnosis  of  diph- 
theria was  established  beyond  doubt  by  carefully-conducted  necropsies  and 
microscopic  examinations : 


DIPHTHERIA.  597 

The  New  York  Foundling  Asylum  at  Sixty-First  Street  and  Tenth  Avenue  has  during 
the  twenty-three  years  of  its  existence  been  remarkably  free  from  contagious  and  infectious 
maladies,  but  from  September  1,  1887,  to  April,  1888,  an  epidemic  of  diphtheria  occurred 
in  the  institution.  During  this  time  five  new-born  intants  had  diphtheria,  the  pseudo- 
membrane  appearing  in  its  usual  situation  on  the  pharyngeal,  nasal,  and  laryngo-tracheal 
surfaces,  and  in  one  of  the  cases  also  lining  the  oesophagus. 

Case  I. — Violet  M.  was  born  after  normal  labor  on  January  5,  1888,  and  the  umbilicus 
was  dressed  with  borated  cotton.  The  mother  did  well,  and  was  able  to  leave  her  bed  on 
the  seventh  or  eighth  day.  Nothing  unusual  was  noticed  in  the  infant  until  January  11, 
when  a  little  suppuration  was  observed  in  the  umbilical  fossa,  at  or  around  the  point  of 
attachment  of  the  cord,  and  on  examination  the  walls  of  the  umbilicus  were  found  thickened 
and  indurated.  The  appearance  indicated  the  commencement  of  an  umbilical  phlegmon, 
and  the  skin  covering  it  was  red  as  in  erysipelas.  The  phlegmon  increased  until  January 
14,  when  the  thickening  and  infiltration  extended  to  the  distance  of  about  one  and  a  half 
inches  in  every  direction  from  the  umbilicus,  so  that  the  form  of  the  phlegmon  was  circular 
or  wheel-shape.  The  pulse  on  the  13th  varied  from  132  to  144,  and  the  rectal  temperature 
was  101.8°  F. 

On  January  14,  when  the  patient  was  nine  days  old,  we  observed  for  the  first  time  the 
grayish-white  exudate  of  diphtheria  on  each  side  of  the  fauces,  and  a  day  or  two  later  also 
on  the  Schneiderian  surface,  so  closing  the  nostrils  that  respiration  through  them  was  impos- 
sible. The  baby  on  attempting  to  draw  the  nipple  became  cyanotic  and  was  obliged  to 
relinquish  the  hold.  During  the  14th  and  15th  the  temperature  fell  to  98.5°  and  98°  F., 
the  pulse  was  very  feeble  and  too  rapid  to  be  counted  accurately,  and  the  respiration  varied 
from  24  to  48.     Death  occurred  on  the  15th,  at  the  age  of  ten  days. 

The  autopsy  revealed  a  diphtheritic  pseudo-membrane  upon  the  faucial  surface  on  both 
sides,  extending  downward  so  as  to  cover  both  surfaces  of  the  epiglottis,  the  entrance  of  the 
larynx,  and  the  laryngeal  surface,  completely  concealing  the  vocal  cords  and  the  portion  of 
the  larynx  above  them.  The  trachea  and  bronchial  tubes  were  free  from  the  exudate. 
The  lungs  in  every  part  were  thickly  mottled  with  points  of  extravasated  blood.  The 
weather  at  the  time  was  very  cold,  and  the  body  in  the  dead-house  was  frozen  soon  after 
death.  Prof.  Prudden,  of  the  laboratory  of  the  College  of  Physicians  and  Surgeons,  dis- 
covered and  cultivated  two  forms  of  microbes  in  the  phlegmon,  and  in  the  thrombus  that 
plugged  the  vein,  to  wit,  the  staphylococcus  pyogenes  aureus  and  the  streptococcus  pyo- 
genes. 

Case  II. — Hilda  M.,  born  February  28,  1888,  plump  and  robust,  weighed  eight  pounds 
and  seven  ounces.  The  mother  seemed  to  be  well  until  March  3,  when  she  had  fever, 
apparently  due  to  pelvic  cellulitis,  probably  of  septic  origin.  The  infimt  was  fretful  on 
March  3  and  4,  and  on  the  5th  a  small  ulcer  was  observed  in  the  umbilical  fossa.  The  skin 
surrounding  the  umbilicus  over  an  area  the  size  of  a  silver  dollar  had  a  deep-red  color,  and 
the  tissues  underneath  constituting  the  abdominal  walls  were  infiltrated  and  thickened. 
The  phlegmon  extended  so  that  on  March  6  it  nearly  reached  the  ensiform  cartilage  above 
and  the  pelvis  below.  The  fauces  had  been  daily  inspected,  and  at  five  p.m.  on  March  6 
the  characteristic  diphtheritic  pellicle  was  observed  for  the  first  time  covering  the  tonsil  on 
each  side.  On  March  7  the  exudate  had  increased,  the  cry  was  hoarse,  the  fingers  livid  at 
times,  and  fluid  regurgitated  through  the  nostrils.  The  phlegmon  occupied  nearly  the 
entire  abdominal  wall  anteriorly.  March  8,  surface  cyanotic,  respiration  labored  and  at 
times  accompanied  by  the  expiratory  moan  ;  a  diphtheritic  pseudo-membrane  in  the  right 
nostril.  Death  occurred  at  6.30  a.m.,  March  9,  at  the  age  of  ten  days,  on  the  fifth  day  of 
the  phlegmon  and  the  third  day  of  the  diphtheritic  pellicle  on  the  fauces. 

Prof.  Prudden  immediately  took  charge  of  the  bodj^,  and  made  the  autops}'  with  steril- 
ized instruments,  and  with  all  possible  precautions  to  prevent  the  access  of  adventitious 
germs.  His  report  states,  "  The  pharynx,  larynx,  and  trachea  showed  soft  reddi.sh  friable 
patches  of  diphtheritic  membrane,  partially  covering  their  free  surfaces."  This  membrane 
did  not  extend  into  the  bronchial  tubes.  Both  lower  lobes  of  the  lungs  were  inflamed, 
broncho-pneumonia  with  considerable  consolidation  being  present.  In  examining  the 
umbilicus  and  the  adjacent  walls  of  the  hypogastric  arteries  and  the  umbilical  vein  he 


598  DIPHTHERIA. 

found  them  infiltrated  with  spheroidal  bacteria,  and  in  a  small  pus-cavity  at  the  site  of  the 
umbilicus  were  not  only  spheroidal  bacteria,  but  a  few  rod-like  microbes.  The  most  abun- 
dant species  was  the  staphylococcus  pyogenes  aureus.  Dr.  Prudden  adds,  "  The  anatomi- 
cal diagnosis,  then,  is  diphtheria  of  the  pharynx,  larynx,  and  trachea,  with  double  broncho- 
pneumonia, localized  septic  inflammation  of  the  umbilical  vein  and  hypogastric  arteries, 
and  the  abdominal  wall  surrounding  them." 

Case  III. — Olivia  G.,  born  January  8,  and  wet-nursed  by  its  mother,  was  apparently 
well  until  January  14,  when  she  became  restless.  On  the  15th,  when  she  was  seven  days 
old,  she  was  carefully  examined,  and  diphtheritic  patches  were  observed  on  the  faucial  sur- 
face ;  rectal  temperature  100°  P.,  respiration  36,  pulse  120.  She  had  commencing  nasal 
catarrh,  with  the  usual  infiltration  and  muco-purulent  discharge,  which  so  obstructed  the 
nostrils  that  she  could  not  take  the  breast,  and  she  was  fed  with  the  mother's  milk  from  a 
spoon.  Probably  patches  of  pseudo-membrane  were  present  in  the  nostrils,  but  none  were 
observed  upon  the  visible  parts  until  the  17th,  when  the  characteristic  pellicle  occluded  the 
right  nostril.  Daily  notes  of  the  case  have  been  preserved,  and  the  symptoms  as  regards 
temperature,  respiration,  pulse,  and  the  cyanosis  bore  a  close  resemblance  to  those  in  the 
above  cases.  Death  occurred  on  the  18th.  At  the  autopsy,  in  addition  to  the  diphtheritic 
patches  already  mentioned  occurring  upon  the  faucial  and  nasal  surfaces,  a  pseudo-mem- 
brane was  found  covering  the  larynx,  trachea,  and  oesophagus  to  within  one  inch  of  the 
stomach.  No  notable  change  was  observed  in  the  appearance  of  the  internal  organs,  with  the 
exception  of  numerous  points  of  extravasation  in  the  lungs. 

Case  IV. — Victor  K.,  born  December  7,  1887,  appeared  to  be  in  usual  health  until 
January  13,  when  at  the  age  of  thirty-seven  days  the  mother  called  the  attention  of  the 
resident  physician.  Dr.  Davis,  to  him,  as  he  appeared  to  be  seriously  sick.  His  temperature 
was  103.2°  F.,  and  his  breathing  indicated  acute  nasal  catarrh.  On  the  following  day,  the 
14th,  the  grayish-white  exudate  of  diphtheria  was  observed  covering  the  left  side  of  the 
uvula.  The  inability  to  remove  it  by  the  brush  or  washing  demonstrated  its  diphtheritic 
nature.  His  subsequent  history  resembled  those  given  above.  Death  occurred  on  the  15th. 
At  the  autopsy  no  pseudo-membrane  was  observed  except  that  already  described. 

Case  V. — Vincent  B.,  born  December  31,  1887,  was  well  until  January  17,  1888,  when 
symptoms  of  a  catarrhal  nature  attracted  attention.  The  nostrils  seemed  to  be  unaffected, 
but  upon  the  posterior  portion  of  the  fauces  was  a  grayish-white  patch  of  the  usual  diph- 
theritic appearance.  By  antiseptic  and  solvent  inhalation  this  pellicle  became  smaller,  and 
on  the  21st  had  disappeared.     The  infant  recovered. 

Diphtheria  of  the  newly-born  is  sometimes  wrongly  diagnosticated. 
Thus,  in  the  New  York  Foundling  Asylum,  where  diphtheria  was  occur- 
ring, the  tonsils  of  an  infant  a  few  days  after  birth  presented  a  grayish- 
white  appearance,  suspected  to  be  diphtheritic.  After  its  death,  the  curator, 
Dr.  Northrup,  discovered  a  pultaceous  state  of  the  surface  of  the  tonsils, 
but  no  pseudo-membrane.  The  disease  was  apparently  not  diphtheritic; 
but,  as  regards  the  cases  related  above,  diphtheria  was  undoubtedly  present 
in  the  first  three,  and  there  can  be  little  doubt  that  this  was  also  the  disease 
in  the  remaining  two.  The  occurrence  of  these  cases  in  so  short  a  time  in 
a  small  maternity  service  shows  that  under  certain  circumstances  the  newly- 
born  infant  exhibits  considerable  susceptibility  to  diphtheria. 

Incubation. — The  duration  of  the  incubative  stage  in  experimental 
inoculation  is  short,  varying  from  twelve  hours  to  three  days.  In  Trende- 
lenburg's experiments  the  incubation  was  mostly  from  one  to  three  days  ;  in 
Lagrave's,  about  twenty  hours.  In  Duchamp's  inoculations  the  animals 
died  after  forty-eight  hours  with  the  larynx  and  trachea,  upon  which  the 
infectious  material  was  applied,  covered  with  pseudo-membrane.      Oertel 


DIPHTHERIA.  599 

savs  that  the  rabbits  upon  which  he  experimented  by  inoculation  of  the 
muscles  perished  in  from  thirty  to  thirty-six  hours,  rarely  after  forty-two 
hours,  the  disease-process  extending  rapidly  to  neighboring  tissues.  When 
diphtheria  is  contracted  by  a  child  upon  an  excoriated  or  wounded  sur- 
face, as  after  circumcision,  ablation  of  the  tonsils,  or  upon  a  leech-bite  or 
a  burn,  the  incubative  period  is  short,  but  it  may  be  as  long  as  four  days. 
Thus,  the  British  3Iedical  Journal  and  subsequently  the  Archives  of  Pedi- 
atries published  the  following  interesting  case,  contributed  by  Mr.  Phillips. 
A  few  hours  after  the  performance  of  tracheotomy  for  diphtheritic  croup, 
the  same  instruments  were  employed  for  performing  circumcision  in  a  child 
of  eighteen  months.  Four  days  later  a  false  membrane  appeared  upon  the 
wound  of  the  prepuce,  which  by  the  following  day  had  extended  over  the 
glans,  with  much  cedema  of  the  prepuce  and  retention  of  urine. 

When  diphtheria  is  contracted  in  the  usual  manner, — that  is,  by  the  in- 
spiration of  air  containing  the  specific  principle, — the  period  of  incubation 
appears  to  be  on  the  average  somewhat  longer  than  when  it  is  communicated 
by  direct  contact.  My  observations  lead  me  to  believe  that  when  the  incu- 
bative period  is  short  the  disease  is  likely  to  be  severe,  and  mild  when  the 
incubative  period  is  long.  I  was  enabled  to  ascertain  very  nearly  the  incu^ 
bative  period  in  the  following  cases.  A  boy  of  nine  years  was  in  the  same 
room  about  one  hour  on  Saturday  with  a  child  who  had  fatal  diphtheria. 
On  the  following  Tuesday,  without  any  other  exposure,  he  sickened  with  a 
severe  and  fatal  form  of  the  disease.  Mrs.  E.  assisted  in  nursing  a  severe 
case  of  diphtheria  from  November  11  to  13,  1874,  after  which  she  returned 
home,  several  blocks  away.  On  the  evening  of  the  15th  she  complained 
of  sore  throat,  and  on  the  following  day  the  diphtheritic  pseudo-membrane 
was  observed  upon  her  tonsils.  On  the  19th  the  exudation  had  disappeared, 
and  she  was  convalescent.  On  the  20th  her  sister,  who  resided  with  her,  and 
who  had  not  been  elsewhere  exposed,  was  also  attacked.  The  only  other 
case  in  the  family,  a  boy,  sickened  with  diphtheria  on  December  2.  In  the 
first  of  these  cases  the  incubative  period  seems  to  have  been  from  two  to 
four  days,  while  in  the  last  it  was  longer.  In  April,  1876,  a  little  girl  died 
of  malignant  diphtheria  in  West  Forty-First  Street,  Xew  York  City.  Her 
sister,  aged  one  year,  remained  with  her  from  April  14  to  17,  when  she  was 
removed  to  a  distant  part  of  the  city  and  placed  in  a  family  where  there  had 
been  no  diphtheria.  On  April  24,  seven  days  after  her  removal,  this  infant 
was  observed  to  be  feverish,  and  on  the  following  day,  when  I  was  called  to 
examine  her,  the  characteristic  diphtheritic  patch  had  begun  to  form  over 
the  left  tonsil.  In  April,  1875,  two  sisters,  aged  five  and  seven  years,  re- 
sided with  their  parents  in  a  boarding-house  in  West  Twenty-Second  Street. 
A  playmate  in  the  same  house  had  symptoms  which  were  supposed  to  be 
due  to  a  cold,  but  which  were  diphtheritic,  when  one  night  severe  laryngitis 
occurred,  and  ended  fatally  the  following  day.  The  physician  who  had  been 
summoned  diagnosticated  diphtheria,  and  the  two  sisters  were  innnediately 
removed  to  a  hotel.     Seven  days  subsequently  diphtheria  commenced  in  the 


600 


DIPHTHERIA. 


older  child.  The  younger  sister  was  then  removed  to  a  distant  part  of  the 
same  hotel,  but  six  or  seven  days  later  she  also  was  attacked.  Sann6  says 
that  in  ninety-eight  cases  the  incubative  period  appears  to  have  been  as 
follows : 


From  1  to    2  days 7  cases. 

"      2  to    8     "       48     " 

"      8  to  13     "       23     " 


From  13  to  15  days 6  cases. 

"      15  to  20     " 14     " 


But  diphtheria  is  so  insidious  and  the  modes  of  exposure  so  many  that 
in  some  of  the  cases  of  an  apparently  long  incubation  there  may  have  been 
a  second  exposure.  The  above  statistics  show  that  the  incubative  period 
varies,  but  is  most  frequently  from  t\^'o  to  eight  days. 

Nature. — Diphtheria  resembles  scarlet  fever  in  certain  particulars :  in. 
its  incubative  period  varying  from  two  to  eight  days,  with  occasional  cases 
outside  these  limits,  in  its  variability  of  type  from  a  very  mild  to  a  malig- 
nant form,  in  the  common  seat  of  its  inflammations, — to  wit,  upon  the 
fauces  and  nasal  passages, — in  the  profound  prostration  and  blood-poisoning 
in  the  graver  cases,  and  in  the  frequent  occm-rence  of  nephritis  as  a  compli- 
cation or  sequel.  It  resembles  both  scarlet  fever  and  small-pox  in  the  fact 
that  it  has  the  twofold  mode  of  communication  through  the  air  and  by  con- 
tact or  inoculation.  It  resembles  erysipelas  in  the  variableness  of  its  dura- 
tion, and  in  the  fact  that  one  attack  does  not  prevent  the  occurrence  of 
another.  In  its  etiology  it  resembles  typhoid  fever ;  for  it  is  not  only  com- 
municable from  person  to  person,  but  it  is  communicated  by  foul  exhala- 
tions, as  sewer-gas,  in  which  the  poison  lurks.  But,  while  there  are  certain 
resemblances,  it  is  distinguished  from  all  these  infectious  diseases  by  marked 
peculiarities. 

Diphtheria  is  primary  or  secondary.  The  secondary  form  most  fre- 
quently occurs  during  epidemics  of  the  other  infectious  diseases  and  as  a 
complication  of  them.  Those  infectious  maladies  which  are  accompanied 
by  inflammation  of  the  fauces  and  air-passages  are  most  liable  to  this  com- 
plication, if  they  occur  in  a  locality  where  diphtheria  prevails.  In  these 
instances  of  secondar}^  diphtheria  the  diphtheritic  inflammation  supervenes 
upon  the  inflammations  which  pertain  to  the  primary  diseases.  Scarlet 
fever  beyond  any  other  malady  appears  to  furnish  the  conditions  which  are 
most  favorable  for  the  occurrence  of  diphtheria,  in  the  latter  part  of  the 
first  week  or  in  the  second  week  of  its  continuance.  If  scarlet  fever  and 
diphtheria  be  epidemic  in  the  same  locality,  not  infrequently  towards  the 
close  of  the  first  week  of  the  former  disease  a  sudden  aggravation  of  symp- 
toms occurs,  and  the  cause  is  soon  rendered  apparent  by  the  appeamnce  of 
the  diphtheritic  exudate  upon  the  faucial  surface,  usually  upon  its  tonsillar 
portion.  The  discrimination  under  these  circumstances  of  tlie  diphtheritic 
inflammation  from  a  severe  scarlatinous  angina  is  to  be  carefully  made,  and 
is  sometimes  not  easy,  for  the  scarlatinous  inflammation,  if  intense,  occa- 
sionally becomes  gangrenous,  so  as  to  present  an  appearance  resembling  that 


DIPHTHERIA.  601 

of  a  pseudo-membrane.  The  other  infectious  maladies  which  are  most 
liable  to  the  diphtheritic  complication  are  measles,  variola,  whooping- 
cough,  and  typhoid  fever,  the  catarrhal  inflammation  of  these  diseases 
changing  to  a  pseudo-membranous  inflammation. 

It  is  an  interesting  and  important  fact  that  when  diphtheria  is  con- 
tracted by  a  person  having  inflammation  of  one  of  the  surfaces  the  specific 
inflammation  with  the  pseudo-membrane  usually  occurs  upon  the  part 
which  is  already  inflamed.  A  catarrhal  inflammation,  however  produced, 
is  liable  under  the  influence  of  the  virus  to  become  diphtheritic  and  pseudo- 
membranous. Thus,  at  one  time  diphtheria  entered  the  eye-ward  of  the 
Xew  York  Foundling  Asylimi,  and  three  children,  who  v>-ere  under  treat- 
ment for  inflammation  of  the  eyelids,  were  attacked  by  diphtheritic  con- 
junctivitis, exemplifying  the  remark  by  Billroth  that  "  catarrhal  conjunc- 
tivitis, which  is  so  very  common,  may  become  diphtheritic."  ^  Catarrhal 
inflammation  from  abrasions,  burns,  wounds  however  produced,  are  liable 
to  be  attacked  by  the  diphtheritic  inflammation  and  become  covered  with 
the  pseudo-membrane.  In  Paris,  where  diphtheria  is  very  prevalent,  the 
circumcised  prepuce  has  so  often  become  the  seat  of  the  diphtheritic  exudate 
that  the  distinguished  surgeon  Saint-Germain  considers  this  fact  a  strong 
argument  in  favor  of  stretching,  which  he  practises  instead  of  circumcision. 
He  also  for  the  same  reason  among  others  reconmiends  the  treatment  of 
enlarged  tonsils  by  galvano-cautery  instead  of  excision.  However,  in  one 
instance  in  which  I  was  employing  dilatation  of  the  prepuce,  and  in  which 
the  mucous  membrane  may  have  been  injured  by  the  o^Jeration,  a  severe 
diphtheritic  inflammation  set  in  on  the  following  day,  and  extended  from 
the  tip  of  the  prepuce  to  the  body,  with  intense  redness  and  swelling.  The 
tonsils  at  the  same  time  were  inflamed  and  covered  with  the  membranous 
exudation.     Although  severely  sick,  the  patient  recovered  in  a  few  days. 

This  general  fact  in  regard  to  the  nature  of  diphtheria  and  its  mode  of 
manifestation,  to  wit,  that  in  one  affected  by  it  the  diphtheritic  inflamma- 
tions appear  by  preference  upon  such  surfaces  as  are  already  inflamed,  has 
an  important  practical  bearing.  In  frequent  instances  during  epidemics 
of  diphtheria,  inflammations  which  physicians  of  experience  believe  to  be 
simple  or  catarrhal,  and  have  diagnosticated  as  such  to  the  friends,  are  seen 
in  a  few  days  to  be  diphtheritic.  The  most  serious  error  of  this  kind,  if  it  be 
one,  is  to  diagnosticate  and  treat  diphtheritic  croup  as  a  simple  or  catarrhal 
laryngitis,  until  the  increasing  dyspncea  reveals  the  true  nature  of  the  dis- 
ease. This  experience  always  places  the  physician  in  an  unfavorable  light. 
But  is  it  not  probable  that  in  a  certain  proportion  of  such  cases  the  disease 
was  at  first  a  simple  catarrhal  inflammation,  and  that  it  became  diphthe- 
ritic during  its  progress,  just  as  scarlatinous  angina  or  rubeolous  laryngitis 
becomes  a  diphtheritic  inflammation  in  those  who  contract  diphtheria  ? 

The  frequent  occurrence  of  diphtheria  in  all  civilized  countries  during 


^  Encyc.  Pathol.,  tran-laUxl,  p.  267. 


602  DIPHTHERIA. 

the  last  thirty  years,  and  the  great  mortality  which  attends  it,  have  awakened 
an  interest  in  this  malady  which  has  led  to  a  careful  study  of  its  causes  and 
nature.  At  first  these  inquiries  were  chiefly  clinical,  but  in  later  years 
microscopic  examinations  and  experiments  on  animals  have  furnished  im- 
portant aid  in  elucidating  the  nature  of  the  disease.  The  importance  of 
these  microscopic  examinations  and  experiments  cannot  be  overestimated. 
In  connection  with  clinical  observations,  they  render  highly  probable  the 
theory  which  has  been  stated  above,  that  diphtheria  is  produced  by  micro- 
organisms, which  coming  in  contact  with  the  mucous  membrane,  or  the 
cuticle  deprived  of  its  epidermis,  adhere  to  it,  and,  multiplying  rapidly,  act 
as  an  irritant  and  produce  the  characteristic  inflammation ;  and  the  fact  that 
since  antiseptic  treatment  has  come  into  general  use,  microbes,  in  at  least 
many  instances,  have  not  been  found  in  the  blood-vessels,  lymphatics,  or 
internal  organs,  in  those  Avho  have  died  of  diphtheria,  has  led  to  the  belief, 
as  we  have  already  remarked  under  the  head  of  etiology,  that  the  systemic 
poisoning  occurs  through  the  agency  of  chemical  products,  or  ptomaines, 
which,  produced  by  microbic  action,  are  absorbed  into  the  system.  Whether 
this  theory  be  entirely  true  or  not  will  be  determined  by  future  investiga- 
tions. If  true,  it  of  course  establishes  the  fact  that  diphtheria  is  primarily 
a  local  disease.  Whether  it  is  primarily  local  or  constitutional  has  been 
and  is  still  much  discussed.  It  is  sufficient  for  the  wants  or  purposes  of 
the  practising  physician  to  be  assured  that  in  all  cases,  unless  of  the  mild- 
est type,  diphtheria,  if  not  primarily  constitutional,  is  attended  by  systemic 
blood-poisoning  very  early,  even  on  the  first  day,  so  that  in  all  cases  of 
average  severity  constitutional  as  well  as  local  treatment  is  required.  The 
following  facts  indicate  the  early  blood-poisoning  in  diphtheria. 

1.  It  is  a  law  in  pathology  that  those  diseases  which  have  or  may  have 
a  long  incubative  period — say  of  a  week  or  more — are  constitutional. 

2.  Another  fact,  which  indicates  primary  blood-poisoning  in  diphtheria, 
is  observed  in  certain  cases,  namely,  the  occurrence  of  severe  constitutional 
symptoms  for  a  longer  or  shorter  tim,e,  perhaps  for  half  a  day,  before  the 
appearance  of  the  usual  inflammation.  Thus,  a  girl  of  five  years,  having 
malignant  diphtheria,  whom  I  saw  in  consultation,  was  carefully  examined 
on  the  first  day  of  her  sickness  by  the  attending  physician,  and,  although 
he  closely  inspected  the  fauces,  there  was  no  appearance  which  indicated  the 
nature  of  the  malady  till  the  subsequent  day.  In  such  cases,  a  sufficient 
number  of  which  I  have  observed,  there  is  likely  to  be  complaint  of  soreness 
of  the  throat,  or  difficulty  in  swallowing,  almost  from  the  beginning  of  the 
general  symptoms ;  but  the  pain  and  tenderness  seem  to  be  in  the  deeper 
tissues  of  the  neck. 

Again,  treatment  of  the  inflammations  by  the  most  reliable  and  efficient 
antiseptics  and  disinfectants  which  we  possess,  commenced  at  the  earliest 
possible  moment  and  repeated  at  short  intervals,  does  not  prevent  the  occur- 
rence of  indubitable  symptoms  of  blood-poisoning  in  cases  of  a  severe  type. 
Thus,  I  have  treated  every  portion  of  the  inflamed  surface,  so  far  as  it  was 


DIPHTHERIA.  603 

accessible,  every  second  or  third  hour,  with  carbolic  acid  and  other  disinfec- 
tants, almost  from  the  very  commencement  of  diphtheria,  and  so  thoroughly 
that  any  vegetable  or  animal  poison  with  which  the  remedies  had  come  in 
contact  would  probably  have  been  destroyed  or  rendered  inert,  and  yet, 
except  in  mild  cases,  symptoms  of  diphtheritic  blood-poisoning  have  oc- 
curred, and  as  early  and  uniformly  as  if  less  energetic  local  measures  had 
been  employed.  While,  therefore,  I  do  not  fail  to  recommend  local  treat- 
ment as  calculated  to  diminish  septic  poisoning  and  relieve  the  inflamma- 
tions, I  have  lost  confidence  in  it  as  a  means  of  preventing  the  entrance  of 
the  diphtheritic  poison  into  the  blood.  Its  powerlessness  to  prevent  con- 
tamination of  the  blood  by  the  diphtheritic  virus  is  an  additional  evidence 
that  this  contamination  occurs  early. 

3.  The  quick  succumbmg  of  the  system  in  certain  malignant  cases  is  evi- 
dently due  to  diphtheritic  toxaemia.  We  sometimes  observe  a  fatal  result 
on  the  second,  third,  or  fourth  day,  without  any  dyspnoea  or  sufficient  laryn- 
gitis to  compromise  life.  Cases  of  this  kind,  terminating  fatally  even  in 
the  first  day,  have  been  reported.  The  system  is  suddenly  overpowered  by 
the  poison,  struck  down,  as  it  were,  by  the  profound  blood-change,  while 
the  inflammations  are  still  in  their  incipiency. 

4.  Important  evidence  of  the  constitutional  nature  of  diphtheria  is 
afforded  also  by  the  state  of  the  kidneys.  No  internal  organs  are  so  often 
affected  in  diphtheria  as  the  kidneys,  and,  on  account  of  their  location  and 
anatomical  relation,  it  is  evident  that  the  poison  first  passes  through  the 
system  before  it  reaches  them.  Any  clinical  or  anatomical  fact,  therefore, 
which  indicates  that  the  diphtheritic  virus  has  reached  and  affected  the  kid- 
neys affords  proof  that  it  has  penetrated  the  system  and  poisoned  the  blood. 
Now,  the  occurrence  of  albumen,  with  granular  or  hyaline  casts,  in  the 
urine,  in  cases  unattended  by  dyspnoea,  affords  proof  of  nephritis,  caused  by 
the  action  of  the  poison  on  the  kidneys. 

Sir  John  Eose  Cormack,  of  Paris,  in  a  series  of  interesting  and  useful 
papers  relating  to  diphtheria,  published  in  the  Edinburgh  Medical  Journal 
during  1876,  states  that  albuminuria,  and  of  course  the  nephritis  on  which 
it  depends,  sometimes  begin  as  early  as  the  first  day.  My  observations 
confirm  this  statement,  as  in  the  following  cases : 

Case  I. — L.  McD.,  aged  three  years,  was  first  visited  by  me  on  February  29,  187G.  I 
learned  from  the  parents  that  she  had  been  feverish  during  the  preceding  forty-eight  hours, 
and  her  urine  very  scanty.  A  moment's  examination  was  sufficient  to  show  that  the  case 
was  one  of  malignant  diphtheria,  for  the  fauces  were  already  nearly  covered  by  the  diph- 
theritic pellicle,  tile  temperature  was  103 J°  F.,  and  the  pulse  140.  The  skin  was  hot  and  dry, 
and  there  was  moderate  swelling  under  the  ears,  and  a  muco-purulent  discharge  from  the 
nostrils.  On  account  of  the  scantiness  of  the  urine,  the  amount  not  exceeding  f^iv-v  dailj', 
it  was  impossible  to  obtain  sufficient  for  examination  till  the  following  day.  It  was  then 
found  to  have  a  specific  gravity  of  1032,  to  contain  a  deposit  of  urates  and  hyaline  and  gran- 
ular casts,  a  dimini.shed  amount  of  urea,  and  a  large  quantity  of  albumen.  It  can  hardly 
be  doubted,  from  the  scantiness  of  the  urine,  and  the  large  amount  of  albumen  found  when 
the  urine  was  first  examined,  that  albuminuria  had  been  present  on  the  first  day. 

Case  II. — The  following  was  a  similar  case.    K.,  aged  four  years,  living  in  West  Thirty- 


604  DIPHTHERIA. 

Sixth  Street,  was  visited  by  me  in  consultation  on  January  29,  1875.  Her  sickness  had  also 
continued  forty-eight  hours ;  her  fauces  were  swollen,  and  covered  with  the  diphtheritic 
pellicle,  which  was  dark  and  offensive ;  respiration  guttural ;  pulse  120 ;  temperature  101° 
F. ;  she  had  a  free  discharge  from  each  nostril ;  urine  scanty,  its  specific  gravity  1030 ;  it 
contained  a  small  amount  of  albumen,  with  casts,  and  a  large  amount  of  urates,  with  no 
apparent  diminution  of  the  urea.     Death  occurred  on  the  fourth  day. 

In  such  severe  cases,  in  which  albumen  and  casts  are  found  in  the  urine 
at  the  first  visit  of  the  physician,  there  can  be  little  doubt  that  the  nephritis 
begins  nearly  or  quite  as  early  as  the  pharyngitis ;  and  therefore,  since 
poisoning  of  the  blood  must  antedate  the  renal  disease,  diphtheria  aifects  the 
system  very  early,  probably  from  the  occurrence  of  the  first  symptoms. 

Again,  there  are  cases,  though  not  frequent, — three  I  can  recall  to  mind 
during  the  last  two  years  in  my  practice, — in  which  the  external  manifesta- 
tions of  diphtheria  are  very  mild,  even  insignificant,  and  quickly  cured, 
but  in  which  the  kidneys  are  early  and  severely  affected.  The  occurrence 
of  such  cases  is  best  explained  on  the  supposition  of  an  early  and  profound 
blood-chano-e.     The  followino;  are  histories  of  two  of  the  cases  alluded  to : 

The  house  229  West  ISTineteenth  Street,  iSTew  York,  is  an  old  wooden  structure,  and  the 
family  which  has  occupied  it  during  the  last  five  years  has  been  three  times  visited  by  diph- 
theria, the  first  case,  that  of  the  oldest  child,  proving  fatal.  In  February,  1876,  one  of  the 
children  had  diphtheria  in  a  moderately  severe  form.  He  recovered,  and,  after  my  visits 
had  been  discontinued,  his  sister,  aged  six  years,  who  had  had  scarlet  fever  when  eighteen 
months  old,  became  feverish,  and  complained  of  her  throat.  Xo  rash  appeared  on  her  skin, 
and  there  was  apparently  no  coryza.  Inspection  of  the  fauces  by  the  parents  revealed  a 
small  diphtheritic  patch  over  each  tonsil.  Although  diphtheria  was  so  fi-ightful  a  malady. 
to  this  family  from  their  past  experience,  the  case  seemed  so  mild  that  the  parents  treated  it 
without  medical  attendance,  by  the  remedies  which  had  been  employed  for  the  boy.  A  mix- 
ture of  carbolic  acid,  subsulphate  of  iron,  and  glycerin  was  applied  to  the  fauces  every  third 
hour,  sufficiently  often,  apparently,  to  destroy  all  bacteria  or  other  vegetable  or  animal 
organisms  with  which  it  might  have  come  in  contact,  and  within  two  or  three  days  the  in- 
flammation of  the  throat  seemed  to  the  parents  to  be  cured.  Nevertheless,  with  this  insig- 
nificant inflammation  of  the  fauces,  so  quickly  subdued,  and  with  no  other  apparent  inflani- 
naation  of  the  mucous  surfaces,  there  was  severe  internal  disease  going  on  as  the  result  of 
the  general  infection.  The  child  did  not  regain  her  former  appetite ;  she  had  increa&ing 
pallor,  although  able  to  play  about  the  house  ;  and  finally,  in  the  third  week,  when  I  was 
called  to  see  her,  slight  oedema  of  the  face  and  limbs  was  observed.  Her  urine,  which  was 
scanty,  was  found  to  contain  pus  and  blood-corpuscles,  albumen,  and  granular  casts,  and 
nearly  two  months  elapsed  before,  under  treatment,  it  became  normal  and  her  health  was 
restored. 

The  second  case  occurred  in  January,  1878,  in  "West  Fifty-First  Street.  A  boy,  aged 
six  years,  in  a  family  in  which  diphtheria  was  occurring,  had  slight  sore  throat,  which 
abated  in  two  or  three  days.  It  was  attended  by  little  or  no  exudation,  and  would  not  have 
been  considered  diphtheritic  except  for  the  circumstances  in  which  it  occurred,  and  the  sub- 
sequent history.  Still,  the  boy  remained  ill  and  fretful,  and  four  days  subsequently  his  urine 
was  found  to  be  very  scanty  and  very  albuminous ;  and  three  days  later  death  occurred, 
preceded  by  total  suppression  of  urine.  The  last  urine  passed,  which  was  not  more  than  a 
teaspoonful,  became  nearly  semi-solid  by  heat.    There  had  been  no  scarlet  fever  in  the  family. 

Cases  like  the  above,  in  which  there  is  an  early  and  profound  systemic 
infection,  with  ])ut  slight  evidence  of  lodgement  of  the  virus  upon  the  fancial 
or  other  exposed  surface,  are  interesting  as  showing  the  constitutional  nature 


DIPHTHERIA.  605 

of  the  malady,  even  when  the  symptoms  and  visible  lesions  have  extreme 
mildness.  Certain  clinical  observations,  therefore,  lend  support  to  the  theory 
that  diphtheria,  even  if  it  be  in  most  instances  local  at  first,  is  in  some  cases 
svstemic  from  its  commencement,  and  seem  to  justify  the  remark  made  by 
Dr.  A.  Jacobi,  that  probably  in  some  instances  the  diphtheritic  virus  enters 
the  system  through  the  lungs, — a  supposition  which  demands  consideration, 
notwithstanding  the  fact  that  many  pathologists  now  believe  that  the  specific 
germ  acts  only  upon  the  surface.  Whether  diphtheria  be  always  local  in 
its  commencement,  or  sometimes  systemic,  it  answers  the  wants  of  the  prac- 
titioner to  be  assured  that,  in  cases  of  a  severe  type,  diphtheria  is  systemic 
at  so  early  a  period  that  constitutional  remedies  are  required  at  the  first 
visit.  He  will  be  the  most  successful  practitioner  who  fully  recognizes  the 
fact  that  he  has  to  deal  with  a  malady  which  has  both  a  local  and  a  systemic 
character. 

Diagnosis. — It  Is  very  important  that  the  diagnosis  of  a  case  of  diph- 
theria be  early  made,  so  that  proper  remedial  measures  may  be  employed 
at  the  beginning,  as  well  as  measures  designed  to  prevent  propagation.  In 
a  large  proportion  of  cases  the  diagnosis  is  easy  after  diphtheria  has  con- 
tinued twenty-four  hours,  since,  in  addition  to  the  fever,  and  pain  in  swal- 
lowing, the  characteristic  grayish-white  pellicle  has  begun  to  form  on  one 
or  both  tonsils.  Under  such  circumstances  the  nature  of  the  malady  is 
apparent  on  insjiecting  the  fauces.  But  many  cases  are  not  so  quickly  and 
readily  diagnosticated,  even  by  experienced  physicians.  The  diagnosis  is 
uncertain,  and  is  postponed  until  two  or  more  days  have  elapsed.  One 
reason  of  failure  to  diagnosticate  early  is  the  fact  -that  many  patients,  even 
those  old  enough  to  express  their  sensations,  do  not  complain  of  the  throat. 
I  have  many  times  been  informed  by  parents  or  nurses  that  there  was  no 
need  of  examining  the  fauces,  as  there  was  no  complaint  of  pain  in  the 
throat,  and  yet  on  examination  have  observed  unequivocal  evidence  of 
diphtheria.  A  physician  practising  in  a  locality  where  diphtheria  is  pre- 
vailing should  at  his  first  visit  inspect  the  fauces  of  a  child  to  whom  he  is 
summoned,  especially  if  there  be  fever,  and  he  will  often  discover  evidences 
of  diphtheria  which  without  such  examination  would  not  have  been  de- 
tected. 

When  diphtheria  has  continued  from  twelve  to  twenty-four  hours, 
external  examination  of  the  neck  usually  reveals  some  tenderness  as  well  as 
fulness  in  the  tonsillar  regions,  and  the  enlargement  of  the  tonsils  can  be 
readily  detected  on  palpation ;  but  in  some  instances  the  tenderness  and 
swelling  are  so  slight  as  to  be  scarcely  appreciable.  In  not  a  few  cases  it  is 
impossible  to  make  a  positive  diagnosis  until  the  disease  has  been  under 
observation  some  days  and  its  progress  and  character  have  been  carefully 
noted,  the  difficulty  in  diagnosis  arising  from  the  fact  that  the  membranous 
exudate  is  concealed  from  view.  Thus,  in  nasal  diphtheria,  the  pseudo- 
membrane  may  be  located  upon  the  superior  and  posterior  portions  of  the 
Schneiderian  membrane,  and  therefore  be  invisible,  while  the  anterior  and 


606  DIPHTHERIA. 

visible  portions  of  the  nares,  and  the  faucial  surface,  are  hypersemic  and 
secreting  muco-pus  in  abundance,  but  are  free  from  the  pseudo-membranous 
exudate.  The  pseudo-membrane  may  and  probably  will  appear  upon  visi- 
ble parts  before  the  disease  terminates,  but  not  early  enough  to  establish  a 
diagnosis  in  the  first  days  of  the  sickness.  Occasionally  iu  the  milder  forms 
of  pharyngeal  diphtheria  membranous  patches  occur  in  the  depressions  of 
the  faucial  surface,  and  are  not  visible  on  cursory  inspection.  They  are 
brought  into  view  when  the  patient  coughs,  or  by  firm  external  pressure 
upon  the  side  of  the  neck,  which  elevates  the  depressed  surfaces. 

In  laryngo-tracheal  diphtheria,  diagnosis  is  not  infrequently  delayed  in 
a  similar  manner.  The  child,  without  known  exposure  to  the  diphtheritic 
virus,  becomes  hoarse,  and  the  hoarseness  with  fever  increases.  The  fauces 
show  the  characteristics  of  catarrhal  inflammation,  and  the  nostrils  are  not 
affected,  or  are  affected  but  slightly.  The  diagnosis  between  catarrhal  croup, 
non-specific  membranous  croup,  and  diphtheritic  croup  is  uncertain.  The 
patient  may  die  without  any  visible  pseudo-membrane,  unless  the  laryngo- 
scope be  used,  and  without  a  diagnosis  except  the  general  one  of  croup. 
The  occurrence  of  albuminuria  with  casts  may  enable  us  to  make  the 
probable  diagnosis  of  diphtheria,  and  this  opinion  may  be  confirmed  by 
the  contemporaneous  or  subsequent  occurrence  of  diphtheria  in  other  mem- 
bers of  the  family ;  but  in  other  instances  no  such  aid  is  obtained,  and  the 
nature  of  the  attack  continues  to  be  a  matter  of  probability  only.  Such  are 
some  of  the  hinderances  in  the  way  of  accurate  diagnosis. 

The  following  is  a  resum6  of  the  characteristics  of  the  white,  grayish, 
or  grayish-white  products  of  disease  which  occur  on  the  faucial  surface  and 
which  are  liable  to  be  mistaken  for  the  pseudo-membrane  of  diphtheria. 
Let  us  first  consider  the  characteristics  of  the  diphtheritic  exudate.  It  is 
deeply  set  in  the  mucous  membrane,  penetrating  it  and  being  incorporated 
with  it.  It  consists  of  necrosed  mucous  tissue  and  firm  fibrinous  material 
exuded  from  the  minute  vessels,  and  it  cannot  be  detached  from  the  faucial 
surface,  except  at  an  advanced  stage  of  the  disease,  without  producing  hem- 
orrhage. It  is  surrounded  by  inflamed  and  swollen  mucous  membrane  as 
the  crystal  of  a  watch  is  surrounded  by  the  rim.  Compare  these  character- 
istics of  the  diphtheritic  pseudo-membrane  with  the  products  of  other  and 
distinct  diseases  of  the  pharynx.  First,  follicular  tonsiHitis.  This  is  a  com- 
mon disease.  In  New  York,  and  probably  elsewhere,  it  frequently  extends 
through  families  as  if  contagious,  all  or  most  of  the  children  being  affected 
by  it.  It  is  attended  by  fever  and  dysphagia.  It  has  no  marked  premoni- 
tory symptoms,  unless  of  very  brief  duration,  and  commences  suddenly, 
like  diphtheria,  with  headache,  chilliness,  heat  of  surface,  the  temperature 
often  rising  to  103°  F.,  languor,  and  frequently  pain  in  the  back  and  ex- 
tremities. The  dysphagia  attracts  attention  to  the  fauces,  the  surface  of 
which  is  seen  to  be  hyperaemic,  especially  its  tonsillar  portion.  In  a  few 
hours  a  whitish  material  exudes  from  the  crypts  of  the  tonsils,  consisting  of 
the  secretion  of  the  crypts  and  epithelial  cells,  and  forming  rounded  masses 


DIPHTHERIA.  607 

of  the  size  of  a  small  pin's  head.  The  secretion,  occurring  as  small,  rounded, 
salient  masses,  distinct  from  one  another,  is  distinguished  by  its  appearance 
from  the  diphtheritic  pseudo-membrane,  which  at  first  is  a  thin,  pellucid 
film,  becoming  thicker  subsequently.  Consisting  simply  of  epithelial  cells 
held  together  by  the  secretion,  these  small  rounded  masses  are  quickly  de- 
tached by  the  swab  or  brush,  when  they  are  found  to  be  friable,  readily 
crushed  between  the  thumb  and  fingers,  and  having  a  fetid  odor.  If  two 
or  more  of  them  happen  to  unite,  forming  an  appearance  like  that  of  the 
diphtheritic  membrane,  they  still  present  the  same  physical  characters,  and 
are  readily  detached  from  the  tonsillar  surface  without  hemorrhage.  This 
peculiar  secretion  of  follicular  tonsillitis  is  usually  limited  to  the  tonsillar 
portion  of  the  pharynx,  and  is  of  short  duration,  ceasing  to  appear  after 
two  or  three  days.  The  inflammation  abates  soon.  In  a  large  number  of 
cases  which  I  have  observed,  the  clinical  history  of  this  disease  has  been  as 
mentioned  above,  except  in  one  instance,  when  death  occurred  apparently 
from  a  sudden  extension  of  the  inflammation  to  the  larynx  and  the  occur- 
rence of  oedema  glottidis.  The  diagnosis  of  follicular  tonsillitis  from  diph- 
theria is  easily  made  except  as  regards  the  mildest  form  of  diphtheria. 

Pultaceous  Pharyngitis. — This  form  of  pharyngitis  usually  occurs  in  low 
or  debilitated  states  of  the  system.  It  occurs  most  frequently  in  the  old 
and  feeble,  and  in  such  exhausting  diseases  as  scarlatina  and  typhoid  fever. 
As  the  term  "  pultaceous"  indicates,  the  inflammatory  product  is  soft  and 
friable,  coming  away  in  fragments,  when  touched  by  the  brush  or  sponge, 
without  bleeding  or  any  injury  to  the  mucous  membrane.  Under  the  micro- 
scope it  is  found  to  consist  of  epithelial  cells,  often  in  fragments,  nuclei  and 
nucleoli,  but  no  fibrin.  When  this  substance  is  removed,  as  it  readily  can 
be,  the  mucous  membrane  underneath  is  entire,  hypersemic,  and  covered  by 
a  newly-formed  epithelial  layer.  The  appearance  of  the  pultaceous  product 
to  the  naked  eye  may  closely  resemble  that  in  diphtheria,  but  its  friable 
character,  its  epithelial  nature,  and  the  absence  of  fibrin  which  the  micro- 
scope reveals,  render  the  diagnosis  certain. 

Scarlatinous  Pharyngitis. — The  frequency  of  scarlet  fever  and  diphtheria, 
and  the  facts  that  epidemics  of  the  two  are  not  uncommon  at  the  same  time, 
and  that  diphtheria  often  attacks  a  scarlatinous  patient,  render  important 
the  diflerentiation  of  scarlatinous  pharyngitis  from  diphtheritic  pharyn- 
gitis supervening  upon  and  complicating  the  scarlatinous.  Very  commonly 
when  the  pharyngitis  of  scarlet  fever  is  severe,  an  abundant  desquamation 
of  epithelial  cells  occurs,  which,  aggregating,  produce  the  pultaceous  pseudo- 
membrane  described  above.  This  membrane  resembles  the  diphtheritic  in 
a]>])earance,  but  its  anatomical  character,  consisting  as  it  docs  of  epithelial 
cells  as  stated  above,  suffices  to  show  that  it  is  not  a  diphtheritic  exudate. 
The  grayish-white  or  brown  product  of  scarlatinal  inflammation  seldom 
appears  upon  other  parts  than  the  tonsillar  or  lateral  pharyngeal  surfaces, 
whereas  the  diphtheritic  membrane  often  appears  upon  the  uvula,  upon  the 
posterior  faucial  surface,  and  in  the  nares,  in  addition  to  the  tonsillar  surface. 


608  DIPHTHERIA. 

Gangrenous  Pharyngitis. — This  variety  of  phanmgitis  occurs  oftener  in 
connection  with  scarlet  fever  than  with  any  other  malady  unless  diphtheria^ 
and  when  it  complicates  scarlet  fever  the  appearance  resembles  very  closely 
that  in  advanced  cases  of  malignant  diphtheria.  The  diagnosis  is  not  dif- 
ficult if  the  case  be  observed  from  the  beginning.  The  diphtheritic  pseudo- 
membrane  is  in  the  commencement  white  or  grayish-white.  It  presents 
the  dark-gray  color  of  gangrene  only  at  an  advanced  stage,  by  imbibition 
of  blood  and  commencing  disintegration.  Gangrenous  sore  throat  is  from 
the  first  of  a  dark-gray,  brownish,  or  even  dark  color.  Gangrene  produces 
a  fetid  breath,  malignant  diphtheria  does  not  produce  fetor  to  such  an  ex- 
tent until  decomposition  begins  or  gangrene  supervenes.  Gangrene  not 
infrequently  complicates  the  later  stages  of  severe  diphtheria. 

Herpetic  Pharyngitis. — No  one  can  mistake  herpes  of  the  fauces  in  its 
commencement  for  diphtheria,  the  minute  vesicles  of  the  former  disease  are 
so  unlike  the  diphtheritic  exudate.  But  when  the  vesicles  have  disappeared, 
and  are  replaced  by  minute  ulcerations,  covered  by  a  white  and  adherent 
exudate,  the  differentiation  of  herpes  from  benign  diphtheria  is  not  easy. 
The  presence  of  herpes  labialis  affords  presimiptive  evidence  that  the 
pharyngitis  is  herpetic,  but  not  conclusive,  for  it  is  sometimes  also  present 
in  diphtheria.  Immediately  after  the  disappearance  of  the  vesicles,  small 
rounded  concretions  distinct  from  one  another  occupy  their  place,  presenting 
an  appearance  entirely  unlike  that  of  diphtheria,  which  exhibits  at  first  a 
film,  soon  becoming  a  thick  and  firm  patch.  It  is  when  the  concretions 
unite,  forming  a  patch,  that  the  diagnosis  is  difficult.  I  need  not  state  that 
herpetic  pharyngitis,  like  follicular  tonsillitis,  is  often  mistaken  for  benign 
diphtheria,  and  vice  versa. 

Ulcero- Membranous  Pharyngitis. — This  is  an  extension  of  ulcero-mem- 
branous  stomatitis.  It  is  characterized  by  a  necrosis,  limited  in  extent,  and 
superficial,  of  the  mucous  membrane.  The  presence  of  ulcero-membranous 
stomatitis  as  the  important  part  of  the  disease,  predominating  over  the 
pharyngeal  affection,  aids  to  a  correct  diagnosis.  Constitutional  symptoms 
are  slight  or  are  wanting  in  this  form  of  pharyngitis.  Fever,  albuminuria, 
and  glandular  swellings,  which  characterize  diphtheritic  pharyngitis,  are 
absent  or  insignificant.  The  sphacelus  over  the  tonsils,  unlike  that  in  diph- 
theria, is  in  patches  isolated  from  one  another.  The  microscope  reveals 
epithelial  cells,  and  bands  of  elastic  fibres  pertaining  to  the  chorion,  as  the 
elements  in  the  necrosed  tissue. 

Anatomical  Characters. — The  characteristic  and  diagnostic  feature  of 
diphtheria  is  the  formation  upon  one  of  the  mucous  surfaces,  usually  the 
fauces,  or  upon  the  skin  denuded  of  its  cuticle,  of  a  whitish  or  grayish-white 
pseudo-membrane.  This  membrane,  occurring  upon  mucous  surfaces  lined 
by  pavement-epithelium,  penetrates  and  is  incorporated  with  the  mucous 
membrane,  which  undergoes  necrosis.  The  mucous  membrane  when  the 
pseudo-membrane  is  fully  formed  loses  its  vitality  and  becomes  a  part  of 
the  pseudo-membranous  mass.     It  cannot,  therefore,  be  detached  without 


DIPHTHEEIA.  609 

tearing;  the  fibres  of  connective  tissue  and  the  vessels  which  unite  the 
mucous  membrane  to  the  submucous  tissues,  until  such  time  as  it  becomes 
detached  by  the  sloughing  process.  Upon  such  mucous  surfaces  as  are  lined 
by  columnar  epithelium  the  pseudo-membrane  does  not  form  an  integral 
connection  with  the  mucous  membrane,  but  lies  over  it,  or  lines  it,  so  that 
it  can  be  removed  without  injuring  it.  This  form  of  pseudo-membrane 
occurs  upon  the  respiratory  tract  below  the  superior  vocal  cord.  Above 
this  cord  squamous  epithelium  lines  the  larynx,  except  in  front,  where 
columnar  epithelium  occurs  as  high  as  the  middle  of  the  epiglottis.  If 
croup  occur  during  the  course  of  diphtheria  and  a  pseudo-membrane  form 
upon  the  laryngo-tracheal  surface,  in  addition  to  that  already  existing  upon 
the  faucial  surface,  the  patient  has  both  forms  of  pseudo-membrane  de- 
scribed above.  Moreover,  in  the  vicinity  of  these  pseudo-membranous  in- 
flammations, and  extending  from  them,  we  ordinarily  find  a  catarrhal 
inflammation  of  greater  or  less  extent,  an  inflammation  characterized  by 
redness  aud  swelling  of  the  mucous  surface,  and  a  muco-purulent  secre- 
tion, but  without  the  false  membrane.  Sometimes  also  when  diphtheria  is 
occurring  in  a  family,  one  of  the  children  has  a  simple  catarrhal  inflam- 
mation of  the  fauces  of  a  few  days'  continuance.  If  he  have  a  pseudo- 
membrane  upon  any  of  the  surfaces,  it  is  not  visible.  These  three  forms 
of  inflammation,  that  in  which  the  mucous  membrane  undergoing  necrosis 
becomes  incorporated  with,  and  forms  an  integral  part  of,  the  pseudo- 
membrane,  that  in  which  the  pseudo-membrane  covers  the  mucous  mem- 
brane but  is  anatomically  distinct  from  it,  and  that  in  which  no  j)seudo- 
membrane  occurs,  the  catarrhal,  we  are  in  the  habit  of  designating  by  the 
term  diphtheritic,  inasmuch  as  they  occur  from  the  irritating  action  of  the 
diphtheritic  poison.  Unfortunately,  the  most  renowned  living  pathologist, 
Virchow,  restricts  the  use  of  the  term  diphtheritic  to  that  form  of  inflam- 
mation in  which  mucous  membrane  undergoing  necrosis  forms  part  of  the 
pseudo-membrane,  while  he  does  not  apply  the  term  diphtheritic,  but  the  term 
croupous,  to  that  form  of  inflammation,  although  occurring  in  a  diphtheritic 
patient,  in  which  the  pseudo-membrane  lies  upon  the  mucous  surface.  This 
explanation  seems  to  be  necessary  in  order  to  avoid  confusion  in  the  use  of 
the  terms  diphtheritic  and  croupous  as  employed  by  the  school  of  Virchow. 

Soon  after  diphtheria  commences,  as  manifested  by  fever  and  the  con- 
comitant symptoms,  we  observe  redness  upon  one  of  the  surfaces  which  is  to 
be  the  chief  seat  of  the  local  manifestation  of  the  disease.  When  the  malady 
is  contracted  in  the  usual  manner,  this  local  manifestation  is  ordinarily  upon 
the  faucial  surface,  and  primarily  upon  the  tonsillar  portion.  If  there  be  a 
pre-existing  inflammation  of  one  of  the  other  mucous  surfaces,  or  a  portion 
of  the  cuticle  denuded  of  its  epidermis  and  inflamed,  the  specific  inflamma- 
tion is  likely  to  appear  primarily  upon  this  part,  as  we  have  stated  above, 
with  or  without  its  simultaneous  appearance  upon  the  faucial  surface. 

The  inflammation  varies  greatly  in  severity  ard  extent.     In  a  mild 

attack  it  is  often  limited  to  a  part  of  the  fauces,  and  tl'ere  are  few  exceptions 
Vol.  I.— 39 


610  DIPHTHEEIA. 

to  the  rule  that  the  tonsillar  portion  is  affected,  the  redness  gradually  fading 
away  in  the  healthy  membrane  beyond.  But  in  the  course  of  a  few  hours, 
in  all  except  the  mildest  cases,  the  entire  faucial  surface  presents  the  charac- 
teristic inflammatory  redness  and  swelling,  and  its  follicles  are  tumefied  and 
actively  secreting.  In  severe  cases  the  uvula  is  elongated  and  enlarged  from 
infiltration,  and  the  inflammation  even  extends  to  the  submucous  connective 
tissue,  which  becomes  hypersemic  and  swollen,  and  the  submucous  lymphatic 
glands,  especially  the  tonsils,  also  swell  and  are  painful.  The  color  of  the 
inflamed  surface  is  sometimes  a  deep  bright  red,  almost  like  arterial  blood ; 
in  other  cases  it  is  a  dusky  red,  which  indicates,  if  there  be  no  croupal 
symptoms,  an  adynamic  and  dangerous  type  of  the  disease.  The  dusky- 
red  hue  is  more  common  in  secondary  than  in  primary  diphtheria. 

Within  a  day  and  usually  within  a  few  hours  from  the  commencement 
of  the  inflammation,  a  small,  slightly-raised,  whitish  or  grayish  spot,  or 
patch,  is  observed,  usually  upon  the  tonsillar  portion  of  the  inflamed  sur- 
face, very  significant  as  a  diagnostic  sign  and  as  a  forerunner  of  what  is 
to  happen.  This  patch,  termed  the  pseudo-membrane,  gradually  becomes 
firmer,  and  at  the  same  time  thicker  and  broader  from  fresh  exudations 
underneath.  It  retains  for  a  time  its  grayish-white  color,  but  it  becomes 
brownish- white  from  age.  In  mild  cases  the  pseudo-membrane  is  usually 
limited  to  the  tonsillar  surface,  but  in  severe  cases  it  covers  the  uvula, 
portions  of  the  velum,  the  isthmus,  and  the  walls  of  the  pharynx,  both 
lateral  and  posterior.  It  does  not  ordinarily  attain  a  greater  thickness  than 
one-eighth  to  one-sixth  of  an  inch.  I  have  seen  it,  however,  not  far  from 
one-third  of  an  inch  thick. 

Briefly  stated,  the  pseudo-membrane  of  diphtheria  is  found  to  consist  of 
fibrin  forming  a  delicate  interlacing  net-work,  epithelial  cells  more  or  less 
altered  by  the  inflammatory  process,  leucocytes,  nuclei,  mucus,  and  amor- 
phous matter.  It  also  contains,  as  has  been  remarked  above,  different 
species  of  bacteria,  of  which  the  micrococci  are  most  abundant.  The  sig- 
nificance of  the  bacteria  is  fully  dwelt  upon  elsewhere  in  this  article.  The 
same  pseudo-membrane  is  often  firmer  in  one  part  than  in  another,  the  outer 
and  central  portions  being  more  compact  and  tough  for  a  time  than  that 
underneath,  which  is  more  recent.  After  a  few  days,  however,  decompo- 
sition begins,  and  then  that  which  was  first  formed  becomes  softer  than  the 
more  recent  production.  When  this  occurs,  the  color  of  the  exudation . 
changes  to  a  dirty  brown,  and  its  exposed  surface  is  uneven  and  jagged, 
from  the  partial  separation  of  shreds  and  fibres.  Sometimes  the  diph- 
theritic patch  has  a  reddish  tinge,  due  to  rupture  of  the  capillaries  and 
escape  of  blood-corpuscles.  Its  lower  or  attached  surface  may  be  blood- 
stained, while  the  exposed  surface  has  the  usual  grayish-white  hue. 

The  inflamed  mucous  membrane  is  not  only  hypersemic  and  infiltrated 
with  serum,  but  also  contains  numerous  round  white  corpuscles  (leucocytes), 
which  may  result  in  part  from  proliferation  of  connective-tissue  corpus- 
cles, but  are  believed  by  most  pathologists,  since  Cohnheim's  well-known 


DIPHTHERIA.  611 

discover}',  to  be  in  great  part  wandering  white  corpuscles  of  the  blood, 
which  have  escaped  through  the  walls  of  the  blood-vessels  along  with  the 
fibrin.  In  the  commencement  of  the  diphtheritic  inflammation,  before  the 
pseudo-membrane  forms,  we  often  observe  a  grayish  tinge  of  the  mucous 
surface,  which  is  due  to  the  crowding  of  these  cellular  elements  in  and 
underneath  the  mucous  membrane ;  for  these  newly-formed  cells  not  onlv 
infiltrate  the  mucous  membrane,  but  can  also  be  traced  into  the  submucous 
connective  tissue.  Even  where  the  inflammation  remains  catarrhal,  as  it 
does  over  certain  areas  in  all  cases  of  diphtheria,  this  infiltration  of  the 
mucous  and  submucous  tissues  with  cells  is  common. 

During  the  active  period  of  diphtheria,  it  is  often  astonishing  to  see  with 
what  rapidit}'^  the  pseudo-membrane  returns  when  removed  by  force.  A  few 
hours  suffice  to  restore  it  as  firm  and  extensive  as  before  the  interference. 
In  the  most  favorable  cases  the  membrane  is  detached  in  a  few  days,  and 
is  not  reproduced.  Its  separation  is  promoted  by  the  secretions  underneath, 
especially  by  pus,  which  is  secreted  in  abundance  between  it  and  the  tissues 
underneath,  which  have  preserved  their  integrity.  In  most  instances  it  does 
not  separate  in  mass,  but  disappears  by  progressive  liquefaction.  Occasion- 
ally, even  in  cases  which  do  not  present  a  severe  t}^e,  the  diphtheritic 
patch  does  not  disappear  until  the  lapse  of  four  or  five  or  even  six  weeks, 
or,  if  it  softens  and  is  detached,  another  appears  in  its  place.  In  these 
instances  of  an  unusual  prolongation,  diphtheria  has  been  designated  chronic. 

Such  are  the  appearances,  character,  and  history  of  the  pseudo-mem- 
brane in  this  malady.  Although  its  common  seat  is  upon  the  fauces,  and 
in  mild  cases  it  is  limited  to  them,  nevertheless  all  the  mucous  surfaces  are 
liable  to  be  attacked  by  the  inflammation,  in  consequence  of  infection  of  the 
blood,  and  therefore  in  severe  cases,  -and  even  in  cases  of  moderate  severity, 
we  often  find  the  product  elsewhere  as  well  as  upon  the  fauces,  and  in  lo- 
calities where  from  its  mechanical  effect  it  greatly  increases  the  danger  and 
even  compromises  life.  The  mucous  membrane  of  the  nostrils,  mouth, 
larynx,  trachea,  bronchial  tubes.  Eustachian  tube,  conjunctiva,  cesophagus, 
stomach,  intestines,  vagina,  prepuce,  and  even  the  delicate  lining  membrane 
of  the  middle  ear,  are  at  times  the  seat  of  diphtheritic  inflammation  with 
the  characteristic  product.  In  a  case  which  occurred  in  the  Xursery  and 
Child's  Hospital  of  New  York,  the  surface  of  the  stomach  was  almost  com- 
pletely lined  by  the  diphtheritic  formation,  so  as  apparently  to  abolish  the 
function  of  that  important  organ.  The  occurrence  of  the  pseudo-membrane 
in  the  nares  is  common,  and  is  attended  by  the  discharge  from  the  nose  of 
thin  mucus  and  pus.  Nasal  diphtheria  involves  great  danger,  from  the  fact 
that  it  is  likely  to  give  rise  to  systemic  infection  of  a  grave  type.  In  the 
nursing  infant  it  is  also  dangerous,  since  by  its  mechanical  effect  it  interferes 
with  lactation.  The  thin,  irritating  discharge  produces  excoriations  around 
the  nostrils  and  upon  the  upper  lip.  I  have  met  only  one  case  of  diph- 
theritic inflammation  of  the  intestines  in  which  the  diagnosis  Avas  certain. 
A  physician  in  whose  family  diphtheria  Avas  occurring  became  seriously  sick 


612  DIPHTHERIA. 

with  symptoms  wliicli  closely  resembled  those  of  typhoid  fever.  After  a 
long  sickness,  he  expelled  per  rectum  about  one  foot  of  pseudo-membrane 
of  a  cylindrical  form,  evidently  derived  from  the  surface  of  the  intestines. 
In  the  subsequent  months  the  patient  suifered  from  constipation  and  severe 
abdominal  pains,  apparently  due  to  contraction  in  healing  of  the  large  intes- 
tinal ulcer.  Death  finally  occurred  from  this  state  of  the  intestines.  The 
formation  of  the  diphtheritic  pellicle  upon  the  vulva  and  vaginal  walls  is 
not  infrequent,  and  in  parturient  women  exposed  to  diphtheria  it  sometimes 
occurs  upon  the  uterine  walls,  usually  with  a  fatal  result.  A  considerable 
number  of  cases  are  on  record  in  which  diphtheritic  inflammation  occurred 
upon  the  prepuce  after  circumcision,  producing  the  usual  pseudo-membrane, 
and  in  one  instance  in  my  practice,  referred  to  above,  it  attacked  the  pre- 
puce the  day  after  I  had  dilated  it  with  an  instrument  clean  and  free  from 
infection. 

In  mild  cases  of  diphtheria,  in  which  the  pellicle  is  small,  superficial, 
and  limited  to  the  fauces,  systemic  infection  is  usually  slight ;  and  it  is  the 
belief  of  many  that  the  disease,  when  of  this  mild  type,  not  infrequently 
remains  local.  But  in  grave  cases,  in  which  the  diphtheritic  pellicle  is 
extensive  and  deeply  embedded,  systemic  infection  commonly  results,  not- 
withstanding the  most  efficient  local  antiseptic  treatment.  The  lymphatics 
and  blood-vessels  which  are  in  immediate  relation  with  the  under  surface  of 
the  pseudo-membrane  take  up  poisonous  ptomaines.  Septic  blood-poisoning 
as  distinct  from  diphtheritic  blood-poisoning  is  also  likely  to  occur  in  those 
cases  in  which  the  pseudo-membrane  has  become  dark-gray  and  friable 
from  decomposition,  producing  an  ichorous  discharge  and  oifensive  breath. 

The  Blood. — The  blood  in  cases  of  a  severe  type  is  usually  darker  than 
in  health,  and  the  clots  soft.  After  death  from  diphtheritic  croup  it  is  also 
dark  from  the  excess  of  carbonic  acid  in  it.  The  chemical  changes  which 
the  blood  undergoes  in  diphtheria  are  little  known.  MM.  Andral  and 
Gavarret  found  a  notable  diminution  of  fibrin  in  grave  infectious  diseases, 
as  typhoid  fever,  puerperal  fever,  etc.,  and  it  is  not  improbable  that  the  same 
is  true  of  diphtheritic  blood,  although  the  exudation  of  blood  is  so  abun- 
dant. M.  Bouchut  and  others  have  noted  an  excess  of  the  white  corpuscles 
in  the  blood  in  diphtheritic  patients,  so  that,  instead  of  three  or  four  in  the 
field  of  the  microscope,  as  many  as  sixty  have  been  counted.  M.  Sanne 
writes  of  diphtheria,  "  It  is  necessary  to  recognize  in  the  dark-brown  blood 
an  abnormal  accumulation  of  the  debris  of  the  red  corpuscles,  debris  of 
little  abundance  in  the  normal  state,  augmented  considerably  under  the 
noxious  influence  of  the  diphtheritic  poison,  which  has  rapidly  produced 
destruction  of  a  great  number  of  globules."^  Small  extravasations  of  blood 
in  the  various  organs  are  among  the  most  constant  lesions.  They  have 
been  most  frequently  observed  in  the  brain  and  its  meninges,  the  lungs, 
spleen,  and  kidneys.     In  one  case  which  I  examined  after  death,  in  the 

1  Traite  de  la  Diphtheric,  p.  107,  Paris,  1877. 


DIPHTHERIA.  613 

New  York  Foundling  Asylum,  the  extravasations  in  and  under  the  gastric 
mucous  membrane  produced  mottling  as  great  as  that  of  the  skin  in  measles. 

Brain  and  Spinal  Cord. — The  anatomical  changes  occurring  in  these 
organs  are  in  a  measure  described  in  our  remarks  on  diphtheritic  paral- 
ysis. Oertel  discovered,  as  the  earliest  anatomical  change  in  the  brain 
and  spinal  cord,  as  well  as  in  the  membranes,  a  venous  hypersemia,  with 
small  extravasations  of  blood  "  not  larger  than  a  pea"  in  the  white  medul- 
lary matter  of  the  brain,  while  in  the  cortical  layer  and  in  the  central  parts 
no  extravasation  was  found.  In  the  most  severe  forms  of  the  disease,  small 
hemorrhages  not  larger  than  a  pea  were  found  not  only  in  the  cerebral 
meninges,  but  also  in  various  parts  of  the  brain.  These  produced  some 
softening  in  their  immediate  neighborhood.  These  small  hemorrhages  have 
been  found  also  in  or  upon  the  medulla  oblongata  and  spinal  cord,  but  with 
less  softening.  Buhl,  in  addition  to  the  extravasations  in  and  upon  the  brain 
and  spinal  cord,  discovered  in  one  case  great  enlargement  of  the  anterior  and 
posterior  roots  and  the  ganglionary  swellings  of  the  spinal  nerves.  The 
swelling  was  found  to  be  due  to  the  accumulation  of  cells  and  nuclei  in  the 
sheaths  of  the  nerves  and  to  extravasations  of  blood.  These  anatomical 
changes  were  most  marked  at  the  roots  of  the  lumbar  nerves.  For  further 
particulars  relating  to  the  pathology  of  the  nervous  system  in  diphtheria 
the  reader  is  referred  to  our  remarks  on  paralysis. 

The  most  minute  examinations  of  the  organs  in  diphtheria  yet  published 
are  those  recently  made  by  Oertel,  and  we  will  present  a  summary  of  them 
in  the  following  pages. 

Tonsils. — Covering  these  organs  is  the  pseudo-membrane,  consisting  of 
the  usual  fibrillar  mesh-work,  enclosing  leucocytes,  changed  epithelial  cells, 
and  amorphous  matter  :  the  older  the  exudation,  the  coarser  is  the  net- work. 
The  adenoid  tissue  and  the  septa  have  undergone  hyperplasia.  The  folli- 
cles are  crowded  with  cells  which  have  undergone  necrobiosis.  As  a  result 
of  the  necrobiosis,  masses  are  formed  of  various  shapes  and  sizes,  staining 
deeply.  In  consequence  of  the  necrobiosis  and  degenerative  changes,  the 
follicles  become  a  hyaline  net-work  infiltrated  with  leucocytes  and  granules. 
In  advanced  cases  the  adenoid  and  connective  tissues  undergo  a  similar 
necrobiotic  change,  and  are  so  blended  with  the  pseudo-membrane  that  it  is 
difficult  to  determine  where  the  latter  ends  and  the  tonsillar  tissue  begins. 
The  vessels  of  the  tonsils  undergo  a  hyaline  thickening  of  their  walls ;  and 
if  this  occur  chiefly  in  the  intima,  total  occlusion  may  result.  In  the 
tissues  immediately  surrounding  the  tonsils,  hyaline  degeneration  of  the 
muscular  fibres  occurs  (Zenker's  degeneration),  and  the  connective  tissue 
between  the  muscular  fibres  is  infiltrated  with  leucocytes. 

Faucial  Surface  and-  Uvula. — These  parts  are  often  also  covered  with 
pseudo-membrane,  and  are  more  or  less  changed  by  the  application  of  reme- 
dies. The  line  of  separation  of  the  exudate  and  underlying  tissues  oannot 
be  readily  distinguished.  The  upper  portion  of  the  diphtheritic  pellicle  is 
filled  with  bacteria  and  with  leucocytes  and  other  cells  which  have  under- 


614  DIPHTHEEIA. 

gone  necrobiosis.  In  the  mucosa  next  to  the  pseudo-membrane,  hyaline 
degeneration  of  the  connective  tissue  occui's,  and  the  mucosa  is  infiltrated 
with  cells  which  have  undergone  marked  changes.  The  nuclei  of  the  con- 
nective-tissue cells  exhibit  various  stages  of  degeneration  and  decay,  though 
the  cells  may  retain  their  form.  The  deeper  layers  of  the  mucosa,  like  the 
upper,  are  infiltrated  with  leucocytes. 

The  uvula  in  severe  cases  is  usually  swollen  and  oedematous,  and  some- 
times entirely  covered  by  the  diphtheritic  pellicle.  When  the  uvula  is  in- 
volved in  the  general  faucial  inflammation,  necrobiosis  of  the  cells  and 
nuclei  occurs  in  every  part  of  it.  The  cells  in  the  arterial  adventitia  and  in 
the  perivascular  tissue  exliibit  necrobiotic  change,  theu'  nuclei  being  disinte- 
grated. In  the  uvula,  also,  hyaline  degeneration  occurs  in  the  walls  of  the 
vessels. 

Epiglottis. — The  epithelial  cells  covering  the  epiglottis  undergo  marked 
proliferation  early  in  the  disease,  and  are  infiltrated  with  leucocytes.  They 
soon  begin  to  undergo  degeneration,  forming  granular  masses.  Areas  of 
necrobiosis  occur,  and  finally  hyaline  degeneration  of  the  net-work  takes 
place.  The  leucocytes  extend  deeply  into  the  mucous  membrane,  followed  by 
degenerative  and  necrobiotic  changes.  In  places  the  epithelium  is  thrown 
off,  and  a  pseudo-membrane  forms  of  exuded  fibrin  and  necrobiotic  leucocytes 
and  epithelium.  Bacteria,  along  with  leucocytes  and  degenerated  epithelial 
cells,  occupy  the  meshes  of  the  pseudo-membrane. 

Liings. — The  anatomical  characters  of  the  air-passages  are  fully  treated 
of  in  the  article  on  diphtheritic  croup.  Catarrhal  bronchitis  is  common  in 
diphtheria.  It  is  not  often  absent  in  croup,  and  one  of  the  chief  sources 
of  danger  in  this  disease  is  the  extension  of  pseudo-membrane  from  the 
laryngo-tracheal  surface  to  the  bronchial,  and  the  transformation  of  the 
catarrhal  into  a  croupous  inflammation,  When  bronchitis  occurs,  the  in- 
flammation creeps  downward  gradually  from  the  laryngo-tracheal  surface, 
and  its  severity  is  proportionate  to  the  degree  of  extension.  When  there  is 
a  general  bronchitis,  and  it  is  very  liable  to  become  croupous,  the  muco- 
purulent exudation  is  abundant.  When  pseudo-membranous  bronchitis 
occurs,  there  are  usually  portions  of  the  bronchial  tree  in  which  the  in- 
flammation remains  catarrhal.  One  of  the  chief  sources  of  danger  in  diph- 
theritic croup  is  the  extension  of  the  inflammation  to  the  bronchial  tubes, 
and  the  abundant  secretion  of  muco-pus,  which  clogs  the  tubes  and  pre- 
vents proper  decarbonization  of  the  blood.  When  the  bronchitis  becomes 
croupous,  a  thin  easily-detached  film  appears  upon  the  intensely-red,  hyper- 
semic,  and  swollen  bronchial  surface.  It  increases  in  thickness  and  firm- 
ness, and  assumes  a  dull  white  color.  Still  later,  it  becomes  thicker,  firmer, 
and  of  a  brownish-gray  color.  Whatever  the  stage  of  the  inflammation, 
the  pseudo-membrane  can  always  be  readily  detached  from  the  bronchial 
surface,  since  its  relation  to  it  is  one  of  apposition,  and  not  of  integral  con- 
nection as  upon  the  phaiyngeal  surface.  In  the  large  tubes,  and  those  of 
medium  size,  hollow  cylinders,  more  or  less  complete,  form;    but  in  the 


DIPHTHERIA.  615 

smaller  tubes,  if  the  pseudo-membrane  extend  to  them,  solid  cylinders  are 
produced.  Frequently  in  the  bronchial  crouj)  of  diphtheria,  while  the  entire 
bronchial  surface  is  intensely  red  and  swollen,  the  pseudo-membrane  is 
absent  in  certain  parts ;  in  other  parts  it  forms  cylinders,  in  other  parts  still, 
longitudinal  bands  of  a  ribbon  shape  are  produced,  and,  in  more  or  fewer 
of  the  minuter  tubes,  plugs  which  entirely  fill  the  lumiua  and  prevent  the 
entrance  of  air.  The  alveoli  beyond  these  plugs  gradually  collapse,  and 
more  or  fewer  of  them  return  to  the  unexpanded  foetal  state.  From  the 
tubes  which  are  still  pervious  the  muco-pus  is  wdth  difficulty  expectorated, 
on  account  of  its  \ascidity,  and  the  thick  muco-pus  which  collects  contains 
floating  particles  of  pseudo-membrane.  Pseudo-membranous  bronchitis  in 
diphtheria  is  in  nearly  all  instances  an  extension  of  a  laryngo-tracheal 
croup.  It  occurs,  according  to  Sanne,  most  frequently  between  the  second 
and  sixth  days. 

Various  forms  of  pulmonar}"  disease  occur  in  diphtheria,  usually  as  a 
complication,  and  often  as  a  final  result  of  the  downward  extension  of  in- 
flammation from  the  larynx,  trachea,  and  bronchial  tubes.  Splenization, 
atelectasis,  and  broncho-pneumonia,  the  inflammation  commencing  upon  the 
laryngo-tracheal  surface  and  extending  downward,  are  common  complica- 
tions of  diphtheritic  croup.  Broncho-pneumonia,  like  pseudo-membranous 
laryngo-tracheitis  and  pseudo-membranous  bronchitis,  upon  which  it  largely 
depends,  occurs  usually  in  the  first  week  of  dij)htheria.  In  one  hundred 
and  twenty-one  cases  of  broncho-pneumonia  complicating  diphtheria,  ob- 
sen^ed  by  Sanne,  the  pneumonia  commenced  in  two  on  the  first  day  of 
diphtheria  and  in  seventy-one  between  the  second  and  sixth  days  inclusive. 

Pulmonary  congestion,  occupying  by  preference  the  depending  portions 
of  the  lungs,  especially  the  posterior  and  inferior  portions  of  the  lower 
lobes,  is  also  not  infrequent.  It  occurs  when  res23iration  is  obstructed  in 
croup,  and  when  the  circulation  is  feeble  in  consequence  of  heart-failure. 
In  the  dyspnoea  which  accompanies  paralysis  of  the  pneumogastrics,  venous 
<X)ugestion  of  the  lungs  commonly  occurs. 

The  pneumonia  which  occurs  in  diphtheria  usually  results,  as  stated 
above,  from  extension  of  inflammation  from  the  bronchial  tubes,  occurring 
largely  in  cases  of  pseudo-membranous  bronchitis.  It  is  a  broncho-pneu- 
monia. Simple  pneumonia,  or  pneumonia  occurring  independently  of 
bronchitis,  is  also  sometimes  met  with.  Peter  cites  a  case,  and  Sann6  states 
that  he  has  observed  forty-eight  cases.  lu  nine  of  thirty-two  of  these 
cases,  verified  by  autopsies,  he  found  gray  hepatization. 

Peter  found  the  lesions  of  pleurisy  nine  times  in  one  hundred  and 
twenty-one  autopsies  in  diphtheria,  and  Sanne  observed  them  in  twenty 
cases.  The  latter  writer  says,  "All  forms  of  diphtheria,  but  particularly 
croup  and  pseudo-membranous  bronchitis,  are  to  be  found  with  pleurisy. 
Pleurisy  always  accompanies  some  other  phlegmasia." 

Vesicular  emphysema  commonly  occurs  during  the  progress  of  croup. 
Whenever,  in  consequence  of  occlusion  of  the  tubes,  a  considerable  part  of 


616  DIPHTHEEIA. 

a  lung  fails  to  receive  air,  its  alveoli  begin  to  retract  and  collapse,  and  the 
alveoli  which  receix^e  air,  which  are  principally  those  in  the  superior  and 
anterior  portions  of  the  lung,  are  overdistended,  since  their  function  is  com- 
pensatory. Vesicular  emphysema  consequently  results,  and  in  exceptional 
instances  the  vesicles  rupture  and  the  escaped  air  passes  into  the  connective 
tissue,  producing  interstitial  emphysema. 

Pulmonary  apoplexy  occasionally  occurs,  the  extravasations  usually  being 
of  small  size  and  disseminated  through  the  lungs.  It  is  most  frequent  in 
malignant  cases, — in  cases  attended  by  profound  blood-poisoning.  It  has 
been  attributed,  in  some  instances,  to  pulmonary  emboli  resulting  from  car- 
diac thrombosis,  or  microbic  masses,  intercepted  in  the  capillaries.  Pul- 
monary oedema  also  occasionally  occurs,  especially  in  cases  of  bronchial 
croup,  pulmonary  congestion,  and  broncho-pneumonia.  Oertel  in  his  recent 
microscopic  examinations  of  the  lungs  noted  subpleural  hemorrhages  and 
hemorrhages  extending  to  the  alveoli,  which  were  comjjressed.  "Leuco- 
cytes infiltrated  the  alveolar  septa,  and,  in  later  stages,  invaded  the  alveoli, 
the  epithelium  of  which  became  detached  and  the  characters  of  catarrhal 
pneumonia  were  thus  produced."  Some  alveoli  contained  fibrinous  exuda- 
tion, and  in  one  severe  case  the  alveolar  contents  consisted  of  nuclei  which 
exhibited  disintegrating  changes  somewhat  like  those  in  necrobiosis. 

Lym]ihatiG  Glands. — Enlargement  of  the  cervical  and  submaxillary 
glands  is  of  common  occurrence  in  diphtheria,  and  it  is  a  diagnostic  symp- 
tom of  some  value.  Hyperplasia  of  the  cells  of  these  glands  occurs,  with 
numerous  hemorrhagic  points  in  their  capsules  and  in  the  periglandular 
tissue.  Points  of  necrobiosis,  staining  faintly,  occur  in  the  glands,  more  in 
the  cortical  than  in  the  central  portions.  The  cells  exhibit  evidences  of 
disintegration ;  and  when  this  process  is  advanced,  granular  masses  form  in 
the  affected  foci.  Hyaline  degeneration  is  also  observed  in  portions  of  the 
glandular  tissue,  a  degeneration  common  in  other  organs  in  diphtheria. 
Where  disintegration  is  not  too  far  advanced,  cells  with  polymorphous 
nuclei  are  observed, — evidence  of  an  active  hyperplasia.  Hyperplasia  with 
points  of  hemorrhagic  extravasation  takes  place  also  in  the  bronchial  glands, 
but  fewer  points  of  necrobiosis  occur  than  in  the  cervical  and  submaxillary 
glands,  and  these  chiefly  in  the  follicles.  The  lymph-ducts  may  contain 
no  normal  cells,  and  only  those  with  disintegrated  nuclei  along  with  other 
products  of  disintegration. 

Heart. — The  state  of  the  heart  will  be  in  part  described  in  our  re- 
marks relating  to  cardiac  paralysis.  Small  extravasations  of  blood  under 
the  pericardial,  and  less  frequently  the  endocardial,  surface,  have  been 
observed.  Oertel  attributes  these  hemorrhages  to  changes  in  the  walls  of 
the  vessels  caused  by  the  diphtheritic  virus,  and  Buhl,  to  nuclear  prolifera- 
tion in  the  walls  and  mechanical  obstruction.  Leucocytes  in  masses  often 
occur  under  the  pericardium  and  endocardium  and  between  the  muscular 
fibres.  Sometimes  the  muscle-nuclei  have  undergone  segmentation  and 
degenerative  changes.     These  nuclear  changes  occur  mostly  in  fibres  under 


DIPHTHEEIA.  617 

the  endocardium  and  around  the  coronary  arteries.  The  nuclei  in  the  mus- 
cular coat  of  the  arteries  are  increased  in  size,  and  slight  proliferation  and 
desquamation  of  the  endothelia  and  infiltration  of  the  adventitia  also  take 
place. 

3Iouth,  Stomach,  Intestines. — The  diphtheritic  pellicle  sometimes  forms 
in  the  cavity  of  the  mouth,  generally  in  small  patches ;  but  the  buccal  sur- 
face is  usually  only  superficially  involved,  except  upon  the  tongue,  where 
the  pellicle  extends  more  deeply.  I  have  elsewhere  stated  that  the  diph- 
theritic exudate  sometimes  occurs  upon  the  surface  of  the  stomach  and 
portions  of  the  intestines,  producing  more  or  less  destruction  of  the  mucous 
membrane.  Necrobiotic  foci  have  been  observed  by  Bizzozero  and  Oertel 
in  the  intestinal  follicles  and  agminate  glands,  but  to  a  less  extent  than 
upon  the  respiratory  surfaces.  Active  cell-proliferation  and  disintegration, 
and  cleavage  of  nuclei,  occur,  but  these  altered  cells  are  mixed  with  others 
which  are  normal.  The  epithelium  is  for  the  most  part  retained  and  normal, 
and  hyaline  changes  have  not  been  observed  in  the  gastro-intestinal  vessels. 
The  mesenteric  glands  sometimes  undergo  enlargement  from  hyperplasia, 
especially  when  the  intestines  are  aifected,  and  points  of  necrobiosis  occur 
in  them.  For  the  most  part,  however,  the  gastro-intestinal  surface  is  less 
frequently  affected  than  other  mucous  surfaces. 

Spleen. — The  diphtheritic  virus  reaches  this  organ  through  the  blood- 
current.  The  spleen  is  swollen,  so  as  to  render  its  capsule  tense.  The  pulp 
is  soft,  rising  up  through  the  cut  surface  of  the  capsule ;  the  follicles  are 
large  and  prominent ;  in  the  pulp  are  extravasations  of  blood  and  hsema- 
toidin  masses,  and  the  vessels  are  distended.  Hyperplasia  of  the  splenic 
corpuscles  occurs,  which  is  most  marked  around  the  bifurcations  of  the 
arteries,  so  that  the  reticulum  is  less  prominent.  The  follicles  are  sur- 
rounded by  a  wide  zone  of  the  reticulated  cells,  among  which  we  find  lym- 
phoid corpuscles,  leucocytes,  and  large  round  cells.  The  nuclei  in  the  cells 
undergo  two  changes  :  first,  direct  segmentation  as  in  ordinary  cell-division, 
and  fragmentation,  in  which  the  chromatin  is  broken  up  in  small,  irregu- 
larly-disposed masses  and  the  nuclear  juice  is  susceptible  of  staining.  In 
the  Malpighian  follicles  either  numerous  epithelioid  cells  form,  as  mentioned 
by  Stilling,^  or  large  cells  occur.  The  latter  stain  better  by  coloring  reagents 
than  the  epithelioid  cells,  but  less  than  the  leucocytes.  The  epithelioid  cells 
occur  mostly  in  young  patients.  A  wide  zone  of  leucocytes  surrounds  and 
invades  the  follicles.  The  necrobiotic  process  also  occurs  as  in  other  organs, 
beginning  with  nuclear  disintegration,  and  when  at  its  maximum  the  fol- 
licles are  surrounded  and  loaded  with  the  altered  nuclei  furnished  by  the 
round  or  epithelioid  cells.  Hemorrhages  also  occur  in  the  follicles.  In  some 
protracted  cases  the  vessels  of  the  pulp  exhibit  the  hyaline  degeneration. 

Liver. — Capillary  hemorrhages  take  place  within  the  capsule,  and  occa- 
sionally within  the  parenchyma.     Leucocytes  occur  at  certain  points  within 

1  Virchow's  Archiv,  Bd.  ciii. 


618  DIPHTHERIA. 

the  liver,  infiltrating  the  tissue  of  the  organ.  They  occupy  the  interlobular 
spaces,  and  do  not  exhibit  nuclear  changes.  The  hepatic  cells  are  unchanged, 
or  they  become  fatty. 

Kidneys. — Albuminuria  occurs  from  different  causes,  as  we  have  stated 
elsewhere.  Feeble  heart-action,  obstructed  respiration,  fever,  and  the  direct 
irritating  action  of  the  diphtheritic  virus  upon  the  blood  and  the  kidneys, 
are  sufficient  causes.  The  kidneys  may  be  normal  in  cases  of  albuminuria, 
or  exhibit  different  degrees  of  parenchymatous  inflammation.  Hemor- 
rhages, glomerulitis,  and  disseminated  nephritis  are  common  lesions  ob- 
served in  the  kidneys  in  those  who  have  died  having  diphtheritic  albumi- 
nuria. Hemorrhagic  points  occur  not  only  under  the  capsule,  but  also  in 
the  glomeruli  and  in  and  between  the  tubules.  Cell-infiltration  takes  place 
around  the  vessels,  and  the  cells  exhibit  nuclear  disintegration.  On  exam- 
ining the  glomeruli,  thickening  of  Bowman's  capsule  is  sometimes  observed, 
with  some  albuminous  exudation  underneath  it,  and  epithelial  proliferation 
and  desquamation.  The  nuclei  and  endothelia  of  the  glomerular  capillaries 
are  increased,  and  the  chromatin  and  nuclear  juice  have  undergone  dis- 
integrating and  degenerative  changes,  results  of  inflammation.  The  capil- 
laries are  therefore  in  a  degree  diseased  through  the  action  of  the  blood- 
poison.  The  epithelium  of  the  convoluted  and  straight  tubes  is  also  dis- 
eased. The  epithelial  cells,  undergoing  cloudy  swelling,  become  detached 
from  the  basement-membrane,  fill  the  lumina  with  the  necrosed  product, 
and,  some  of  them,  escape,  forming  casts  in  the  urine.  Occasionally  only 
the  outer  portion  of  the  cell  is  necrosed  and  detached,  the  part  adjacent  to 
the  basement-membrane,  containing  the  nucleus,  remaining  in  situ.  Oertel 
says  that  when  the  entire  cells  are  thrown  ofP,  granular  casts  are  formed, 
but  if  only  the  outer  portions  are  lost,  hyaline  casts  are  produced.  The 
collecting  tubes,  filled  with  granular  masses  containing  broken  nuclei,  cells, 
and  epithelia,  may  be  dilated. 

The  above  description  of  the  anatomical  changes  which  occur  in  the 
various  organs  is  for  the  most  part  a  resume  of  the  recent  investigations 
by  Oertel.  Whether  his  published  statement  will  be  fully  sustained  by 
subsequent  microscopic  examinations  remains  to  be  seen. 

Symptoms. — Diphtheria,  like  scarlet  fever,  varies  greatly  in  severity, 
from  a  form  so  mild  that  medical  advice  is  not  sought  and  the  child  is  not 
even  confined  to  his  home,  to  a  form  so  severe  that  the  system  is  at  once 
overpowered  and  the  patient  is  in  a  critical  state  from  the  first.  In  general 
in  the  commencement  of  an  epidemic  the  symptoms  are  more  severe  than 
when  the  epidemic  influence  is  abating.  During  the  continuance  of  the 
attack,  the  prominent  symptoms,  such  as  arrest  attention,  are  often  dispro- 
portionate to  the  gravity  of  the  attack.  Striking  cases  illustrative  of  this 
fact  have  occurred  in  my  practice,  the  friends  not  supposing  that  there  was 
any  serious  ailment,  and  not  seeking  medical  advice  until  the  fatal  termina- 
tion was  near. 

In  benign  diphtheria  the  initial  symptoms  are  often  slight,  such  as 


DIPHTHEEIA.  619 

languor  or  lassitude,  slight  chilliness  succeeded  by  fever  of  a  light  form, 
mild  headache,  pain  or  aching  in  the  body  or  limbs,  thirst,  and  impaired 
appetite.  Usually  some  soreness  of  the  throat  is  noticed  in  swallowing 
soon  after  the  attack  begins,  and  this  continues.  But  the  patient  with  mild 
diphtheria  often  continues  to  walk  about,  in  the  belief  that  he  is  affected 
with  a  slight  and  temporary  ailment.  Children  with  mild  diphtheria,  in 
the  poorer  families,  are  usually  allowed  to  go  abroad,  and  do  great  harm 
by  propagating  the  disease.  The  symptoms  in  these  mild  cases  so  closely 
resemble  those  from  a  severe  cold  that  the  disease  is  liable  to  be  mistaken 
for  it.  The  slight  tenderness  or  sensation  of  fulness  in  the  fauces  usually 
experienced  by  those  old  enough  to  express  their  sensations  should  always 
lead  to  an  examination  of  the  fauces, — when  the  character  of  the  attack 
will  frequently  be  apparent.  A  distinguished  clergyman  of  the  Pacific 
coast,  who  fell  a  victim  to  this  disease,  dreamed  a  few  nights  before  he 
complained  of  his  illness  that  his  throat  was  cut.  Doubtless  the  diph- 
theritic inflammation  had  already  commenced,  so  that  what  seemed  a  fore- 
warning had  a  natural  explanation.  So  insidious  was  the  commencement 
in  this  case  that  the  disease  had  advanced  beyond  all  hope  of  relief  when 
medical  advice  was  first  sought. 

Soon  after  the  attack  commences,  inspection  of  the  fauces  reveals  red- 
ness of  the  tonsillar  surface,  and  this  extends  until  the  entire  fauces  present 
an  infected  appearance.  After  the  lapse  of  twelve  to  thirty-six  hours,  or 
even  as  late  as  forty-eight  hours,  from  the  commencement  of  the  disease, 
the  diphtheritic  exudate  begins  to  form  over  the  tonsils,  producing  the 
characteristic  pellicle.  Before  it  forms  we  often  observe  a  grayish  color  of 
the  prominent  part  of  the  tonsils,  produced  by  the  infiltration  of  the  mucous 
membrane,  and  even  of  the  surface  of  the  tonsils,  with  newly-formed  cells. 
The  exudate  may  appear  as  points,  which  coalesce,  forming  a  patch,  or  as 
a  pellicle,  which  soon  becomes  thicker  and  at  the  same  time  firm.  Its 
anatomical  characters  are  described  elsewhere. 

But  in  most  cases,  in  all  except  of  the  mildest  type,  the  initial  symp- 
toms are  more  severe  than  we  have  delineated  above.  The  attack  in  the 
ordinary  as  well  as  severe  form  of  diphtheria  commences  abruptly,  like  scarlet 
fever,  without  a  premonitory  stage,  and  with  pronounced  symptoms  from 
the  first.  The  temperature  rises  to  102°,  103°,  or  even  104°  F.,  with  cor- 
responding heat  of  surface,  thirst,  languor,  loss  or  impairment  of  appetite, 
tenderness  of  throat,  etc.  Delirium  as  well  as  eclampsia  may  occur ;  but 
both  are  rare.  The  temperature  ordinarily  begins  to  fall  after  the  second 
or  third  day  in  favorable  cases,  and  often  in  those  of  a  grave  and  fatal 
type.  Subsequently  to  the  third  or  fourth  day  the  temperature  is  fre- 
quently but  little  elevated.  The  diphtheritic  poison,  when  the  system  is 
fully  under  its  influence,  does  not  exhibit  any  marked  tendency,  like  that 
of  scarlet  fever,  to  increase  the  animal  heat.  Even  in  profound  and  fiital 
diphtheritic  blood-poisoning  rapidly  approaching  an  unfavorable  termina- 
tion, the  thermometer  often  indicates  nearly  the  normal  temperature,  so  that 


620  DIPHTHERIA. 

the  inexperienced  practitioner  may  be  deceived  by  this  fact  in  his  prognosis. 
A  continued  elevation  of  temperature  considerably  above  the  normal  should 
lead  the  physician  to  examine  for  some  complication,  perhaps  nephritis. 

The  tongue  is  moist  and  slightly  furred.  Many  patients  vomit  in  the 
commencement ;  and  if  this  symptom  cease,  or  be  not  repeated,  it  is  not 
of  grave  import ;  but  vomiting  occurring  often,  so  that  a  considerable  part 
of  the  food  is  rejected,  is  common  in  grave  cases,  and  is  an  unfavorable 
prognostic  symptom.  It  frequently  is  due  to  uraemia.  The  appetite,  in 
severe  cases,  is  usually  poor.  Hepugnance  to  food  from  loss  of  appetite, 
and  pain  in  swallowing,  characterize  severe  forms  of  the  disease.  There 
are  no  notable  symptoms  referable  to  the  state  of  the  intestines.  The  stools 
appear  normal,  except  as  they  are  changed  by  the  medicines  prescribed.  In 
all  cases  except  the  mildest,  a  rapid  destruction  of  red  corpuscles  occurs,  and 
a  relative  increase  of  white  corpuscles.  Hence  the  anaemia  which  is  soon 
manifested  by  pallor  of  the  surface,  and  which  rapidly  increases  as  the  dis- 
ease advances.  The  early  loss  of  the  tendon  reflex  has  recently  been  brought 
to  the  notice  of  the  profession.  It  often  occurs  as  early  as  the  first,  second, 
or  third  day.  It  is  fully  treated  of  in  our  remarks  relating  to  diphtheritic 
paralysis  in  subsequent  pages.  It  is  a  symptom  of  diagnostic  value.  Diph- 
theritic inflammations  have  a  marked  tendency  to  produce  hyperplasia  and 
consequent  notable  enlargement  of  the  lymphatic  glands  in  their  immediate 
neighborhood.  The  poisonous  and  irritating  products  of  the  inflammation 
upon  the  surface  taken  up  by  the  lymphatics,  and  deposited  in  the  adjacent 
glands,  produce  in  them  tenderness,  swelling,  an  increased  afflux  of  arterial 
blood,  and  a  rapid  increase  of  the  cellular  elements.  An  inflammation  both 
of  the  lymphatic  ducts  and  glands  arises,  with  more  or  less  oedema  and 
sometimes  inflammation  of  the  adjacent  connective  tissue.  Suppuration  of 
the  glands  and  connective  tissue,  though  it  may  occur,  is  much  less  frequent 
than  in  scarlet  fever. 

Temperature. — There  is  jirobably  no  other  di'sease  in  which  the  ther- 
mometer furnishes  so  little  aid  to  an  understanding  of  the  case  as  in  this, 
since  the  degree  of  fever  does  not  sustain  any  fixed  relation  to  the  amount 
of  blood-poisoning.  Malignant  diphtheria  with  profound  blood-poisoning 
and  approaching  a  fatal  termination  may  be  almost  apyretic,  while  a  benign 
form  of  the  disease  with  but  little  blood-poisoning  may  commence  with 
considerable  fever  (102°,  103°,  or  104°  F.).  Fever  in  diphtheria  is  rather 
a  symptom  of  the  inflammation  than  of  the  blood-poisoning.  Consider- 
able elevation  of  temperature  in  diphtheria  usually  indicates  an  active 
pharyngitis,  tonsillitis,  laryngo-tracheitis,  bronchitis,  pneumonia,  or  ne- 
phritis. Therefore,  although  the  thermometer  does  not  aid  in  determining 
the  amount  of  blood-poisoning,  it  enables  us  to  form  an  opinion  in  regard 
to  the  extent  and  severity  of  the  inflammation  Avhich  may  be  present.  The 
thermometer  is  also  useful  when  diplitheria  occurs  as  a  complication  of  an- 
other constitutional  disease,  as  scarlet  fever,  measles,  typhoid  fever,  since  it 
indicates  the  severity  of  this  disease. 


DIPHTHERIA.  621 

Such  is  the  clinical  history  of  diphtheria  as  it  usually  occurs ;  its  local 
manifestation  being  primarily  upon  the  tonsillar  portion  of  the  fauces,  and 
extending  from  the  tonsils,  when  the  case  is  severe,  to  the  posterior  surface 
of  the  fauces,  over  the  anterior  and  posterior  pillars,  and  to  the  uvula. 
The  uvula,  when  it  is  involved,  becomes  greatly  swollen,  even  two  or  thi'ee 
times  its  normal  size,  so  as  to  lie  upon  the  tongue,  and,  especially  if  it  be 
covered  by  a  pseudo-membrane,  to  fill  up  the  space  between  the  swollen 
tonsils  and  intercept  the  view  of  the  posterior  fauces.  When  the  inflam- 
mation is  intense  and  the  pseudo-membrane  has  not  yet  formed  or  has  been 
removed  by  solvent  applications,  the  tonsillar  portion  of  the  fauces  often 
presents  a  grayish  appearance,  from  infiltration  of  leucocytes.  This  infil- 
tration, if  so  great  as  to  obstruct  the  circulation,  leads  to  necrosis ;  but,  as 
we  have  stated  elsewhere,  the  necrosis  of  the  mucous  membrane  is  more 
likely  to  occur  when  it  is  still  covered  by  the  pseudo-membrane,  the  pseudo- 
membrane  and  mucous  surface  being  incorporated  with  each  other  and  being 
detached  together.  The  color  of  the  pseudo-membrane,  at  first  whitish  or  a 
grayish  white,  becomes  in  a  few  days,  in  severe  cases,  a  yellowish  brown  by 
the  action  of  the  atmosphere,  and  sometimes  by  extravasation  of  blood.  If 
the  membrane  be  abundant,  it  is  likely  to  have  in  a  few  days  a  musty  and 
offensive  odor,  due  to  commencing  decomposition.  The  constant  inhalation 
of  the  highly  poisonous  gases  which  result  is  detrimental  to  the  patient,  and 
they  increase  the  danger  of  infection  in  others.  However,  with  the  use  of 
disinfectants,  now  so  commonly  employed,  the  poisonous  gaseous  products 
of  decomposition  are  not  so  common  as  in  former  times.  Since  the  pseudo- 
membrane  is  incorporated  with  the  mucous  membrane,  and  capillaries  pene- 
trate its  under  surface,  forcible  detachment  of  the  pellicle  is  likely  to  give 
rise  to  hemorrhage.  Hemorrhage  is  always  a  bad  prognostic  sign.  The 
duration  of  the  pseudo-membrane  is  very  variable.  On  the  average,  in 
favorable  cases  it  is  from  one  to  two  weeks.  There  are  cases,  however,  in 
which  the  ulcerated  surface  is  long  in  healing,  and  the  ulcers  are  covered 
many  days  with  the  grayish-white  diphtheritic  exudate.  In  exceptional 
cases  at  the  close  of  the  third  or  even  fourth  week  we  occasionally  observe 
on  the  faucial  surface  diphtheritic  patches  two  or  three  lines  in  diameter, 
without  surrounding  inflammation,  in  those  who  consider  themselves  nearly 
well,  and  who  would  appear  in  the  streets  if  they  were  allowed  to  do  so. 
We  will  consider  elsewhere  how  long  enforced  seclusion  of  the  patient 
should  be  enjoined  in  order  to  prevent  the  propagation  of  the  disease  to 
others. 

Nare.H. — Usually  inflammation  of  the  nostrils  occurring  in  diphtheria  is 
secondary  to  tliat  of  the  pharynx.  The  pharyngitis  has  continued  one  or 
more  days,  when  a  discharge  of  a  thin  serous  appearance  occurs  from  the 
nostrils.  This  is  attended  by  swelling  of  the  Sclineiderian  membrane  ;  and 
in  proportion  to  the  amount  of  swelling  the  respiration  through  the  nostrils 
is  embarrassed.  As  the  inflammation  continues,  the  swelling  increases,  and 
respiration  is  accompanied  by  a  nasal  snuflle,  or  the  occlusion  of  the  nostrils 


622  DIPHTHERIA. 

is  SO  great  that  it  is  performed  entirely  through  the  mouth.  The  impedi- 
ment to  respiration  in  infants  at  the  breast  is  often  so  great  that  spoon- 
feeding is  necessary.  The  discharge  is  very  acrid  and  irritating,  causing 
excoriation  around  the  entrance  of  the  nostrils  and  even  upon  the  cheeks. 
It  soon  becomes  more  viscid  or  less  fluid  than  at  first,  and  it  presents  a 
creamy  appearance  from  the  large  proportion  of  pus-corpuscles.  When  the 
inflammation  of  the  nares  is  severe,  the  glands  around  the  articulation  of 
the  lower  jaw  usually  undergo  hyperplasia,  becoming  nodular  and  promi- 
nent, so  as  to  be  apparent  not  only  to  the  touch  but  also  to  the  sight. 

Although  commonly  diphtheritic  inflammation  of  the  nasal  surface  is 
secondary  to  that  of  the  fauces,  it  is  sometimes  the  primary  inflammation. 
It  may  exist  for  some  days  before  the  fauces  become  aflected,  and  under 
such  circumstances  the  diagnosis  is  frequently  not  made  until  the  disease  is 
in  an  advanced  stage  and  profound  blood-poisoning  has  occurred.  In  nasal 
diphtheria  the  pseudo-membrane  probably  occurs  as  early  as  in  other  forms 
of  diphtheritic  inflammation,  but,  being  usually  out  of  sight,  it  is  not  ob- 
served in  the  first  days  or  until  it  has  extended  so  that  its  anterior  edge  can 
})e  seen  on  inspecting  the  nasal  fossa.  From  its  concealed  position  it  is  easy 
to  perceive  why  the  disease  is  so  frequently  overlooked  and  a  simple  nasal 
catarrh  is  supposed  to  be  present  when  there  is  no  inflammation  of  the 
fauces  to  aid  the  diagnosis,  or  it  is  late  in  appearing. 

Nasal  diphtheria  always  involves  great  danger,  since  it  is  very  liable  to 
give  rise  to  systemic  infection  from  the  large  number  of  lymphatics  lodged 
in  the  connective  tissues  of  the  nares.  In  certain  severe  cases  accompanied 
by  swelling  of  the  face  there  is  reason  to  think  that  the  inflammation  has 
entered  the  aiitrum  of  Highmore,  a  very  serious  extension.  It  sometimes 
extends  up  the  tear-duct,  producing  its  occlusion,  and  also  along  the  Eusta- 
chian tube.  Hemorrhage  sometimes  occurs  in  nasal  diphtheria.  In  those 
who  recover,  the  Schneiderian  membrane  returns  slowly  to  its  normal  state. 

The  Eye. — We  have  stated  above  that  the  inflammation  sometimes 
passes  along  the  tear-duct  to  the  conjunctiva,  but  in  other  instances  the 
inflammation  occurs  independently  of  this  mode  of  propagation.  Thus, 
if  a  child  with  simple  conjunctivitis  contract  dijihtheria,  the  pre-existing 
inflammation  is  very  liable  to  assume  a  diphtheritic  character,  in  accordance 
with  the  law  already  stated,  that  diphtheria  attacks  by  preference  surfaces 
that  are  already  inflamed.  I  have  elsewhere  stated  that  diphtheria  at  one 
time  entered  the  ophthalmic  wards  of  the  New  York  Foundling  Asylum, 
and  three  children,  under  treatment  for  granular  lids,  who  contracted  the 
disease,  had  diphtheritic  inflammation  of  the  lids,  with  the  usual  pseudo- 
membranous exudate.  The  result  of  diphtheritic  conjunctivitis,  even  with 
prompt  and  aj^propriate  treatment,  is  likely  to  be  disastrous  as  regards  the 
eye.  The  eyelids  become  red  and  greatly  swollen  from  oedema,  and  their 
under  surface  is  soon  lined  by  a  thick  and  firm  pseudo-membrane.  The 
eye  itself  is  the  seat  of  chemosis.  The  pseudo-membrane  upon  the  ocular 
conjunctiva  is  less  firm,  not. so  thick,  and  more  in  flakes,  than  that  upon 


DIPHTHERIA.  623 

the  palpebral  conjunctiva.  The  eye  affected  by  this  disease  should  be 
closely  watched  and  promptly  and  efficiently  treated ;  but,  unfortunately^ 
under  the  most  judicious  treatment  the  cornea  is  likely  to  become  hazy,  and 
sloughing  or  ulceration  follow,  with  total  destruction  of  sight,  and  perhaps 
prolapse  of  the  iris. 

The  Ear. — The  ear  may  become  inflamed  by  extension  of  the  inflam- 
mation along  the  Eustachian  tube  from  the  fauces.  The  opening  of  this 
tube  upon  the  faucial  surface  is  small  and  slit-like  in  the  child,  and  moderate 
inflammation  and  exudation  are  sufficient  to  close  it.  When  this  occurs, 
the  patient  complains  of  pain  in  the  site  of  the  tube,  and  in  the  ear.  The 
formation  of  a  membrane  plugging  the  tube  and  the  extension  of  the  in- 
flammation to  the  ear,  producing  an  otitis  media,  add  very  much  to  the 
gravity  of  the  case.  Perforation  of  the  drum,  caries  of  the  bones  of  the 
ear,  and  that  grave  disease  otitis  interna,  may  occur,  increasing  very  much 
the  gravity  of  the  case.  Fortunately,  this  extension  of  the  inflammation 
is  not  frequent.  It  does  not  often  occur  except  in  those  malignant  cases 
which  are  likely  to  be  fatal  from  other  causes.  Sometimes,  also,  a  diph- 
theritic otitis  externa  occurs.  It  is  usually  preceded  by  a  catarrhal  inflam- 
mation which  has  arisen  from  other  causes  and  was  present  when  the 
diphtheria  commenced.  Bezold  described  three  cases  of  otitis  externa  with 
a  diphtheritic  pellicle  upon  the  drum.^  Moos  and  Callan  have  also  narrated 
cases. 

The  Mouth. — During  the  progress  of  diphtheria  any  sore  or  abrasion  of 
the  mouth  is  likely  to  become  the  seat  of  the  diphtheritic  exudate.  Usually 
the  fauces  and  sometimes  the  nares  are  at  the  same  time  affected.  The 
diphtheritic  pellicle,  commonly  of  small  extent,  may  appear  upon  the  inside 
of  the  cheek,  the  tongue,  gums,  and  lips.  Usually  the  inflammation  of  these 
paints  is  of  secondary  importance,  but  in  malignant  or  highly  septic  cases  it 
may  be  attended  by  considerable  infiltration  and  thickening.  Buccal  diph- 
theria, if  severe,  is  painful,  and  it  may  interfere  with  the  proper  nutrition. 
The  clinical  history  of  diphtheritic  inflammation  of  the  fauces  and  respira- 
tory tract  below  the  epiglottis  is  sufficiently  presented  elsewhere. 

(Esophagus,  Stomach,  Intestines. — The  upper  part  of  the  oesophagus  not 
infrequently  participates  in  the  inflammation  of  the  pharynx.  Its  walls  are 
thickened,  and  the  pseudo-membrane  presents  the  same  characters  as  upon 
the  fauces.  Occasionally  nearly  the  entire  oesophagus  is  the  seat  of  diph- 
theritic inflammation,  the  oesophageal  walls  being  greatly  thickened  from 
infiltration  of  cells,  and  very  vascular.  In  one  of  the  cases,  related  in  a 
foregoing  page,  of  diphtheria  of  the  newly-born,  the  oesophagus  was  in 
nearly  its  entire  length  covered  by  the  di[)]itheritic  pseudo-membrane.  In 
only  one  instance  have  I  observed  a  severe  diphtheritic  gastritis.  In  this 
ease  nearly  the  entire  surface  of  the  stomach  was  covered  by  a  thick  pellicle. 
Probably  the  inflamed  follicles  did  not  secrete  normal  pepsin.     A  few  cases 

^  Virchow's  Archiv,  Ixx.  329. 


624  DIPHTHERIA. 

are  on  record  of  diphtheritic  inflammation  of  the  intestines.  Dr.  A.  Jacobi 
relates  the  case  of  a  child  of  three  years  who  had  diphtheritic  enteritis. 
Fever,  moderate  tenderness  of  the  abdomen  with  but  little  tympanitis,  con- 
stipation, and  great  prostration  were  the  prominent  symptoms.  The  autopsy 
revealed  the  presence  of  a  diphtheritic  inflammation  in  the  jejunum  and 
ileum,  the  membrane  consisting  of  "■  a  dense  net-work  with  granular  con- 
tents." The  most  marked  case  of  diphtheritic  intestinal  inflammation  which 
has  come  under  my  notice  was  that  of  a  physician  to  whose  case  I  have 
elsewhere  referred.  He  lost  his  appetite,  had  fever,  lost  flesh  and  strength, 
had  distress  in  the  abdomen  which  raised  the  suspicion  of  a  typhoid  fever ; 
but  at  the  usual  time  for  the  termination  of  a  self-limited  fever  no  abate- 
ment of  symptoms  occurred.  Finally,  after  weeks  of  suffering,  he  expelled 
a  cast  of  the  intestine  several  inches  in  length,  probably  from  the  colon. 
Obstinate  constipation  was  the  most  prominent  symptom  during  this  time 
and  subsequently,  due,  probably,  to  cicatrization  and  contraction  of  the 
intestine.  The  patient  died  from  the  effects  of  the  disease  several  months 
subsequently,  having  suffered  constantly  from  faulty  digestion,  abdominal 
pain,  and  constipation,  which  no  treatment  could  relieve  or  benefit. 

Genito-  Urinary  Organs. — Diphtheria  of  the  prepuce  commonly  occurs 
after  some  injury.  It  either  arises  by  direct  inoculation  upon  an  abrasion 
or  wound,  or  is  contracted  by  exposure  to  an  infected  atmosphere.  Many 
cases  are  on  record.  I  have  elsewhere  stated  that  the  eminent  surgeon  M. 
Germain  See,  whose  practice  is  in  a  locality  where  diphtheria  is  endemic  and 
very  prevalent,  now  recommends  stretching  of  the  prepuce  in  nearly  all  cases 
of  narrow  and  adherent  prepuce  rather  than  circumcision,  for  the  reason, 
among  others,  that  diphtheria  is  more  liable  to  follow  the  latter  operation. 
Diphtheria  of  the  prepuce  is  contracted  by  the  use  of  infected  instruments, 
sponges,  or  fingers,  in  the  operation  of  circumcision,  or  by  the  performance 
of  the  operation  with  clean  instruments  and  hands  but  in  an  infected  atmos- 
phere. Thus,  Dr.  F.  Lang6  saw  a  case  of  preputial  and  scrotal  diphtheria  in 
a  child  of  three  weeks  who  had  been  circumcised  when  diphtheria  was  occur- 
ring in  the  family.^  Dr.  Greves  states  that  a  boy  who  had  been  circumcised 
for  phimosis  was  admitted  into  the  Liverpool  Infirmary  w^ith  an  unhealthy 
prepuce,  which  had  never  healed  after  the  operation.  Weak  and  ansemic 
when  admitted,  he  continued  to  sink,  and  died  of  heart-failure.  The 
wound  and  subjacent  tissues  were  infiltrated  with  micrococci  presenting  the 
same  characters  as  those  in  pharyngeal  pseudo-membranes.  In  a  preceding 
page  I  have  alluded  to  a  case,  related  by  Mr.  Phillips,  of  preputial  diph- 
theria occurring  after  circumcision  by  infected  instruments,  and  have  related 
a  case  in  my  o^vn  practice  of  a  severe  diphtheria  of  the  prepuce,  and  simul- 
taneously of  the  fauces,  occurring  after  instrumental  dilation  of  the  fore- 
skin. Dr.  A.  Jacobi  states  that  he  incised  the  upper  part  of  the  prepuce 
in  a  healthy  boy  of  three  years,  employed  stitches,  and  applied  carbolized 

1  Medical  Record,  July  10,  1880. 


DIPHTHERIA.  625 

dressing.  On  the  following  day  diphtheria  attacked  the  wound,  with  the 
usual  swelling  and  erysipelatous  appearance.  The  stitches  were  removed, 
but  death  occurred  four  days  after  the  operation.  Dr.  A.  Jacobi  also  relates 
the  case  of  a  boy  of  four  years  whom  he  circumcised  and  dressed  the  wound 
with  antiseptic  solutions.  Diphtheria  supervened,  and  in  a  few  days  the 
entire  prepuce  and  a  small  portion  of  the  penis  became  gangrenous.  The 
boy  eventually  recovered,  with  deformity  of  the  organ. 

Billroth  has  called  attention  to  the  fact  that  diphtheria  in  localities 
where  it  is  prevailing  is  likely  to  attack  wounds  produced  by  operations  on 
the  urinary  apparatus,  as  after  lithotomy  or  urethrotomy,  and  in  cases  of 
ectopia  vesicae  and  vesico-vaginal  fistula.  The  inflammation  under  such 
circumstances  is  usually  localized,  but  it  may  extend  to  the  retroperitoneal 
connective  tissue  and  produce  a  fatal  peritonitis.  The  marked  liability  of  the 
uterus,  vagina,  and  vulva  when  wounded  in  any  way,  as  in  parturition,  to 
become  the  seat  of  diphtheritic  inflammation  in  case  of  exposure  to  the  infec- 
tion is  well  known  to  the  profession,  and  no  prudent  obstetrician  will  attend 
an  obstetrical  case  after  visiting  a  diphtheritic  patient,  without  change  of 
apparel  and  personal  disinfection.  Some  years  ago  I  was  summoned  to  a 
young  lady  who  during  the  week  following  her  confinement  insisted  on 
seeing  her  child,  then  in  the  commencement  of  diphtheria.  The  child  was 
brought  to  her  bedside  for  a  moment.  Within  a  day  or  two  she  was 
attacked  with  a  violent  form  of  metro-peritonitis,  which  was  speedily  fatal. 
In  children  diphtheritic  vulvitis  and  vaginitis  occasionally  occur,  associated 
or  not  with  pharjmgitis.  I.  Zit  has  records  of  thirteen  cases  of  diphtheritic 
vulvitis,  in  some  of  which  inflammation  was  the  first  manifestation  of  dijjh- 
theria.  Diphtheritic  inflammation  of  the  vulva  and  vagina  is  believed  to 
be  rare  without  a  pre-existing  catarrhal  inflammation. 

Shin. — An  efflorescence  is  sometimes  observed  upon  the  skin  during  the 
time  in  which  the  temperature  is  exalted.  It  is  the  erythema  fugcix  of 
dermatologists,  suddenly  appearing  and  disappearing.  This  eruption,  which 
is  common  in  the  febrile  and  inflammatory  affections  of  childhood,  does  not 
seem  to  present  any  peculiar  characters  in  diphtheria.  But  there  is  another 
eruption  which  I  have  not  infrequently  observed,  and  which  is  attributable 
to  diphtheritic  toxsemia  or  septicaemia.  It  appears  after  the  sixth  or  seventh 
day,  in  the  form  of  red  points  or  spots  not  more  than  a  line  in  diameter, 
and  interspersed  with  patches  of  efflorescence  with  irregular  margins,  one 
to  two  inches  in  diameter.  This  roseolar  eruption  is  slightly  raised,  like 
that  of  measles.  Sometimes  it  is  punctate.  It  disappears  on  pressure,  and 
in  my  practice  it  has  usually  appeared  in  grave  cases,  in  which  there  were 
other  evidences  of  blood-poisoning.  Occasionally  extravasations  of  blood 
occur  in  and  under  the  skin,  like  those  in  internal  organs.  Tlie  pallor  of 
the  skin  Avhich  diplitheritie  an;emia  and  toxaemia  produce  in  and  after  the 
second  week  is  known  to  all  who  have  had  experience  with  this  disease. 

Tlie  anatomical   characters  and   symptoms  pertaining  to   the   nervous 

system  and  kidneys  will  be  treated  of  at  length  in  our  remarks  on  albu- 
VoL.  I.— 40 


626 


DIPHTHEEIA. 


minuria  and  paralysis.  Albuminuria  and  paralysis,  whether  we  regard 
them  as  symptoms,  complications,  or  sequelae,  occur  so  frequently  and  are 
of  such  grave  import  that  it  is  proper  to  treat  of  them  at  length.  They 
are  the  most  important  of  the  phenomena  pertaining  to  the  symptomatology 
of  diphtheria. 

Albuminuria. — It  is  perhaps  remarkable  that  numerous  epidemics  of 
diphtheria  had  been  observed  before  it  became  known  that  albuminm-ia 
is  a  common  accompaniment  of  it.  The  fact  that  the  kidneys  are  affected 
so  as  to  give  rise  to  albuminous  urine  was  discovered  by  Mr.  Wade,  of 
Birmingham,  England,  in  1857.  The  interesting  paper  communicating  his 
discovery  was  published  in  The  Midland  Quarterly  Journal  of  Mediciney 
1857.  Immediately  after  its  appearance,  the  subject  to  which  he  drew  atten- 
tion was  ftilly  investigated  in  different  countries,  and  in  the  same  year  Mr. 
James  published  his  observations  in  the  Medical  Times  and  Gazette.  In 
the  following  year — 1858 — two  noteworthy  papers  appeared  on  the  same 
subject,  one  by  MM.  Bouchut  and  Empis,  read  before  the  Parisian  Acad- 
emy of  Sciences  and  published  in  the  Gazette  des  Hopitaux,  and  another  by 
Germain  S^e,  read  before  the  Soci^te  des  Hopitaux.  Since  1858,  mono- 
graphs and  reports  of  cases  too  numerous  to  mention  have  been  published, 
so  that  the  literature  of  dij^htheritic  albuminuria  is  quite  full. 

As  to  the  frequency  of  albuminuria  in  diphtheria,  Bouchut  and  Empis 
found  it  in  two-thirds  of  their  cases,  Germain  S§e  in  one-half  of  his,  and 
Sann6  in  two  hundred  and  twenty-four  cases  out  of  four  hundred  and  ten. 
In  New  York  City,  where  diphtheria  has  been  many  years  naturalized  or 
endemic,  I  made  in  the  years  1875  and  1876  daily  examinations  of  the 
urine  in  sixty-two  consecutive  cases,  and  found  it  present  in  twenty-four, 
while  thirty-eight  were  recorded  exempt.  But  the  proportion  of  cases  as 
stated  in  my  statistics  is  probably  below  the  truth,  for  the  albuminuria  is 
sometimes  transient,  and.  it  often  occurs  as  a  mere  trace  and  is  liable  to  be 
overlooked.  Its  duration  is  frequently  not  more  than  from  one  to  three 
days,  and  in  the  majority  of  instances  it  does  not  continue  longer  than  ten 
days ;  but  we  are  all  familiar  with  cases  in  which  it  continues  fifteen  or 
twenty  days,  or  even  months. 

The  date  of  the  commencement  of  albuminuria  varies  greatly  in  differ- 
ent cases.  Perhaps  the  largest  number  of  observations  bearing  on  this 
point  are  those  of  Sann6.  In  two  hundred  and  twenty-four  cases  albumi- 
nuria was  detected  on  the  first  day  of  diphtheria  in  three,  on  the  second  day 
in  ten,  on  the  third  day  in  thirty,  on  the  fourth  day  in  thirty,  on  the  fifth 
day  in  twenty-two.  From  the  sixth  day  to  the  eleventh  the  number  on 
each  day  in  whom  albuminuria  was  present  for  the  first  time  varied  from 
ten  to  thirty-three.  After  the  eleventh  day  there  were  only  nine  new  cases, 
and  after  the  fifteenth  day  only  one  new  case.  Hence  from  these  statistics 
we  infer  that  there  is  little  danger  that  albuminuria  will  occur  after  the 
second  week,  if  the  patient  have  exhibited  no  symptoms  of  it  previously. 

The  amount  of  albumen  in  the  urine  varies  greatly  in  different  patients^ 


DIPHTHERIA.  627 

from  a  slight  cloudiness,  scarcely  visible  afi^er  boiling,  to  so  large  a  quantity 
that  it  becomes  semi-solid  by  the  application  of  heat  or  nitric  acid.  When 
the  proportion  of  albumen  is  very  large  there  is  also  usually  a  notable 
diminution  in  the  quantity  of  urine  passed.  In  ordinary  cases  the  percentage 
of  albumen  varies  at  different  times.  It  sometimes  disappears  during  one 
or  two  days,  and  we  are  led  to  think  that  the  patient  is  rapidly  recovering, 
but  its  reappearance  in  full  quantity  shows  that  the  apparent  improvement 
was  due  to  some  transient  cause.  "  Nothing,"  says  Sann§,  "  is  more  irregu- 
lar than  the  course  of  diphtheritic  albuminuria.  At  one  time  the  precipitate 
is  sudden,  abundant,  and  flocculent ;  at  another  it  commences  with  an 
opaque  cloud,  and  continues  with  this  characteristic  till  the  time  at  which  it 
disappears."  Diphtheritic  albuminuria  differs  in  many  respects  from  that 
in  scarlet  fever.  The  urine  at  first,  when  the  renal  disease  is  active,  some- 
times presents  a  pinkish  tinge,  and  the  microscope  reveals  the  presence  of 
red  blood-corpuscles,  but  afterwards,  and  in  mild  cases  from  the  first,  the 
urine  exhibits  nearly  the  normal  appearance,  even  when  very  albuminous, 
in  contradistinction  to  its  cloudy  appearance  in  scarlet  fever.  The  specific 
gravity  is  low,  falling  to  1010  or  less,  and  casts,  both  granular  and  hyaline, 
are  present.  When  the  kidneys  are  seriously  implicated,  the  quantity  of 
urine  is  usually  notably  diminished.  Great  diminution  is  a  serious  symp- 
tom, and  it  often  precedes  the  fatal  issue. 

In  favorable  cases  the  albuminuria  does  not  in  the  average  continue  as 
long  as  in  scarlet  fever.  The  albumen  may  disappear  from  the  urine  in  two 
or  three  days  if  its  quantity  has  been  small,  and  in  a  large  proportion  of 
cases  it  disappears  within  ten  days ;  but  cases  occur  in  which  albuminuria 
continues  many  months,  with  its  final  disa23pearance  and  the  complete  res- 
toration of  the  health.  Thus,  a  boy  of  six  years  treated  by  me  had  nephritis 
following  a  very  mild  attack  of  diphtheria.  His  urine  in  the  first  weeks 
was  deeply  tinged  by  the  presence  of  red  blood-corpuscles,  but  its  quantity 
was  normal,  as  determined  by  daily  examinations,  and  it  contained  nearly 
or  quite  the  normal  amount  of  urea.  Its  specific  gravity  was  at  or  under 
1010.  After  a  time  the  blood-corpuscles  disappeared,  the  urine  when  not 
heated  had  its  normal  appearance,  its  specific  gravity  became  normal,  and 
the  granular  casts  at  first  present  disappeared.  The  patient  was  uniformly 
cheerful,  was  free  from  fever,  his  appetite  was  good,  and  no  subjective 
symptoms  occurred  to  indicate  renal  disease.  Nevertheless,  after  the  lapse 
of  ten  months,  a  little  albumen  was  still  present  in  the  urine. 

But  the  presence  of  albumen  in  the  urine,  if  considerable,  is  an  unfavor- 
able prognostic  sign.  Sanne  states  that  in  two  hundred  and  thirty-three 
cases  of  diplitlieria  accompanied  by  albuminuria  one  hundred  and  forty-two 
died  and  ninety-one  recovered.  In  one  hundred  and  sixty  cases  in  which 
albuminuria  was  absent,  sixty-three  died  and  ninety-seven  recovered.  The 
statistics  of  others  correspond  with  those  of  Sann6 :  so  that  the  fact  may  be 
considered  established  that  a  larger  proportion  of  cases  of  diphtheria  Avith 
albuminuria  perish  than  of  those  without  albuminuria.     It  does  not  follow 


62S  DIPHTHERIA. 

necessarily  from  this  that  the  affection  of  the  kidneys  which  produces  the 
albuminuria  contributes  to  the  fatal  result,  for  albuminuria  is  more  frequent 
in  grave  cases  than  in  those  of  a  mild  tyi^e.  The  gravity  which  leads  to  a 
fatal  result  may  be  due,  and  often  is  largely  due,  to  other  causes  than  the 
renal  disease. 

Although  severe  and  so-called  malignant  forms  of  diphtheria  are  more 
likely  to  be  complicated  by  albuminuria  than  are  mild  forms  of  the  dis- 
ease, yet,  as  in  scarlet  fever,  severe  and  fatal  renal  disease  giving  rise  to 
albuminuria  sometimes  occurs  in  very  mild  cases  of  diphtheria.  Several 
years  ago  I  attended  a  child  of  six  years  with  the  following  history.  He 
had  mild  pharyngitis,  with  scarcely  appreciable  exudation,  and  almost  no 
constitutional  disturbance.  On  the  second  day  the  patient  seemed  so  nearly 
well  that  both  the  doctor  and  the  intelligent  grandmother  who  had  charge 
of  him  did  not  think  farther  medical  attendance  necessary.  One  week 
subsequently  I  was  summoned  to  the  child  in  haste  on  account  of  nearly 
complete  suppression  of  urine.  About  one  df  achm  was  passed  each  time,  and 
at  lono;  intervals.  This  when  heated  became  semi-solid.  The  late  Prof. 
Austin  Flint,  who  saw  the  case  in  consultation,  and  myself  notified  the 
family  of  the  extreme  gravity  of  the  case  and  its  approaching  fatal  termi- 
nation, a  prediction  which  was  verified  in  forty-eight  hours.  In  such  rare 
cases,  while  the  diphtheritic  poison  acts  with  great  power  upon  the  kidneys, 
producing  a  fatal  nephritis,  its  influence  is  feebly  felt  in  those  tissues  which 
are  the  usual  seat  of  diphtheritic  inflammation.  Diphtheritic  albuminuria 
is  rarely  attended  by  anasarca  or  by  symptoms  of  ursemic  poisoning.  In 
two  hundred  and  twenty-four  cases  of  diphtheritic  albuminuria  embraced  in 
Sann^'s  statistics,  dropsy  occurred  in  only  seven.  Trousseau  did  not  meet 
it  ofl;ener  than  in  one  case  in  twenty.  Its  infrequency  has  been  attributed 
to  the  fact  that  only  one  kidney,  or  only  portions  of  the  kidneys,  have  been 
affected,  the  sound  portions  performing  sufficiently  the  excretory  function. 

Oertel  says,  "  The  albuminuria  of  diphtheria  is  referable  to  many  causes, 
of  which  the  virus  circulating  in  the  blood  is  only  one.  Cardiac  failure, 
respiratory  difficult}',  the  febrile  process,  are  adequate  for  the  production 
of  this  symptom.  The  kidneys  in  cases  where  albuminuria  has  been  present 
may  be  quite  normal,  or,  on  the  other  hand,  they  may  exhibit  varj'ing 
degrees  of  parenchymatous  inflammation."  ^  The  two  common  causes  ap- 
pear to  l^e  passive  congestion  of  the  kidneys,  as  of  other  organs,  occurring 
during  the  dyspnoea  of  croup,  or  from  heart-failure,  the  albumen  escaping 
from  the  over-distended  renal  veins,  and  parenchymatous  nephritis,  in  which 
the  tubules  contain  detached  and  disintegrating  epithelial  cells.  In  paren- 
chymatous nephritis  granular  casts  are  commonly  present. 

As  regards  prognosis,  writers  agree  that  diphtheritic  albuminuria  in  itself 
does  not  tend  to  a  fatal  result  in  most  cases,  the  unaffected  portions  of  the 
kidneys,  as  stated  above,  being  sufficient  for  the  excretion  of  the  deleterious 

1  Synopsis  of  Oertel's  monograph,  London  Lancet. 


DIPHTHERIA.  629 

products,  especially  the  urea,  whose  reteution  in  the  system  would  involve 
danger.  Therefore  Sanne  says  "that  diphtheritic  albuminuria  is  an  epi- 
phenomenon  which  in  the  vast  majority  of  cases  remains  without  influence 
upon  the  course  of  the  disease."  But  cases  do  occur,  as  we  have  seen  by 
the  history  related  above,  in  which  fatal  albuminuria,  or  fatal  nephritis 
producing  albuminuria,  does  take  place  as  a  complication  or  sequel  of 
diphtheria. 

Unruh  in  1881^  expressed  the  opinion  that  the  albuminuria  of  diph- 
theria results  from  a  simple  transudation.  But  more  exact  microscopic 
examinations  show  that  it  is  only  in  cases  of  croupal  asphyxia  or  heart- 
failure  that  that  degree  of  passive  renal  congestion  occurs  which  leads  to 
a  transudation  of  serum.  When  there  is  no  obstructed  resjDiration,  and  no 
marked  weakness  of  the  pulse,  the  albuminuria  is  a  result  and  symptom  of 
infectious  nephritis.  Prof.  Bouchard  ^  states  that  infectious  nephritis,  what- 
ever the  cause  or  source  of  the  infection,  is  a  parenchymatous  nephritis. 
Says  he,  "  The  kidneys  are  sometimes  augmented  in  volume  and  weight. 
Their  capsule  has  the  ordinary  ajDpearance  and  adherence.  The  cortical 
substance  appears  sometimes  grayish,  sometimes  congested  and  sprinkled 
with  whitish  tracts.  The  medullary  substance  preserves  its  normal  aspect. 
In  kidneys  thus  changed  microscopic  pathological  anatomy  reveals  integ- 
rity of  the  tubes  of  Henle,  catarrhal  change  of  the  straight  tubes,  and  to  a 
considerable  extent  of  the  convoluted  tubes.  In  the  convoluted  tubes  the 
epithelial  cells  remaining  in  place  are  swollen  and  sodden  together.  The 
cellular  mass  is  entirely  granular.  .  .  .  Not  only  are  the  convoluted  tubes 
obstructed  by  granular  cells,  but  they  are  filled  in  some  points  by  colloid 
matter  or  by  blood.  The  glomeruli  appear  healthy ;  but  we  have  seen  the 
glomerular  capsule  distended  with  blood.  In  another  case  Renaut  has 
seen  it  distended  by  colloid  matter."  Brault  ^  has  observed  in  diphtheritic 
albuminuria  intense  congestion  of  the  capillaries  of  the  tubules  and  glo- 
meruli, altered  epithelial  cells,  and  transuded  blood-elements  indicative  of 
parenchymatous  inflammation. 

Paralysis. — Another  very  important  symptom  and  sequel  of  diphtheria 
is  paralysis.  It  has  diagnostic  and  prognostic  value.  Writers  in  medicine 
prior  to  the  sixteenth  century  were  either  ignorant  of  diphtheritic  paralysis 
or  they  vaguely  alluded  to  it  when  they  described  the  extreme  debility 
which  sometimes  accompanies  or  follows  diphtheria.  No  clear  and  certain 
allusion  to  it  has  been  discovered  in  medical  literature  until  near  the  close 
of  the  sixteenth  century.  According  to  Sanne,  Nicholas  Lepois  referred  to 
it  in  1580,  and  Miguel  Heredia  in  1690.  Ghisi,  in  a  letter  describing  the 
e])idemic  which  occurred  in  Cremona  on  the  nortli  bank  of  the  river  Po  in 
1747-48,  writes  of  his  own  son,  who  had  paralysis  in  a  severe  form  follow- 
ing diphtheria,  "  I  left  to  nature  the  cure  of  the  strange  consequences,  .  .  . 

»  .Jahrb.  fur  Kinderheilk.  2  Revue  de  Medecine,  1881. 

3  Jour.  d'Aimt.  et  de  Pliys.,  Nov.  1880. 


630  DIPHTHERIA. 

which  had  been  remarked  in  many  who  had  already  recovered,  and  which 
had  continued  for  about  a  month  after  recovery  from  the  sore  throat  and 
abscess.  During  this  period,  this  child  spoke  through  the  nose,  and  food,  par- 
ticularly that  which  was  least  solid,  returned  through  the  nares,  in  place  of 
passing  down  the  gullet."  In  France,  also,  diphtheritic  paralysis  began  to 
attract  attention  at  or  about  the  time  when  Ghisi,  in  Italy,  wrote  the  above. 
Chomel,  in  1748,  described  two  cases,  following  what  he  designated  gan- 
grenous sore  throat.  The  first  jDatient,  he  says,  had  not  quite  commenced 
convalescence  at  the  forty-fifth  day  of  the  disease,  having  still  difficulty  in 
articulating,  speaking  through  the  nose,  and  having  the  uvula  pendulous. 
In  the  second  case  the  patient  became  squint-eyed  and  deformed,  but  day 
by  day  as  his  strength  returned  he  regained  his  natural  appearance. 

In  America,  in  1771,  Dr.  Samuel  Bard,  of  New  York,  also  related  a 
case  of  this  form  of  paralysis.  A  girl  of  two  and  a  half  years  had  re- 
covered from  a  diphtheritic  sore  throat,  and  a  diphtheritic  pseudo-membrane 
upon  the  skin  following  the  application  of  a  blister  had  disappeared,  when 
her  convalescence  was  retarded  by  paralytic  symptoms.  "  Whenever,"  says 
Bard,  "  she  attempted  to  drink,  she  was  seized  with  a  fit  of  coughing ;  yet 
she  was  able  to  swallow  solid  food  without  any  difficulty.  She  improved, 
but  in  the  second  month  she  could  scarcely  walk  or  raise  her  voice  above  a 
whisper." 

From  the  time  of  Chomel,  Ghisi,  and  Bard,  more  than  half  a  century 
elapsed  during  which  diphtheritic  paralysis  attracted  Kttle  attention,  though 
Jurine  and  Albers  alluded  to  it  in  1809.  It  cannot  be  doubted  that  cases 
occurred  in  this  long  period  wherever  diphtheria  prevailed,  but  it  might 
have  been  of  such  a  type  that  the  paralysis  was  infrequent,  for  Bretonneau, 
although  he  was  familiar  with  Ghisi's  and  Bard's  writings,  did  not  recollect 
that  he  had  seen  a  case  of  diphtheritic  paralysis  prior  to  1843.  Although 
a  close  observer  of  diphtheria,  the  paralysis  had  not  been  observed  by  him, 
or  at  least  had  not  attracted  his  attention,  until  it  occurred  in  the  person  of 
his  townsman  Dr.  Turpin  in  1843.  Twelve  years  subsequently,  in  1855, 
Bretonneau  had  made  a  sufficient  number  of  observations  to  convince  him 
that  diphtheria  frequently  gave  rise  to  a  peculiar  form  of  paralysis,  and  in 
his  writings  of  this  year  he  called  the  attention  of  physicians  to  this  fact. 
But  the  opinions  expressed  by  the  eminent  physician  of  Tours  did  not  gain 
general  acceptance  until  his  friend  and  admirer  Trousseau,  at  first  distrust- 
ful of  the  existence  of  such  a  paralysis,  had  made  a  series  of  observations 
which  fully  established  in  his  mind  the  theory  of  Bretonneau.  His  re- 
marks on  this  subject,  published  in  his  "  Treatise  on  Clinical  Medicine," 
are  interesting  as  showing  how  gradually  important  truths  are  revealed  in 
medicine.  He  had  seen  as  far  back  as  1833  a  marked  casein  the  service 
of  R^camier  in  the  H6tel-Dieu,  and  another  equally  severe  and  typical 
case  in  1846,  but  it  was  a  long  time  before  he  recognized  this  ailment  as  one 
of  the  results  of  the  diphtheritic  poison.  Says  he,  speaking  of  the  cases 
seen  in  1833  and  1846,  "They  were  a  dead  letter  to  me,  yet  I  was  ac- 


DIPHTHERIA.  631 

quainted  with  the  case  described  by  Dr.  Turpin  of  Tours.  Bretonneau  related 
it  to  me,  and  said  that  it  was  a  case  of  diphtheritic  paralysis.  The  state- 
ment seemed  to  me  incredible.  I  refused  to  see  anything  more  in  the  case 
than  a  coincidence.  ...  It  was  not  till  about  the  year  1852  that,  enlight- 
ened by  new  cases,  better  studied  and  better  interpreted,  I  understood  diph- 
theritic paralysis  as  Bretonneau  understood  it.  From  this  time,  whenever 
an  opportunity  occurred,  I  in  my  turn  called  the  attention  of  my  colleagues 
to  this  important  subject."  The  clinical  teachings  and  observations  of 
Bretonneau  and  Trousseau  were  widely  read,  and  the  profession  throughout 
the  world  soon  recognized  the  fact  that  diphtheria  often  gives  rise  to  a  form 
of  paralysis  which,  if  not  peculiar  to  it,  is  yet  rare  in  other  infectious  diseases. 
Since  these  observations  of  Trousseau  were  published,  many  observations 
have  been  made  and  many  monographs  on  diphtheritic  paralysis  have  been 
written  by  such  men  as  Roger,  Germain  See,  Herman  Weber,  Charcot  and 
Vulpian,  Gubler,  Lanclouzy,  Suss,  H.  von  Ziemssen,  A.  Jacobi,  and  W.  H. 
Thomson.  But  the  nature  of  this  paralysis  and  the  manner  in  which  it 
occurs  are  still  undetermined.  The  fact  tliat  there  is  such  a  paralysis  was 
slow  in  gaining  acceptance  in  the  minds  of  physicians,  and  so  the  cause  and 
pathology  of  the  paralysis  are  still  not  fully  ascertained. 

Clinical  History. — The  statistics  of  different  writers  vary  in  regard  to 
the  frequency  of  diphtheritic  paralysis.  Probably  it  is  different  in  different 
epidemics,  and  some  observers  may  overlook  the  milder  cases,  which  soon 
recover,  and  which  are  indicated  by  a  slight  impediment  in  swallowing  and 
a  slight  nasal  intonation  of  the  voice.  We  may  accept  as  approximating 
the  truth  as  regards  its  frequency  the  following  statistics  of  well-known 
and  painstaking  clinical  instructors,  who  would  be  likely  to  detect  the 
mildest  forms  of  paralysis.  In  nine  hundred  and  thirty-seven  diphtheritic 
cases  observed  by  Cadet  de  Gassicourt,  paralysis  occurred  in  one  hundred 
and  twenty-eight.  Sixteen  and  six-tenths  per  cent,  of  Roger's  cases  of 
dij^litheria  had  paralysis,  and  eleven  per  cent,  of  Sauna's  cases. 

But  it  must  be  borne  in  mind  that,  since  paralysis  is  in  most  instances 
post-diphtheritic,  those  severe  cases  which  are  speedily  fatal  from  blood- 
poisoning  or  croup  do  not  live  long  enough  to  suffer  from  it,  and  such  cases 
would  be  more  likely  to  have  the  paralysis,  if  they  lived,  than  the  milder 
cases,  which  recover.  Hence  it  has  been  estimated  that,  if  all  diphtheritic 
patients  lived  sufficiently  long,  one  in  every  four,  or  even  oiie  in  every 
three,  would  exhibit  paralytic  symptoms. 

Time  of  Commencement. — In  most  instances  the  paralysis  does  not  begin 
until  the  period  of  apparent  convalescence  from  diphtheria,  and  the  pseudo- 
mcmlirane  has  nearly  or  quite  disappeared.  Sann6  says  it  most  frequently 
appears  from  eight  to  fifteen  days  after  recovery,  the  limit  perhaps  extend- 
ing to  thirty  days,  but  he  adds  that  it  may  appear  from  the  fifth  to  the 
eleventh  and  even  as  early  as  the  second  or  third  day  of  diphtheria.  Cadet 
de  Gassicourt  states  that  in  twenty  of  his  cases  the  paralysis  began  before 
the  disappearance  of  pseudo-membrane,  most  frequently  about  the  seventh 


632  DIPHTHERIA. 

or  eighth  day  of  diphtheria.  In  two  it  coiumenced  on  the  third  day,  and 
once  in  a  prolonged  diphtheria  it  began  as  late  as  the  thirty-fifth  day,  the 
pseudo-membrane  still  being  present.  Usually,  according  to  my  observa- 
tions, when  paralysis  follows  diphtheria  the  nasal  voice  and  some  impedi- 
ment in  swallowing  are  observed  early  in  the  stage  of  convalescence,  and  at 
a  later  period  muscles  remote  from  the  fauces  may  or  may  not  be  affected. 
Dr.  L.  E.  Holt  exhibited  to  the  New  York  Clinical  Society  in  December, 
1887,^  a  child  of  two  years  who  had  diphtheria  in  August  and  a  second 
attack  in  the  middle  of  October.  She  convalesced  slowly,  and  in  her  con- 
valescence had  no  paralytic  symptoms,  except  a  nasal  voice,  until  December 
1,  when  multiple  paralysis  suddenly  developed.  A  brother  of  this  patient 
also  had  diphtheria  in  October,  moderately  severe,  and  early  in  convales- 
cence paralysis  of  the  muscles  of  the  palate  began,  followed  by  that  of 
other  muscles ;  but  it  was  not  until  the  middle  of  December  that  the  lower 
extremities  were  paralyzed.  These  cases  are  examples  of  the  usual  mode 
of  commencement  and  extension  of  the  paralysis. 

Diphtheritic  paralysis  is,  therefore,  with  few  exceptions,  a  late  symptom 
of  diphtheria,  or  a  sequel ;  but  Dr.  Boissarie  ^  has  related  cases  in  which 
the  paralysis  was  not  preceded  by  the  ordinary  symptoms  of  diphtheria, 
and  which,  so  far  as  I  am  aware,  are  unique.  An  officer  in  the  police  had 
been  ailing;  two  or  three  davs  :  he  had  a  nasal  voice,  and  drinks  retm'ned 
through  the  nose.  On  inspection,  the  velum  palati  was  found  insensible 
and  motionless,  but  the  fauces  were  other^^^se  in  their  normal  state.  In  the 
hospital  alongside  the  barracks  in  which  the  above  case  occurred,  a  young 
man  without  fever,  redness,  or  swelling  of  the  fauces  had  also  a  nasal  voice, 
and  return  of  liquid  food  through  the  nose.  The  porter  of  the  hospital 
was  similarly  affected,  and  the  doctor  stated  that  certain  other  patients  in 
like  manner  presented  symptoms  of  paralysis,  without  the  history  of  an 
antecedent  diphtheria.  Dr.  Reynaud,  called  in  consultation,  expressed  the 
opinion  that  the  paralysis  had  a  diphtheritic  origin ;  and  this  opinion  was 
strengthened  by  the  occurrence  immediately  afterwards  of  an  epidemic  of 
diphtheria  in  the  place  where  these  cases  occurred.  It  appeared  as  if  the 
diphtheritic  poison  had  attacked  the  kidneys  without  manifesting  its  action 
in  any  other  part  of  the  system.  Certainly  such  remarkable  cases  should 
have  been  more  minutely  examined.  It  is  remarkable,  inasmuch  as  diph- 
theria is  so  widely  spread  and  so  closely  studied,  that,  if  paralysis  is  some- 
times the  only  manifestation  of  the  operation  of  the  diphtheritic  poison, 
other  similar  cases  have  not  been  observed  and  reported.  It  is,  in  my 
opinion,  more  probable  that  in  the  above  cases  diphtheria  had  occurred  of 
so  mild  a  form  that  it  escaped  notice.  I  have  related  elsewhere  a  case  in 
which  diphtheritic  albuminuria  was  preceded  by  diphtheria  of  so  mild  a 
form  as  regarded  the  usual  manifestations  that  it  nearly  escaped  detection, 


1  New  York  Medical  Journal,  Dec.  1887. 

2  Gazette  Hebdomadaire,  1881. 


DIPHTHERIA.  633 

and  yet  the  renal  complication  or  sequel  was  so  severe  that  death  resulted. 
In  another  instance  a  little  girl,  not  complaining  of  herself,  left  a  call  for  a 
visit  to  her  brother,  whom  I  found  with  diphtheria  of  rather  a  severe  type. 
At  the  time  of  my  visit  she  was  playing  with  other  children  in  the  street, 
and  it  occurred  to  me  to  call  her  in  and  examine  her  throat.  To  the  sur- 
prise of  the  family,  the  characteristic  diphtheritic  patch  was  observed  over 
one  tonsil.  Such  mild  walking  cases  are  not  infrequent  in  Xew  York  City, 
where  diphtheria,  established  for  many  years,  is  constantly  present,  some- 
times pernicious,  and  speedily  fatal,  but  in  other  instances  having  a  type 
at  the  extreme  of  mildness  and  with  no  evidence  of  blood-poisoning.  All 
physicians  who  have  had  much  experience  with  diphtheria,  as  in  localities 
where  it  is  natui'alized  or  endemic,  can  recall  cases  in  which  a  sequel  of 
diphtheria,  such  as  paralysis  or  albuminuria,  has  led  ta  an  accurate  diag- 
nosis of  a  pre-existing  throat-aifection  which  was  so  mild  that  its  true  nature 
was  not  suspected.  In  this  respect  diphtheria  resembles  scarlet  fever,  which 
also  j)resents  an  equally  variable  type,  from  extreme  mildness  to  a  fatal 
severity.  Hence  it  seems  prol^able  that  in  Boissarie's  cases  diphtheria  of  so 
mild  a  form  that  it  escaped  notice  had  preceded  the  paralytic  manifestation. 

The  paralysis,  as  a  rule,  affects  both  motor  and  sensory  nerves.  Thus, 
in  paralysis  of  the  velum  and  pharynx,  anaesthesia  more  or  less  marked 
occurs  of  the  velum,  the  isthmus  of  the  fauces,  and  the  walls  of  the  j^harynx, 
in  addition  to  the  motor  paralysis.  In  the  more  severe  cases,  ansesthesia 
"svith  absence  of  reflex  action  occurs  not  only  over  the  entire  pharynx,  but 
also  over  the  epiglottis.  The  combination  of  motor  and  sensory  paralysis 
should  be  borne  in  mind  in  studying  the  cause  and  nature  of  the  ailment. 
The  muscles  affected  by  diphtheritic  paralysis  atrophy  as  in  other  forms  of 
paralysis.  Dr.  H.  von  Ziemssen^  says  that  such  marked  atrophy  does  not 
occur  in  any  other  disease,  except  in  acute  poliomyelitis  and  saturnine 
paralysis. 

The  symptoms  and  course  of  diphtheritic  paralysis  vary  according  to  its 
location  and  the  muscles  affected.  Therefore  we  will  sketch  the  clinical 
history  of  its  various  forms  separately,  beginning  with  that  which  is  first  in 
time,  most  frequent,  and  least  dangerous, 

1.  Loss  of  the  Tendon  Reflexes. — In  1882,  Dr.  Buzzard  made  the  obser- 
vation that  the  knee-jerk  is  absent  in  cases  of  diphtheritic  paralysis.  Bern- 
hard  ^  stated  that  loss  of  knee-jerk  may  precede  other  nervous  symptoms,  or 
may  occur  without  other  symptoms  indicating  impairment  of  the  nervous 
system.  He  also  stated  a  fact  now  generally  admitted,  that  the  loss  of 
knee-jerk  may  have  a  diagnostic  value  in  indicating  the  diphtheritic  nature 
of  a  pre-existing  obscure  disease.  But  the  profession  in  tin's  country  had 
little  knowledge  of  the  loss  of  the  tendon  reflexes  in  di[)htlieria  until  Prof. 
R.  L.  McDonnell,  of  the  Montreal  General  Hospital,  read  a  paper  on  this 

1  Klinlsche  Vortriige,  1887,  No.  iv. 
^  Virchow's  Archiv,  Bd.  xcix. 


634  DIPHTHERIA. 

subject  before  the  Canada  Medical  Association,  August  31,  1887,  and  pub- 
lished it  in  the  Medical  News  of  Philadelphia  in  the  following  October. 
Dr.  McDonnell's  observations  relate  to  eighteen  cases  of  diphtheria  admitted 
into  the  General  Hospital.  Of  these  eighteen  patients,  ten  had  loss  of  knee- 
jerk  at  the  time  of  admission,  while  in  the  remaining  eight  it  was  present. 
The  cases  observed  by  the  doctor  were  sufficient,  he  believed,  to  enable  him 
to  make  the  following  statement :  Knee-jerk,  in  many  cases  of  diphtheria,  is 
absent  from  the  very  first  day  of  the  illness.  It  is  a  noteworthy  fact  that  in 
most  of  the  cases  detailed  by  McDonnell,  in  which  there  was  loss  of  the 
tendon  reflex,  other  forms  of  paralysis  subsequently  appeared. 

Since  the  publication  of  Dr.  McDonnell's  paper,  many  observations  have 
been  made  confirmatory  of  his  statement.  At  a  meeting  of  the  New  York 
Clinical  Society,  held  December  23,  1887,  Dr.  L.  E.  Holt  exhibited  a 
brother  and  sister  of  five  and  two  years,  with  multiple  paralysis,  who  had 
lost  the  knee-jerk,  and  the  examination  of  one  of  them  showed  complete 
loss  of  the  plantar  reflex.  Since  the  attention  of  the  profession  has  been 
directed  to  the  loss  of  the  tendon  reflexes,  all  observers  admit  that  it  is  not 
only  the  earliest  but  also  the  most  frequent  of  the  paralytic  symptoms, 
probably  occurring  in  one-third  to  one-half  of  all  cases  under  treatment. 
Dr.  Angel  Money,  in  a  discussion  before  the  London  Clinical  Society,  Sep- 
tember, 1887,  stated  that  he  had  observed  an  initial  increase  of  the  knee- 
jerk,  preceding  its  abolition.  Dr.  H.  von  Ziemssen  remarks  that,  while 
the  tendon  reflexes  are  so  often  lost,  the  cutaneous  reflexes  are  frequently 
exaggerated. 

The  loss  of  the  tendon  reflexes,  while,  as  we  have  stated,  it  is  the  first 
in  time  of  the  paralytic  symptoms,  appears  also  to  have  the  longest  duration. 
In  cases  of  multiple  paralysis  it  seems  to  be  the  last  to  disappear.  Thus, 
Dr.  McDonnell  states  that  the  loss  of  knee-jerk  in  a  boy  of  fourteen  years 
continued-  four  months,  and  in  his  two  sisters  it  was  still  present  when  all 
other  symptoms  of  the  disease  had  disappeared. 

2.  Palatal  Paralysis. — With  the  exception  of  the  loss  of  the  tendon  re- 
flexes, the  most  common  form  of  diphtheritic  paralysis  is  that  in  which  the 
velum  palati  and  muscles  of  the  pharynx  are  aflected.  This  form  of  paral- 
ysis is  revealed  by  a  nasal  intonation  of  the  voice,  slow  speech,  snoring  during 
sleep,  difficult  deglutition,  and  return  of  liquids  through  the  nares.  As  the 
paralysis  increases  in  severity  and  extent  and  the  palato-glossus  and  con- 
strictor muscles  of  the  pharynx  become  paralyzed,  the  difficulty  in  swallow- 
ing increases.  The  patient  finds  it  necessary  to  throw  his  head  backward 
in  swallowing  and  to  swallow  slowly  and  in  small  amount.  The  food  de- 
scends in  the  oesophagus  by  its  weight,  and  with  but  little  aid  from  the  plia- 
ryugeal  muscles.  On  examining  the  fauces,  we  discover  the  velum  relaxed 
and  motionless,  and  the  uvula,  deprived  of  its  tonicity,  drops  on  the  base 
of  the  tongue.  On  toucliing  the  uvula  M-ith  the  point  of  a  pen  or  pencil, 
it  is  found  to  b^e  insensible,  no  reflex  action  occurring.  Sensory  paralysis 
occurs,  as  a  rule,  in  typical  cases,  the  patient  experiencing  no  pain  when 


DIPHTHEEIA.  635 

the  parts  are  pricked  with  a  pin  or  other  instrument.  The  fauces  should  be 
inspected  and  tested  from  day  to  day,  in  order  to  determine  the  progress  of 
the  paralysis.  In  mild  cases  it  may  be  limited  to  the  velum  and  palate,  but 
it  frequently  extends  to  the  epiglottis  and  upper  part  of  the  larynx,  so  that 
in  attempts  to  swallow,  portions  of  the  food  enter  the  laiynx,  exciting  a 
cough.  The  affected  muscles  may  regain  their  use  in  less  than  a  week,  but 
frequently  from  one  to  two  months  elapse  before  their  function  is  restored. 

Palatal  paralysis  terminates  favorably,  with  few  exceptions,  if  the  pa- 
tients are  otherwise  in  good  condition ;  but  if  there  be  much  prostration 
from  the  antecedent  diphtheria  and  from  the  dysphagia,  death  may  occur 
from  inanition.  Cadet  de  Gassicourt  has  cited  two  cases  of  death  from  this 
cause,  although  life  was  probably  prolonged  by  feeding  through  an  oesopha- 
geal tube  introduced  through  the  nostrils.  Rarely,  also,  death  has  occurred 
from  the  descent  of  food  into  the  air-passages  and  the  plugging  of  a  bron- 
chus. Tardieu  and  Peter  have  each  related  a  case  of  this  mode  of  death. 
As  a  chief  function  of  the  velum  palati  is  to  close  the  posterior  nasal  fossae 
during  deglutition,  food,  especially  if  liquid,  is  liable  to  be  returned  through 
the  nostrils  until  the  function  of  the  velum  is  restored. 

3.  Multiple  Paralysis. — This  form  of  paralysis  is  commonly  preceded 
by  loss  of  the  tendon  reflexes.  In  most  instances  it  begins  with  loss  of 
power  in  the  muscles  of  the  palate ;  but  exceptions  occur.  Cases  are  re- 
ported in  which  the  muscles  of  the  eye,  those  of  motion  and  of  accommoda- 
tion, are  first  paralyzed,  the  palatal  muscles  being  unaffected  or  subsequently 
attacked.  Trousseau  has  •  stated  that  in  cutaneous  diphtheria  the  first  loss 
of  muscular  power  is  sometimes  in  the  lower  extremities  instead  of  in  the 
palate ;  and  other  observers  have  recorded  cases  in  which  multiple  paralysis 
commenced  in  one  or  more  of  the  extremities.  Therefore  the  order  of  the 
paralytic  seizures  differs  in  different  cases,  and  muscles  are  affected  in  one 
patient  that  escape  in  another.  The  degree  of  paralysis  varies  in  different 
muscles.  In  some  the  loss  of  power  is  complete,  while  in  others  it  is 
partial.  When  the  lower  extremities  are  entirely  motionless,  the  patient 
frequently  has  considerable  use  of  the  upper  extremities. 

Even  in  the  severest  cases  many  groups  of  muscles  entirely  escape. 
Therefore  I  prefer  the  term  multiple  paralysis  to  the  term  general  paralysis 
employed  by  some  writers  to  designate  this  form  of  the  disease. 

Trousseau  speaks  of  what  he  designates  the  mutability  of  diphtheritic 
paralysis.  He  says  the  paralysis  which  occupies  one  limb  disappears  in 
this  limb,  to  manifest  itself  in  another.  "  The  numbness,  for  example, 
which  the  patient  has  been  experiencing  in  one  leg  will  suddenly  cease, 
and  become  greater  in  the  other  leg.  To-day  the  right  hand  will  not  give 
a  dynamometric  pressure  of  more  than  ten  or  twelve  kilogrammes,  and  to- 
morrow its  power  will  have  augmented,  while  that  of  the  left  will  have 
diminished ;  then  the  parts  which  Avere  first  affected  are  a  second  time 
attacked,  and  become  more  affected."  Even  the  dysphagia  may  vary  on 
different  days,  as  Cadet  de  Gassicourt  has  stated.     He  relates  the  case  of  a 


636  DIPHTHERIA. 

child  of  three  and  a  half  years  in  whom  the  velum  palati  suddenly  resumed 
its  function :  the  head,  which  had  dropped  from  paralysis  of  the  muscles  of 
the  neck,  became  erect,  the  patient  was  able  to  sit,  and  the  upper  extremities 
recovered  their  power,  but  the  improvement  was  of  short  duration,  the 
paralysis  returning  as  at  first.  These  sudden  and  unexplained  variations 
in  the  degree  of  paralysis  resemble,  says  Trousseau,  the  mutability  of 
paralysis  in  hysteria.  Among  the  most  noteworthy  of  the  paralyses  result- 
ing from  diphtheria  are  those  pertaining  to  the  eye.  The  media  and  retina 
are  unaffected,  but  the  levator  palpebrse,  the  muscles  of  accommodation,  and 
the  motor  muscles  of  the  eye  are  paralyzed  in  certain  patients,  so  as  to  cause 
dropping  of  the  eyelids,  strabismus,  and  indistinct  vision.  In  addition  to 
the  muscles  already  mentioned,  various  muscles  of  the  trunk,  of  the  neck,, 
the  sphincter  ani,  and  the  sphincter  vesicae  are  sometimes  paralyzed,  pro- 
ducing deformity  and  incontinence  of  urine-  and  fseces.  The  paralysis  of 
the  muscles  of  accommodation  is  usually  such  that  patients  become  presby- 
opic, seeing  distinctly  distant  but  not  near  objects. 

The  muscles  of  the  face  are  also  occasionally  paralyzed.  Many  observers 
have  related  cases  of  facial  hemiplegia.  When  general  paralysis  of  the 
facial  muscles  occurs, — fortunately,  a  rare  event, — whatever  the  mental  state, 
however  great  the  excitement,  the  features  are  entirely  devoid  of  expression ;: 
the  aspect  is  dull  and  idiotic ;  the  face  is  flabby  and  motionless ;  the  lids 
and  lips  droop ;  saliva  flows  from  the  mouth,  and  speech  is  slow  and  diffi- 
cult. At  the  same  time  the  mental  faculties,  deprived  of  the  usual  mode 
of  expression,  are  sound  and  active. 

But  the  most  accurate  idea  of  the  symptoms  of  multiple  paralysis  can 
be  imparted  by  the  narration  of  a  case ;  and  I  select  for  this  purpose  the 
graphic  description  of  this  form  of  paralysis  published  by  Dr.  C.  W.  Fallis 
in  the  Medical  Summary  for  January,  1888.  He  describes  the  ailment  as 
it  occurred  in  his  own  person,  as  follows.  "  About  three  weeks  after  the 
subsidence  of  the  disease  [diphtheria]  the  paralytic  symptoms  began  to 
show  themselves.  Impaired  vision  was  the  first  trouble  noticed,  inability 
to  accommodate  the  eyes  to  near  objects,  and  in  taking  up  the  paper  to  read, 
one  morning,  I  found  I  could  scarcely  see  a  word,  and  soon  after,  although 
distant  objects  could  be  seen  as  well  as  ever,  high-power  glasses  were  re- 
quired to  read  any  kind  of  print.  Double  vision  Avas  noticed  afterwards.  At 
about  the  same  time  numbness  of  the  tongue  was  felt,  the  muscles  of  deglu- 
tition became  paralyzedj  so  that  swallowing  was  attended  with  strangling 
and  regurgitation  of  food  through  the  nose.  There  was  a  rapid  pulse,  120 
to  the  minute,  showing  that  the  pneumogastric  was  involved.  Weakness 
of  the  limbs,  causing  a  staggering  gait,  appeared ;  fingers  became  weak  and 
numb,  so  that  small  objects  could  not  be  pi(;ked  up,  the  symptoms-  becoming^ 
worse  and  worse  as  the  disease  progressed.  The  muscles  of  the  left  side 
of  the  face  became  affected  with  all  the  symptoms  of  fiieial  jiaralysis  from 
organic  disease.  Motion  became  more  and  more  impaired,  till  I  could 
neither  stand  nor  walk,  and  when  at  the  worst  I  was  perfectly  helpless,. 


DIPHTHERIA.  637 

could  not  feed  myself,  had  to  be  lifted  from  chair  to  chair,  turned  in  bed, 
and  could  not  even  lift  my  hand  to  my  head,  or  throw  one  limb  over  the 
other.  Sensation  was  so  impaired  that  hands  and  feet  felt  like  lifeless 
weights,  and  in  the  dark  I  could  not  tell  whether  my  feet  were  on  the  floor 
or  not.  The  muscles  of  respiration  were  at  no  time  affected  to  such  an 
extent  as  to  render  breathing  difficult,  and  the  power  of  perfect  speech 
was  retained.  Paralysis  of  the  bowels  necessitated  the  use  of  warm-water 
injections  to  promote  their  action.  Some  of  the  symptoms  abated,  while 
others  became  more  aggravated,  those  first  to  appear  being  generally  the 
first  to  subside :  however,  the  smaller-sized  muscles  recovered  rapidly, 
while  the  large  fleshy  ones  were  more  tardy  in  reaching  their  normal  state, 
the  facial  paralysis  lasting  but  a  few  days,  while  locomotion  was  either 
labored  or  impossible  for  many  weeks.  The  course  of  the  disease  from 
the  beginning  to  the  worst  stage  was  about  nine  weeks,  when  it  remained 
stationary  for  two  weeks.  Improvement  was  at  first  very  slow  and  tedious, 
but  after  I  could  walk  a  little  it  was  much  more  rapid,  and  by  the  fifteenth 
week,  with  the  exception  of  some  weakness,  I  was  well." 

Multiple  paralysis  not  infrequently  continues  from  two  to  six  months. 
As  might  be  expected,  the  prognosis  is  less  favorable  when  the  paralysis  is 
multiple  than  when  it  is  restricted  to  the  velum  and  pharynx.  In  thirteen 
cases  observed  by  Cadet  de  Gassicourt,  six  died. 

4.  Cardiac  Paralysis  (the  Gardio-pulmonary  paralysis  of  certain  French 
writers). — In  cases  of  the  first,  second,  and  third  forms  of  paralysis  which 
have  been  considered  above,  the  vital  organs  are  not  directly  involved. 
These  paralyses,  however  inconvenient  they  may  be,  are  not  directly  fatal. 
The  paralysis  which  we  are  about  to  consider  presents  a  very  different  clini- 
cal aspect,  inasmuch  as  the  organs  aflected  are  among  the  most  important 
in  the  system,  a  serious  impairment  of  their  functions  rendering  death  in- 
evitable. 

Physicians  who  have  had  experience  in  the  treatment  of  diphtheria  have 
met  cases  in  which  symptoms,  usually  of  sudden  development,  indicated 
dangerous  heart-failure.  Perhaps  the  patient  has  been  gradually  improving, 
the  pseudo-membrane  has  nearly  or  quite  disappeared,  the  temperature  is 
not  far  from  normal,  the  swallowing  is  better  and  more  nutriment  is  taken, 
the  family  are  cheerful  in  the  prospect  of  a  speedy  recovery,  and  the  phy- 
sician expects  soon  to  discharge  the  patient  cured.  Suddenly  the  scene 
changes.  The  pulse  becomes  feeble  and  abnormally  slow  or  rapid, — it  is 
usually  at  first  slow  and  subsequently  rapid, — the  respiration  is  superficial, 
and  the  surface  becomes  pallid,  often  slightly  cyanotic.  In  the  more  favor- 
able of  these  cases  the  patient  may  rally  by  active  stimulation,  and  perhaps 
he  eventually  recovers,  or  after  some  hours  or  a  day  or  two  of  comparative 
comfort  he  succumbs  to  a  return  of  heart-failure.  There  is  no  other  dis- 
ease in  which  these  sudden,  unforeseen,  and  fatal  attacks  of  heart-failure 
occur  so  frequently  as  in  dijihtlieria.  There  is  no  other  disease  in  which 
physicians  are  so  frequently  deceived  in  their  prognosis,  for  various  reasons, 


638  DIPHTHERIA. 

but  largely  on  account  of  the  occurrence  of  these  unexpected  attacks  of 
heart- weakn  ess . 

But  a  clear  and  accurate  idea  of  the  clinical  history  of  these  cases  of 
sudden  heart-failure  can  be  best  imparted  by  the  relation  of  typical  cases. 
For  this  purpose  I  will  briefly  narrate  cases  occurring  in  the  hospital  service 
of  one  of  the  most  trustworthy  clinical  teachers  of  the  present  time,  M. 
Cadet  de  Gassicourt ;  though  I  believe  that  all  physicians  who  have  been 
several  years  in  practice  where  diphtheria  is  prevailing  can  recall  to  mind 
cases  equally  striking  and  typical.  I  select  his  cases  on  account  of  the 
completeness  of  his  records. 

A  child  of  two  years  entered  Cadet  de  Gassicourt's  service  on  January 
3,  with  diphtheritic  pharyngitis  of  ten  days'  continuance.  The  tonsils  were 
large,  still  covered  with  pseudo-membrane,  and  the  submaxillary  glands 
were  also  enlarged.  He  had  no  laryngeal  symptoms,  and  his  urine  was 
without  albumen.  On  the  following  day  the  velum  and  pharyngeal  mus- 
cles were  slightly  paralyzed,  the  speech  nasal,  and  deglutition  moderately 
embarrassed.  He  was  quiet  during  the  night  of  January  4  and  in  the 
morning  of  the  5th,  but  at  ten  a.m.  he  became  chilly,  his  face  and  extremi- 
ties feebly  cyanotic,  and  slight  dyspnoea  and  dilatation  of  the  alse  nasi  were 
observed.  His  pulse,  at  first  abnormally  slow,  became  rapid,  he  was  agitated, 
uttered  loud  screams  of  distress,  and  fell  back  cyanotic  and  dead.  The  death- 
struggle  did  not  occupy  more  than  one  minute.  Another  infant,  also  two 
years  of  age,  entered  the  same  service,  having  diphtheritic  pharyngitis  of 
two  days'  continuance.  The  fauces  presented  the  usual  red  appearance,  the 
tonsils  were  swollen  and  covered  with  a  thick  exudate,  but  there  was  no 
albuminuria  nor  croupiness.  Two  days  later  the  pseudo-membrane  had 
diminished,  but  the  velum  palati  was  paralyzed.  On  the  following  day 
the  general  appearance  was  satisfactory,  and  the  pseudo- membrane  had  still 
further  diminished.  At  eight  p.m.  the  infant  was  suddenly  seized  with 
vomiting,  accompanied  with  great  dyspnoea,  rapid  pulse  (160),  and  a  cyanotic 
hue  of  the  face  and  extremities.  He  was  restless,  and  uttered  cries  of  dis- 
tress. Two  hours  later  he  screamed  loudly,  raised  himself  in  bed,  and  fell 
back  dead.  A  child  of  five  years  was  admitted  with  diphtheritic  pharyn- 
gitis of  two  days'  continuance,  having  enlarged  tonsils  covered  with  pseudo- 
membrane,  and  enlarged  cervical  glands,  but  without  cough  or  albuminuria. 
Seven  days  later,  the  ninth  of  the  disease,  the  pseudo-membrane  had  dis- 
appeared, but  the  velum  palati  was  paralyzed.  On  the  following  day  there 
was  little  change,  except  occasional  vomiting,  but  the  general  state  was 
good,  and  sleep  tranquil.  At  seven  a.m.  on  the  following  day,  the  eleventh 
of  the  disease,  after  a  calm  night,  the  child  uttered  two  or  three  cries,  the 
pulse  became  rapid,  the  respiration  embarrassed,  the  features,  extremities, 
and  finally  the  entire  surface,  cyanotic,  and  at  eight  a.m.  death  occurred 
quietly. 

The  similarity  of  these  three  cases  is  apparent.  Paralysis  of  the  velum 
and  palate  had  continued  in  the  first  case  eighteen  hours,  in  the  second  case 


DIPHTHERIA.  639 

thirty-six  hours,  and  in  the  third  case  forty-eight  hours,  when  suddenly 
the  heart  and  kings  were  greatly  embarrassed  in  their  functions,  and  death 
occurred  within  one  hour  from  the  commencement  of  the  severe  symptoms. 
The  agitation,  repeated  cries  of  distress,  and  the  shrill  cry  that  preceded 
death,  indicated  extreme  suffering. 

Severe  pain,  prsecordial,  epigastric,  or  abdominal,  is  present  in  some  if 
not  in  most  of  these  cases  of  sudden  heart-failure,  as  we  shall  see  from 
cases  presently  to  be  related.  It  was  probably  experienced  by  these  three 
patients,  who  were  too  young  to  express  clearly  their  subjective  symptoms, 

Gombault  made  a  minute  microscopic  examination  of  the  affected  or- 
gans in  these  three  cases,  after  the  tissues  had  been  properly  hardened  by 
chemical  agents.  In  one  of  the  cases  he  examined  the  pneumogastrics  and 
myocardium,  and  both  were  found  in  their  normal  state.  As  regards  the 
nei-vous  centres,  the  anatomical  changes  were  alike  in  all  three.  In  the 
spinal  cord  lesions  were  found  at  the  origin  of  the  anterior  roots  of  the 
spinal  nerves,  characterized  by  fragmentation  of  the  medullary  substance  in 
the  nerve-fibres,  numerous  granules  and  minute  globules  appearing  in  this 
substance  and  occupying  its  place. 

In  addition  to  this,  undue  swelling  of  the  axis-cylinders  was  observed. 
In  the  three  cases  the  gray  substance  in  the  anterior  cornua  had  under- 
gone a  sort  of  rarefaction,  the  microscopic  sections  being  more  transparent 
and  the  elements  in  the  section  being  wider  apart  than  in  the  normal  state. 
No  meningitis  or  injury  of  the  blood-vessels  was  observed  in  the  spinal 
columns,  but  numerous  nerve-cells  were  deprived  of  their  prolongations. 
The  medulla  oblongata,  the  centre  and  source  of  the  nervous  supply  to  the 
heart,  lungs,  and  stomach  through  the  pneumogastrics,  was  also  carefully 
examined  in  the  three  cases,  Nothing  abnormal  was  observed  in  this  organ, 
except  small  masses  of  leucocytes  in  the  vessels.  The  substance  of  the 
medulla  oblongata  and  the  nerve-fibres  constituting  the  roots  of  the  pneumo- 
gastrics seemed  healthy.  The  small  masses  of  leucocytes  in  the  blood- 
vessels were  not  sufficient  to  obstruct  the  circulation,  and  the  appearance  of 
the  blood-corpuscles  was  normal.  Hence  in  the  opinion  of  Gombault  the 
small  aggregations  of  leucocytes  in  the  vessels  had  no  effect  on  the  innerva- 
tipn  of  the  thoracic  organs  deriv^ed  from  the  medulla.  The  points  of  special 
interest  in  the  microscopic  examination  of  the  three  cases  were  the  appar- 
ently healthy  and  normal  state  of  the  pneumogastrics  and  myocardium  in 
the  one  case  in  which  they  were  examined,  and  of  the  medulla  oblongata  in 
the  three  cases,  while  the  gray  matter  of  the  spinal  cord,  which  has  no 
immediate  nerve-connection  with  the  heart,  showed  marked  degenerative 
changes. 

The  al)ove  are  striking  examjiles  of  sudden  and  fatal  heart-failure  oc- 
curring during  apparent  convalescence,  Avhen  the  symptoms  of  diphtheria 
appeared  to  be  abating,  with  the  exception  ol'  the  paralysis  of  the  velum 
and  palate.  The  following  cases  presented  a  clinical  history  in  some  re- 
spects ditferent,     A  child  of  eight  years  had  been  under  treatment  for 


640  DIPHTIIEEIA. 

diphtheria  since  February  9,  1883.  On  February  20  the  membrane  had 
disappeared,  but  slight  paralysis  of  the  velum  and  left  upper  extremity 
was  observed,  and  the  urine  contained  a  little  albumen.  At  three  p.m.  she 
was  seized  with  severe  abdominal  pains,  followed  by  vomiting,  slow  respi- 
ration, slow  and  feeble  but  regular  heart-beat,  imperceptible  pulse,  coolness 
of  surface,  and  cyanosis.  These  symptoms  increased,  and  at  half-past  six 
P.M.  death  occurred.  The  clinical  history  diifered  from  that  in  the  three 
cases  related  above  in  the  fact  that  there  was  no  agitation  or  moaning  at 
the  close  of  life,  and  that  the  heart-beat  remained  abnormally  slow  unless 
during  the  last  moments.  In  another  case  paralysis  of  the  velum  and 
palate  began  on  the  third  day  of  diphtheria,  while  the  pharyngeal  and 
nasal  inflammations  were  in  full  activity.  The  urine  was  slightly  albu- 
minous. Three  days  subsequently,  in  the  morning,  the  muscles  of  the 
nucha  and  right  shoulder  were  paralyzed.  At  two  p.m.  the  child  com- 
plained of  violent  abdominal  pains,  followed  by  nausea  and  vomiting.  The 
vomiting  was  partially  relieved,  but  dyspnoea  and  a  rapid  heart-beat  followed. 
The  cyanosis  increased  until  it  extended  over  the  entire  surface,  and  death 
occurred  three  hours  after  the  commencement  of  symptoms  referable  to  heart- 
failure.  A  boy  of  five  years  had  diphtheritic  croup,  for  which  tracheotomy 
was  performed  and  the  canula  inserted.  He  subsequently  did  well  for  a 
time,  but  afterwards  lost  his  appetite.  On  the  eleventh  day  of  the  disease 
he  had  paralysis  of  the  velum  and  palate.  On  the  twelfth  and  thirteenth 
days  the  disease  seemed  to  be  stationary,  and  the  child  was  quiet.  Suddenly 
at  seven  p.m.  on  the  thirteenth  day  multiple  paralysis  occurred.  Liquid 
food  taken  by  the  mouth  was  returned  in  part  through  the  nostrils,  and  a 
part  entered  the  larynx  and  escaped  from  the  tracheal  opening.  An  hour 
later  the  muscles  of  the  nucha,  the  arms,  and  both  sides  of  the  trunk  were 
paralyzed,  and  the  head  dropped.  At  seven  a.m.  on  the  following  day, 
vomiting,  dyspnoea,  cyanosis  of  the  face  and  extremities,  and  a  very  rapid 
pulse  occurred.  The  asphyxia  increased,  the  pulse  grew  more  feeble,  the 
surface  cool,  and  death  took  place  three  hours  later. 

Cases  like  the  above  are  not  infrequent  in  severe  epidemics  of  diph- 
theria, but  in  some  instances  the  loss  of  power  in  the  heart  occurs  more 
gradually.  A  boy  of  twelve  years  had  diphtheritic  pharyngitis  from  which 
he  was  apparently  convalescing.  Some  days  after  the  disappearance  of  the 
inflammation,  the  velum  palati  and  muscles  of  the  pharynx  were  paralyzed. 
Then  succeeded  paralysis  of  the  muscles  of  the  nucha,  of  the  muscles  of 
accommodation,  and  of  those  of  the  upper  and  lower  extremities.  The 
march  of  the  paralysis  was  for  a  time  progressive.  Then  it  seemed  to 
recede ;  but  the  improvement  did  not  continue.  One  month  from  the  com- 
mencement of  diphtheria,  the  child  uttered  plaintive  cries,  became  motion- 
less as  if  from  general  paralysis,  and  a  state  of  asphyxia  slowly  occurred, 
accompanied  by  cyanosis.  During  the  following  night  the  patient  lay  in  a 
stupor,  and  on  the  ensuing  morning  the  features  presented  a  cadaverous  and 
slightly  cyanotic  hue,  the  extremities  were  cool  and  blue,  the  tongue  pallid, 


DIPHTHERIA.  641 

moist,  and  of  a  normal  warmth,  the  respiration  hurried  and  without  auscul- 
tatory signs  of  disease,  the  pulse  feeble  and  rapid  (148).  Finally  the  sphinc- 
ters were  paralyzed,  the  urine  and  fseces  escaping  involuntarily.  Within  ten 
minutes  after  the  above  notes  were  written,  the  patient  died  of  heart-failure. 
The  feature  of  special  interest  in  this  case  was  the  long  continuance  of  mul- 
tiple paralysis  when  the  cardiac  and  pulmonary  symptoms  occurred. 

Sudden  heart-failure  in  diphtheria  is  usually  fatal ;  but  recovery  is  pos- 
sible. Cadet  de  Gassicourt  in  his  large  clinical  experience  met  one  re- 
covery to  fourteen  deaths.  This  case  is  interesting  since  the  heart-failure 
preceded  the  palatal  and  other  forms  of  paralysis,  instead  of  being  preceded 
by  them,  as  is  ordinarily  the  case.  Twenty  days  after  the  commencement 
of  diphtheria,  and  when  in  apparent  convalescence,  the  patient  was  seized 
with  extreme  pain  in  the  prsecordial  region,  attended  by  a  fall  of  pulse  to 
42.  He  had  cold  sweats,  rigors,  and  vomiting.  In  one  and  a  half  hours 
these  symptoms  abated.  Three  days  subsequently  another  similar  attack 
occurred,  and  subsequently  two  others,  but  less  severe  than  the  first.  On 
the  twenty-eighth  day  from  the  beginning  of  diphtheria,  and  eight  days 
after  the  syncopal  attacks,  paralysis  of  the  velum  and  pharynx  began,  soon 
followed  by  paralysis  of  the  vocal  cords,  of  the  muscles  of  accommoda- 
tion, and  of  those  of  the  extremities,  which  continued  three  months,' when 
recovery  was  complete.  Cases  of  recovery  from  sudden  and  alarming 
symptoms  of  heart-failure  have  also  been  related  by  Sann^,  Billard,  and 
others. 

What  is  the  cause  of  this  sudden  loss  of  power  in  the  heart  in  diph- 
theria, occurring  usually  during  apparent  convalescence?  Does  it  result 
from  disease  in  the  muscular  structure  of  the  heart,  from  thrombosis  or 
ante-mortem  clots  in  the  cavities  of  the  heart,  or  does  it  result  from  disease 
of  the  central  organ  of  innervation,  the  medulla  oblongata,  or  from  disease 
and  deficient  conducting  power  in  the  important  nerve  which  controls  the 
heart's  action,  the  pneumogastric,  or  in  the  branches  which  this  nerve  sup- 
plies to  the  heart  as  well  as  the  lungs  and  the  stomach  ? — for  these  three 
organs  appear  in  most  instances  to  be  aflFected  simultaneously. 

Bouchut  and  Lagrave  attribute  sudden  heart-failure  in  diphtheria  to 
endocarditis ;  and  yet  it  is  very  seldom  that  a  bruit  or  heart-signs  indicative 
of  endocarditis  have  been  observed  during  life.  The  belief  in  the  occur- 
rence of  this  inflammation  is  based  on  the  appearance  of  the  free  edge  of 
the  mitral  valve,  and  sometimes  of  the  aortic  valves  in  addition.  They 
have  appeared  roughened  as  if  from  the  presence  of  minute  vegetations. 
At  the  same  time  the  surface  of  the  valves  and  the  endocardial  surface 
have  undergone  no  appreciable  change  such  as  an  endocarditis  would  be 
likely  to  cause.  Since  the  announcement  of  the  theory  of  Bouchut  and 
Lagrave,  and  attention  has  been  drawn  to  the  subject,  the  roughened  edge 
of  the  mitral  and  aortic  valves,  upon  which  their  theory  of  an  endocarditis 
as  the  causative  agent  of  sudden  heart-failure  is  based,  has  been  found  with 
equal  frequency  in  children  who  have  perished  with  other  diseases.  The 
Vol.  I.— 41 


642 


DIPHTHERIA. 


late  Prof.  Parrot  says  Cadet  de  Gassicourt  expressed  the  decided  conviction 
that  the  roughening  of  the  tips  of  these  valves  does  not  have  an  inflamma- 
tory origin,  but  is  an  anatomical  peculiarity  which  originates  in  the  foetal 
development.  Sann6  says  in  reference  to  Bouchut  and  Lagrave's  theory, 
"  My  personal  investigations  are  absolutely  negative.  Observations  of  diph- 
theria, to  the  number  of  one  hundred  and  forty-nine,  taken  in  these  later 
years,  .  .  .  have  not  furnished  a  single  case  of  endocarditis.  I  should  fear 
to  express  myself  in  such  a  positive  manner  if  I  should  trust  to  the  single 
testimony  of  my  senses ;  but  a  large  number  of  these  patients  were  auscul- 
tated by  Barthez  and  by  D'Espine  and  Gombault.  .  .  .  The  conclusion 
.  .  .  therefore  is  that  diphtheritic  endocarditis  is  extremely  rare,  as  patho- 
logical anatomy  and  clinical  observation  alike  demonstrate."  Therefore 
the  theory  which  attributed  sudden  heart-failure  to  endocarditis  has  not 
been  sustained  by  recent  observations,  and  does  not  appear  to  be  tenable. 

Weakening  of  the  heart's  action  in  diphtheria,  with  sudden  death  as 
a  consequence,  has  with  more  probability  been  attributed  to  granulo-fatty 
degeneration  in  the  muscular  fibres  of  the  heart  consequent  upon  a  pro- 
longed and  severe  diphtheritic  attack.  Oertel  says,  "  When  the  general 
disease  lasts  long  and  is  very  intense,  and  especially  in  cases  in  which 
death  is  caused  suddenly  by  paralysis  of  the  heart,  the  muscle  appears  pale, 
soft,  friable,  broken  by  extravasations  of  blood,  and  on  microscopical  exam- 
ination most  of  its  fibres  are  seen  to  be  already  in  an  advanced  stage  of 
fatty  degeneration."  ^  Such  degenerative  changes  if  occurring  in  a  consider- 
able proportion  of  the  muscular  fibres  of  the  heart  would  inevitably  render 
the  contractile  power  of  this  organ  feeble,  and  perhaps  inadequate.  Still, 
if  we  regard  it  as  a  cause  of  sudden  heart- failure,  it  can  be  regarded  as 
such  in  only  a  relatively  small  number  of  instances,  for  in  most  cases  the 
weakening  of  the  power  of  the  heart  is  sudden  and  during  convalescence, 
— at  a  period,  therefore,  when  degenerative  changes  are  not  likely  to  occur. 
In  most  of  the  recorded  cases  the  contractile  power  of  the  heart  does  not 
appear  to  have  been  notably  weakened  previous  to  the  attack  of  heart- 
failure,  as  it  would  probably  have  been  were  degenerative  changes  in  the 
myocardium  the  sole  or  chief  cause.  The  clinical  history  is  as  if  the  heart 
were  suddenly  overpowered  by  an  agent  of  rapid — never  slow — develop- 
ment. Moreover,  in  typical  cases  of  sudden  heart-failure  the  microscope 
sometimes  reveals  a  healthy  myocardium,  as  in  one  of  the  cases  related 
above.  We  must  look,  therefore,  for  some  other  cause,  although  admitting 
that  degenerative  changes  in  the  muscular  fibres  of  the  heart,  when  present, 
contribute  to  a  weakened  action  of  this  organ. 

Sudden  heart-failure  in  diphtheria  has  also  been  attributed  to  cardiac 
thrombosis ;  but,  as  several  writers  have  pointed  out,  the  heart-clots  are 
identical  in  appearance  and  kind  with  those  found  in  the  heart  after  death 
from  other  diseases  than  diphtheria.     There  is  every  reason  for  the  belief 

1  Ziemssen's  Cyclopsedia,  vol.  i. 


DIPHTHERIA.  643 

that  they  occur  during  the  death-struggle,  and  therefore  are  not  the  primary 
cause  of  the  heart-faihn-e,  but  are  secondary  or  consecutive. 

Among  the  most  strenuous  advocates  of  the  theory  that  cardiac  throm- 
bosis is  the  common  cause  of  sudden  heart-faikire  and  sudden  death  in 
diphtheria  is  Dr.  Beverley  Robinson,  now  a  distinguished  physician  of  New 
York,  whose  able  thesis  on  this  subject,  published  in  1871,  when  he  was  a 
resident  of  Paris,  attracted  much  attention  and  is  alluded  to  by  nearly  all 
recent  French  writers  on  this  subject.  But  the  opinion  of  most  pathologists 
in  reference  to  this  theory  is,  I  think,  expressed  by  Cadet  de  Gassicourt  in 
the  following  passages  published  in  his  clinical  treatise :  "  I  have  often 
shown  you  these  clots,  and  I  have  enabled  you  to  see  that  they  occur  equally 
in  children  who  have  died  of  diphtheria,  as  well  as  in  those  who  have  suc- 
cumbed to  other  maladies,  in  subjects  struck  with  sudden  death  and  in 
those  who  have  not  been  attacked  by  any  sudden  casualty.  This  objection 
is  in  itself  conclusive.  You  have  been  able  to  see  also  that  the  constitution 
of  these  clots  does  not  have  any  of  the  characters  which  authors  the  most 
competent  have  assigned  to  clots  formed  during  life :  they  are  the  clots  of 
the  agony."     Sann6  also  writes  in  almost  identical  language. 

In  searching  for  the  cause  of  sudden  heart-failure  in  diphtheria,  we  must 
note  the  fact  that,  as  a  rule,  in  typical  cases  it  is  preceded  by  palatal  and 
often  multiple  paralysis.  The  paralysis  has  continued  for  a  time,  extending 
perhaps  from  one  group  of  muscles  to  another,  when  suddenly  the  heart 
passes  under  some  powerful  influence  which  restricts  and  overpowers  its. 
action.  The  theory  of  deficient  innervation  or  a  true  cardiac  paralysis 
appears  most  tenable  under  the  circumstances.  It  affords  the  most  satisfac- 
tory explanation  of  those  unfortunately  not  infrequent  cases  in  which  death 
suddenly  occurs  during  apparent  convalescence  from  diphtheria,  when  the 
symptoms  are  fast  disappearing,  with  the  exception  of  the  palatal  or  other 
paralysis.  It  aifords  best  of  all  the  theories  an  explanation  of  the  occur- 
rence of  sudden  death  from  heart-weakness  in  those  obscure  cases  which 
have  puzzled  physicians,  cases  in  which  the  post-mortem  examination  has 
revealed  an  apparently  healthy  state  of  the  heart.  The  theory  of  an  arrested 
or  deficient  innervation  of  the  heart  also  furnishes  an  explanation  of  the 
occurrence  of  concomitant  symptoms  in  these  cases  of  sudden  heart-failure, 
— such  symptoms  as  vomiting,  epigastric  pain,  and  dyspncea,  or  irregular 
respiration;  for  the  heart  derives  its  innervation  from  the  same  source 
as  the  lungs  and  the  stomach, — that  is,  through  the  pneumogastric.  For 
the  reasons  now  given,  we  feel  justified,  in  our  classification  of  the  forms 
of  diphtheritic  paralysis,  to  make  a  distinct  class  having  the  designation 
cardiac  paralysis,  or,  to  adopt  in  our  language  the  French  expression, 
cardio-pulmonarv  ])aralysis. 

Etiology. — Tlic  fi)ur  forms  of  diphtheritic  paralysis — first,  the  abolition 
of  the  tendon  reflexes,  the  most  common,  the  earliest,  and  the  least  danger- 
ous of  all ;  secondly,  palatal  paralysis,  wliich  may  occur  as  early  as  the 
third  day  of  diphtheria,  but  is  most  common  during  its  later  stages,  or  in 


644  DIPHTHERIA. 

the  period  of  convalescence ;  thirdly,  multiple  paralysis,  in  which  various 
muscles  throughout  the  system  are  paralyzed ;  and,  fourthly,  cardiac  paraly- 
sis, the  most  dangerous  of  all — probably  are  produced  by  the  same  cause 
and  have  the  same  pathology  in  most  instances.  We  may,  therefore,  in  the 
following  pages,  in  studying  the  cause  and  nature  of  diphtheritic  paralysis, 
regard  the  various  forms  which  it  exhibits  as  manifestations  of  one  disease. 
What  is  true  of  cardiac  paralysis  as  regards  its  cause  and  nature  we  may 
assume  to  be  true  in  reference  to  palatal  and  multiple  paralysis  and  even 
the  abolition  of  the  tendon  reflexes.  The  most  dangerous  and  fatal  paraly- 
sis, the  cardiac,  is,  as  we  have  stated  above,  in  nearly  all  patients  associated 
with  the  milder  forms,  showing  that  the  same  cause  or  causes  are  operative 
at  the  same  time  in  the  individual. 

Gubler,  in  his  memoir  published  in  1860-61,  attributed  paralysis  of  the 
velum  and  palate  to  disease  of  the  terminal  nerves  produced  by  contiguity  or 
propagation  from  the  inflamed  fauces,  and  he  held  that  the  same  injury  of 
the  nerves  and  paralysis  might  result  from  any  anginose  inflammation,  if 
severe  enough.  But  this  theory  was  short-lived,  for  physicians  soon  per- 
ceived that  it  was  inadequate  to  explain  the  occurrence  of  paralysis  at  a 
distance  from  the  inflamed  surfaces,  and  palatal  paralysis  sometimes  occurs 
after  cutaneous  and  other  forms  of  diphtheritic  inflammation  in  which  both 
the  fauces  and  the  nares  entirely  escape  and  remain  healthy. 

Trousseau,  impressed  with  the  inadequacy  of  Gubler's  theory,  directed 
his  attention  to  the  nervous  centres.  He  was  led  to  believe,  from  the  fact 
that  the  paralysis  usually  terminates  favorably,  and  because  in  certain  fatal 
cases  he  was  unable  to  discover  any  lesion  sufficient  to  produce  the  paralysis 
in  the  brain,  spinal  cord,  or  meninges,  that  it  did  not  occur  from  any  struc- 
tural change  in  the  nervous  system.  Trousseau,  an  unsurpassed  clinical 
observer,  was  not  a  microscopist,  and,  being  unable  to  discover  any  anatom- 
ical cause  of  the  paralysis,  he  relates  the  case  of  the  crew  of  a  vessel  who 
were  paralyzed  by  eating  an  eel  which  contained  some  poisonous  ingre- 
dient, and,  after  alluding  to  instances  of  paralysis  resulting  from  small-pox, 
typhoid  and  typhus  fevers,  and  cholera,  continues,  "  AYell,  then,  diphtheritic 
paralysis  belongs  to  the  same  category  :  its  real  cause  is  the  poisoning  of 
the  system  by  the  morbific  principle  which  generates  the  malady,  on  which 
the  paralysis  depends,  and  in  regard  to  the  mode  of  action  of  which  in 
producing  the  paralysis  we  shall  always  perhaps  remain  in  ignorance." 

Since  the  time  of  Trousseau,  many  eminent  pathologists  have  endeavored 
to  discover  the  anatomical  characters  and  elucidate  the  nature  of  diphthe- 
ritic paralysis  by  patient  and  thorough  microscopic  examinations.  We 
have  already  detailed  the  microscopic  appearances  in  Cadet  de  Gassicourt's 
three  memorable  cases.  In  1862,  Charcot  and  Vulpian  stated  that  they  had 
examined  the  nervous  filaments  in  the  velum  palati  paralyzed  by  diphtheria 
and  found  certain  of  them  entirely  free  from  medullaiy  matter,  granular 
bodies  occupying  its  place ;  but  partial  degeneration  was  more  common. 
In  some  of  the  fibres  the  medullary  matter  was  intact.     Lionville  in  1872 


DIPHTHERIA.  645 

stated  that  he  had  found  degenerative  changes  in  the  -phrenic  nerve  of  a 
patient  who  had  died  of  asphyxia  following  an  attack  of  diphtheria.  The 
contents  of  certain  of  the  fibres  constituting  this  nerve  were  amorphous, 
filled  with  granular  bodies  instead  of  the  normal  nerve-substance.  Ley- 
den  in  1872  discovered  lesions  in  the  j)eripheral  nerves  and  in  the  central 
organ,  upon  which  he  bases  his  theory  of  an  ascending  neuritis.  Roger 
and  Damaschino  in  1875  examined  the  nervous  system  in  four  children 
who  had  died  of  diphtheritic  paralysis,  and  found  atrophy  of  the  nerve- 
fibres  in  the  peripheral  nerves.  The  medullary  matter  appeared  granular 
in  certain  points,  and  in  others  it  had  entirely  disappeared,  while  the  axis- 
cylinder  was  not  notably  altered. 

Such  observations,  to  which  others  might  be  added,  have  fully  estab- 
lished the  fact  of  peripheral  nerve  lesions,  such  as  would  be  likely  to  result 
from  a  neuritis,  in  the  paralysis  of  diphtheria;  but  it  must  be  borne  in 
mind  that  the  various  observers,  while  they  report  degenerative  changes  in 
certain  of  the  nerve  fibres  or  tubes  in  the  peripneral  nerves  of  the  paralyzed 
part,  also  state  that  others  in  the  same  nerves  were  to  appearance  normal 
and  capable  of  performing  their  function.  Such  are  the  facts  upon  which 
the  theory  that  diphtheritic  paralysis  is  caused  by  peripheral  nerve  lesions, 
a  peripheral  neuritis,  is  based. 

In  the  endeavor  to  elucidate  the  cause  of  diphtheritic  paralysis,  attention 
has  also,  as  might  be  expected,  been  directed  to  the  state  of  the  brain  and 
spinal  cord,  and  anatomical  changes  have  been  discovered  in  them  quite  as 
marked  as  in  the  peripheral  nerves.  Buhl,  Roger  and  Damaschino,  Pierret, 
Vulpiau,  Dejerine,  and  Oertel  discovered  in  different  cases,  in  the  brain 
and  spinal  cord,  in  those  who  died  of  paralysis,  various  anatomical  changes, 
among  which  we  may  mention  small  extravasations  of  blood  and  slight 
softening  in  the  cerebral  substance,  extravasations  of  blood  and  thickening 
of  the  neurilemma  in  the  roots  of  paralyzed  nerves  (Buhl),  eudo-  and  peri- 
neuritis at  the  point  of  origin  of  the  affected  nerves,  thickening  of  the  walls 
of  the  vessels  and  accumulation  in  them  of  white  corpuscles  (Pierret), 
rarefaction  of  the  connective  tissue  and  degenerative  change  in  the  nerve- 
cells  in  the  anterior  cornua  of  the  cervical  and  upper  dorsal  region  of  the 
spinal  cord  (Vulpian),  atrophy  and  granular  degeneration  and  fragmenta- 
tion of  the  myeline  in  the  nerve-tubes  in  the  anterior  roots  of  the  spinal 
nerves,  increase  of  nuclei  in  the  white  substance  of  Schwann,  disappearance 
of  the  axis-cylinder  and  slight  fatty  degeneration  of  the  walls  of  the  capil- 
laries (Dejerine.) 

Dejerine  in  the  microscopic  examinations  of  five  cases  of  paralysis 
discovered  anatomical  alterations  in  the  gray  substance  of  the  spinal  cord, 
the  white  substance  being  intact.  He  observed  in  the  gray  substance  cells 
atrophied  or  in  process  of  atrophy,  with  the  disappearance  of  their  prolonga- 
tions, so  that  healthy  cells  were  comparatively  infrequent.  The  cells  seemed 
to  have  undergone  tlie  change  which  occurs  in  acute  or  subacute  myelitis. 
The  vessels  in  the  gray  substance  were  dilated  and  flexuose.     They  were  in 


646  DIPHTHERIA. 

a  state  of  hypersemia  or  congestion,  and  at  points  small  intestinal  liemor- 
rhasres  had  occurred.  Around  the  central  canal  and  in  the  commissures  the 
nuclei  were  increased.  The  white  substance  of  the  spinal  cord  presented 
the  normal  appearance.  These  anatomical  changes  in  the  cord  apparently 
resulted  from  a  myelitis.  The  spinal  nerves  whose  roots  originated  in  the 
diseased  gray  matter  of  the  cord  were  found  to  have  undergone  a  similar 
change  in  their  peripheral  distribution.  Therefore  in  the  five  cases  in  which 
such  minute  examinations  of  the  nervous  system  were  made,  the  lesions  in 
the  cord  and  the  nerves  were  similar. 

In  1883,  Dr.  E.  Hyla  Greves,  of  Liverpool,  Pathologist  to  the  Royal 
Infirmary,  obtained  j)ermission  to  examine  the  spinal  cord  in  a  child  of 
three  years  who  had  died  of  sudden  heart-failure  after  having  suffered  from 
an  aggravated  form  of  multiple  diphtheritic  paralysis.  She  had  had  anaes- 
thesia of  the  fauces  and  all  her  extremities,  liquid  food  regurgitated  through 
her  nostrils  and  entered  her  larynx,  she  passed  urine  and  fgeces  in  bed,  she 
could  not  stand  or  sit  without  support,  her  head  dropped  helpless,  her  speech 
was  indistinct,  her  tongue  could  not  be  protruded,  her  respiration  was  slow 
and  shallow,  her  pulse  50  per  minute  and  feeble,  and  she  was  nourished 
bv  enemata  of  pancreatized  milk.  The  paralysis  increased  so  that  the  dia- 
phragm alone  acted  in  respiration,  the  pulse  became  slower,  irregular,  and 
more  feeble,  and  death  occurred  suddenly.  At  the  autopsy,  which  was 
limited  to  the  spinal  cord,  the  veins  of  the  lower  part  of  the  cord  were 
much  congested  ;  the  white  substance  of  the  cord  presented  the  normal 
appearance  to  the  naked  eye,  but  the  gray  matter  of  the  lumbar  and  lower 
dorsal  regions  was  extensively  softened,  and  in  the  left  half  of  the  cord  dif- 
fluent, so  as  to  flow  from  the  section,  leaving  a  cavity.  Higher  up  in  the 
cord  the  gray  substance  was  hypersemic,  but  not  diffluent.  The  diffluent 
gray  matter  was  unsuitable  for  microscopic  examination,  but  other  portions 
of  the  cord  were  examined,  with  the  following  result :  many  ganglion-cells 
of  the  anterior  cornua  were  destroyed  or  in  the  state  of  "  cloudy  swelling ;" 
others  had  lost  their  processes  and  were  reduced  in  size  ;  increase  in  the 
number  of  nuclei  in  the  neuroglia  throughout  the  cord ;  gray  substance  in 
the  ria:ht  half  of  the  cord  in  an  earlv  stag^e  of  softenins; ;  in  the  dorsal  and 
cervical  regions  everywhere  the  ganglion-cells  were  in  a  state  of  "  cloudy 
swelling."  No  appreciable  change  in  the  white  matter  of  the  cord.  It  is 
evident  that  this  was  an  extreme  and  rare  case  of  degenerative  change  in  the 
cord,  and  one  in  which  the  paraplegia,  had  the  patient  lived,  would  have 
been  permanent,  for  the  diffluent  gray  matter  in  the  cord  could  not  have 
been  restored  to  its  normal  integrity.  It  was  not,  therefore,  an  ordinary 
case,  inasmuch  as  the  paralyzed  muscles,  as  a  rule,  recover  their  function  in 
those  who  survive. 

Such  is  a  summary  of  the  lesions,  peripheral  and  central,  in  the  nervous 
system,  which  have  been  discovered  in  fatal  cases  of  diplitheritic  paralysis. 
AVe  have  presented  the  facts  upon  which  the  theory  of  tlie  cause  and  nature 
of  tliis  disease  must  be  based.     Are  we  able  to  present  a  theory  which  will 


DIPHTHERIA.  647 

hold  good  in  regard  to  cardiac  paralysis  characterized  by  sudden  heart- 
failure,  to  pulmonary  paralysis  characterized  by  superficial  or  embarrassed 
respiration,  to  palatal  and  multiple  paralyses,  with  their  many  inconveni- 
ences, and  to  the  loss  of  the  tendon  reflexes  ? 

ISIust  we,  with  Trousseau,  rest  satisfied  with  the  belief  that  the  manner 
in  which  diphtheria  produces  paralysis  is  beyond  our  comprehension  and 
will  probably  never  be  known  ?  Dr,  Abram  Jacobi,  seeing  the  inadequacy 
of  the  various  theories  to  explain  all  cases  or  forms  of  diphtheritic  paralysis, 
wrote  in  1880  as  follows,  in  his  classical  treatise  on  diphtheria:  "It  may 
be  positively  asserted  that  diphtheritic  paralysis  does  not  in  every  case 
depend  on  one  and  the  same  cause." 

The  theory  which  is  most  strongly  advocated  at  the  present  time,  and 
which  appears  to  be  accepted  by  a  large  proportion  of  the  specialists  in 
nervous  diseases  under  the  lead  of  Charcot,  is,  as  we  have  stated  above,  that 
diphtheritic  paralysis  results  from  a  peripheral  neuritis.  Others,  observing 
central  lesions  in  the  nervous  system,  have  naturally  inferred  that  they  have 
an  important  share  in  the  production  of  the  paralysis.  It  is  very  important 
that  the  practitioner  when  confronted  by  this  grave  malady  should  have  a 
clear  concej)tion  of  its  cause  and  nature,  that  he  may  be  better  able  to  apply 
the  appropriate  remedies.  We  will,  therefore,  examine  with  the  light  ob- 
tained from  clinical  experience  the  prevailing  theory  that  diphtheritic  paral- 
ysis results  from  anatomical  changes,  peripheral  or  central,  or  l^oth,  in  the 
nervous  system.  Is  this  theory  adequate  to  explain  the  paralysis  as  it  com- 
monly occurs?  We  will  give  a  brief  summary  of  the  objections  to  it,  at 
the  risk  of  repeating  what  we  have  already  stated. 

1.  Cases  occur  in  which  carefully-conducted  microscopic  examinations 
reveal  an  apparently  normal  state  of  the  nerve  supplying  the  jjaralyzed  part, 
and  also  of  the  nervous  centre  from  which  this  nerve  originates. 

Thus,  in  the  three  cases  of  typical  cardiac  paralysis  described  above 
occurring  in  the  practice  of  Cadet  de  Gassicourt,  the  pneumogastric  and  its 
l^ranches  examined  in  one  case  appeared  normal,  and  no  lesion  sufficient  to 
cause  paralysis  was  found  in  a  careful  examination  of  the  medidla  oblongata, 
the  central  organ  of  innervation  of  the  heart. 

2.  Palatal  paralysis  sometimes  occurs  as  early  as  the  second  or  third  day 
of  di[)htheria,  and  loss  of  the  tendon  reflexes  as  early  as  the  first  day.  Can 
we  lielieve  that  a  peripheral  neuritis  or  anatomical  changes  in  the  cerebro- 
spinal axis  have  occurred  at  so  early  a  date,  so  as  to  cause  the  paralysis  ? 

3.  In  its  commencement  diphtheritic  paralysis  often  exhibits  what  Trous- 
seau designates  mutability.  It  suddenly  shifts  from  one  group  of  muscles 
to  another.  Muscles  ])aralyzod  on  one  day  have  their  normal  action  on  the 
following  day,  while  other  muscles  are  attacked,  and  on  tlie  third  day  the 
group  of  muscles  first  attacked  are  perhaps  again  paralyzed.  This  muta- 
l)ility  of  the  paralysis,  this  sudden  shifting  from  one  group  of  muscles  to 
another,  militates  strongly  against  the  theory  that  the  cause  of  the  paralysis 
is  a  structural  change  in  the  nervous  system,  whether  cerebral  or  peripheral. 


648  DIPHTHERIA. 

It  would  seem  impossible  that  there  should  be  a  suddeu  recovery  from  the 
paralysis  and  then  on  the  following  day  a  recurrence  of  it,  if  it  resulted 
from  degenerative  changes,  either  central  or  peripheral,  occurring  in  the 
nervous  system.  These  lesions  do  not  undergo  such  sudden  fluctuations, 
such  mutability,  as  we  observe  in  the  paralysis.  A  persistent  cause  should 
produce  a  persistent  and  continuous  effect. 

4.  Several,  jf  not  all,  of  the  microscopists  who  discover  degenerative 
changes  in  the  peripheral  nerves  Avhich  supply  paralyzed  muscles,  state 
that  some  nerve-fibres  have  undergone  complete  or  nearly  complete  degen- 
eration, others  partial  degeneration,  and  others  still  seem  to  be  intact. 
Would  complete  paralysis  result  from  such  a  state  of  the  peripheral 
nerves?  Would,  for  instance,  the  velum  palati,  as  we  observe  it,  be 
motionless  like  a  curtain,  not  exhibiting  the  least  sensitiveness  when  pricked 
by  the  point  of  a  pin  or  other  instrument,  if  the  sole  cause  of  the  paralysis 
were  degenerative  changes  in  the  nerves?  Would  not  the  nerve-fibres  which 
are  still  intact  be  sufficient  to  produce  some  motion?  May  we  not  in  at 
least  some  instances  regard  the  paralysis  as  the  cause  of  the  degeneration 
in  the  nerves  ? — for  it  is  a  well-known  pathological  fact  that  if  a  muscle  be 
paralyzed,  as,  for  instance,  from  a  central  cause,  the  nerves  supplying  it 
usually  undergo  more  or  less  degenerative  change. 

5.  A  clinical  fact  antagonistic  to  the  theory  that  lesions  in  the  cerebro- 
spinal axis  cause  the  paralysis  has  been  alluded  to  both  by  Dr.  A.  Suss  and 
Dr.  W.  H.  Thomson  in  their  interesting  and  instructive  papers.  It  is 
that  diphtheritic  paralysis,  motor  and  sensory,  is  sometimes  limited  to  the 
muscles  supplied  by  a  single  branch  of  a  nerve,  while  the  other  branches 
have  their  normal  function.  This  fact  is,  of  course,  not  antagonistic  to  the 
theory  that  peripheral  nerve  lesions  cause  the  paralysis,  but  it  affords  a 
strong,  if  not  conclusive,  argument  against  the  theory  that  central  lesions 
are  the  cause. 

Such  are  the  clinical  facts  which  militate  against  the  theory  that  inflam- 
matory or  degenerative  changes  in  the  nervous  system  are  the  primary 
and  sole  cause  of  diphtheritic  paralysis.  We  have  stated  above  that  the 
theory  relating  to  the  causation  of  diphtheria,  which  is  now  gaining  accept- 
ance in  both  continents  with  pathologists  and  specialists  in  diseases  of  chil- 
dren, is  that  the  specific  microbe  of  diphtheria  acts  locally  upon  the  surface, 
and  systemic  infection  occurs  from  ptomaines  produced  by  microbic  action, 
which,  entering  the  lymphatics  and  blood-vessels,  are  carried  to  the  interior 
of  the  body  and  exert  their  action  upon  the  blood  and  the  tissues.  If  this 
theory  be  true,  the  symptoms  which  indicate  systemic  infection  are  referable 
to  the  ptomaines.  Dr.  Thomson  in  his  paper  already  alluded  to  writes  as 
follows :  "  It  is  quite  conceivable  that  a  ptomaine  may  follow  upon  the 
changes  which  the  diphtheritic  process  sets  up  in  the  organism,  and  thus 
produce  all  its  characteristic  symptoms.  The  special  tendency  of  diphthe- 
ritic inflammation  to  cause  necrotic  and  gangrenous  lesions  lends  further 
support  to  this  surmise." 


DIPHTHERIA.  649 

The  ptomaines  spring  into  existence  suddenly  and  unexpectedly  under 
favoring  conditions,  as  we  see  in  the  case  of  the  cheese  or  the  milk  ptomaine, 
the  tyrotoxicon ;  and  it  is  not  improbable  that  chemistry  brought  to  the  aid 
of  microscopy  will  yet  reveal  the  fact  that  the  common  cause  of  diphtheritic 
paralysis  is  a  ptomaine  or  chemical  agent  produced  by  microbic  action.  If 
the  cause  be  a  ptomaine,  it  probably  acts  in  a  measure  like  the  poison  of  the 
eel  in  the  cases  alluded  to  by  Trousseau,  or  like  curare.  Clinical  facts  appear 
to  harmonize  best  with  the  theory  that  this  is  the  common  cause  of  the 
paralysis,  especially  in  those  cases  in  which  it  occurs  early  and  the  use  of 
the  paralyzed  muscles  is  soon  regained.  But  it  would  be  idle  to  argue  that 
the  marked  degenerative  central  and  peripheral  lesions  which  are  frequently 
present  in  the  nervous  system,  in  those  who  have  died  of  diphtheritic  paral- 
ysis, do  not  prolong  and  intensify  the  paralysis,  and  perhaps  are  sometimes 
the  primary  cause  of  it. 

Prognosis. — The  prognosis  of  diphtheria,  like  that  of  scarlet  fever, 
varies  greatly  in  different  cases  according  to  its  type.  In  some  epidemics 
a  large  proportion  of  the  cases  are  mild  and  recovery  occurs  with  simple 
treatment.  Between  the  mild  and  the  most  severe  cases,  attended  by  pro- 
found blood-poisoning,  there  is  every  grade  of  severity.  Cases  that  are 
apparently  mild  in  the  beginning,  and  seem  likely  to  recover  with  simple 
measures,  sometimes  become  severe,  dangerous,  and  even  fatal.  On  the 
other  hand,  cases  that  set  in  with  severity  may  become  modified  and  end 
favorably  with  simple  treatment.  So  variable  is  the  type  of  diphtheria  that 
in  certain  epidemics  or  localities  a  large  projDortion  recover,  as  many  even 
as  ninety  or  ninety-five  per  cent.,  while  in  other  epidemics  or  localities  the 
proportion  that  perish  is  much  larger. 

The  prognosis  is  usually  favorable  when  the  inflamed  surface  and 
pseudo-membrane  are  of  little  extent,  the  fever  and  swelling  moderate, 
and  the  neighboring  lymphatic  glands  and  underlying  connective  tissue  but 
little  involved.  In  many  such  cases,  as  we  have  seen  from  the  description 
given  above,  the  patient  remains  in  good  general  health,  or  feels  but  slightly 
indisposed.  On  the  other  hand,  if  the  inflamed  surface  be  extensive,  the 
pseudo-membrane  deep-seated  and  exhaling  an  offensive  odor,  while  the 
adjacent  lymphatic  glands  are  markedly  swollen,  the  patient  will  probably 
perish.  Nasal  diphtheria,  which  is  commonly  present  in  severe  cases,  and 
which  produces  an  offensive,  irritating,  and  highly  infectious  discharge, 
always  involves  great  danger.  It  is  likely  to  give  rise  to  systemic  infection, 
since  the  submucous  connective  tissue  of  the  nostrils  contains  numerous 
lymphatics,  which  take  up  the  poisonous  products  and  convey  them  to  every 
part  of  the  system.  If  while  the  local  disease  is  severe  and  extensive,  the 
breath  and  exhalations  become  offensive,  and  the  countenance  aud  surface 
generally  begin  to  have  a  dusky,  palljd  hue,  profound  blood-poisoning  has 
occurred,  and  the  patient  will  probably  die. 

Physicians  of  experience  are  guarded  in  the  expression  of  a  favorable 
prognosis  in  diphtheria,  since  there  is  no  other  disease  in  which  the  prog- 


650  DIPHTHERIA. 

nostic  signs  on  which  a  favorable  prediction  is  based  are  so  likely  to  be 
fallacious.  We  hear  much  iu  medical  circles  of  the  deceptive  character  of 
diphtheria.  Error  in  expressing  a  favorable  prognosis,  of  which  even  phy- 
sicians of  ample  experience  complain,  is  largely  due  to  the  fact  that  diph- 
theria terminates  fatally  in  several  different  ways.    Death  may  occur  from — 

1.  Diphtheritic  blood-poisoning, — systemic  infection  by  the  specific  prin- 
ciple, whether  acting  directly  or  through  the  agency  of  ptomaines  which  it 
produces. 

2.  Septic  blood-poisoning,  produced  by  absorption  from  the  under  sur- 
face of  the  decomposing  pseudo-membrane,  or  from  gangrenous  tissues. 
But  our  knowledge  is  not  sufficiently  advanced  to  enable  us  to  discriminate 
between  the  constitutional  effects  of  ordinary  sepsis  and  those  produced  by 
the  agency  of  the  diphtheritic  poison.  Septic  infection  is  obviously  most 
likely  to  occur  in  those  cases  in  which  the  pseudo-membrane  is  extensive, 
deeply  embedded,  and  its  decomposition  attended  by  an  offensive  effluvium. 
Cervical  cellulitis  and  adenitis,  which  cause  considerable  swelling  of  the  neck, 
often  occur  from  septic  absorption  from  the  faucial  surface,  the  septic  matter 
being  conveyed  by  the  lymphatic  vessels  to  the  adjacent  glands  and  causing 
inflammation  of  the  glands  and  surrounding  connective  tissue.  Consider- 
able tumefaction  of  the  neck,  therefore,  seldom  occurs  in  diphtheria  without 
manifest  symptoms  of  toxsemia,  and  it  is  to  be  regarded  as  a  sign  of  its 
presence. 

3.  Diphtheritic  croup,  or  pseudo-membranous  laryngo-tracheitis,  a  most 
important  disease,  and  fully  treated  of  in  the  proper  place. 

4.  Uraemia,  or  diphtheritic  nephritis,  also  one  of  the  most  important  of 
the  local  maladies  pertaining  to  diphtheria,  and  produced  by  the  action  of 
the  diphtheritic  poison. 

5.  Sudden  heart-failure.  The  action  of  the  heart  may  be  feeble  from 
granulo-fatty  degeneration  of  its  muscular  fibres,  or  from  anaemia  or  general 
weakness  ;  but  sudden  and  unexpected  death  from  heart-failure  is  commonly, 
as  we  have  seen,  due  to  paralysis  of  this  organ. 

6.  Suddenly-developed  passive  congestion  and  oedema  of  the  lungs, 
probably  due  to  feebleness  of  the  heart's  action,  or  to  paralysis  of  the 
respiratory  muscles.  Death  sometimes  occurs  apparently  from  this  cause 
during  the  period  of  supposed  convalescence,  and  when  the  visits  of  the 
physician  have  been  discontinued.  Thus,  in  a  case  iu  my  practice,  symp- 
toms of  oedema  pulmonum  (abundant  moist  rales  in  both  sides  of  the  chest, 
and  embarrassed  respiration)  suddenly  occurred  nearly  one  month  after  the 
disappearance  of  the  faucial  pseudo-membrane  and  inflammation.  The 
urine,  which  had  contained  considerable  albumen  during  the  active  period 
of  the  malady,  had  for  some  time  shown  no  trace,  or  but  slight  trace,  of 
this  principle,  by  the  proper  tests.  jBy  active  stimulation  these  symptoms 
entirely  disappeared  in  a  few  hours,  and  the  heart's  action  seemed  normal, 
except  that  it  was  a  little  weakened.  On  the  following  day  the  symptoms 
reappeared,  and  death  occurred  before  I  was  able  to  reach  the  house. 


DIPHTHEEIA. 


651 


That  physician  is  obviously  least  likely  to  err  in  prognosis  who  recog- 
nizes the  fact  that  patients  are  liable  to  perish  in  any  of  these  different 
ways,  and  carefully  examines  in  reference  to  all  the  conditions  which  involve 
danger.  Many  physicians,  as  I  have  had  the  opportunity  to  observe,  are 
remiss  in  not  examining  more  frequently  the  urine  of  diphtheritic  patients ; 
for  there  is  often  a  large  amount  of  albumen  with  granular  casts  in  the 
urine  in  diphtheria,  indicating  a  poisonous  quantity  of  urea  in  the  blood, 
and  yet  the  appearance  of  the  urine  to  the  naked  eye  is  probably  normal. 

Among  the  symptoms  which  render  the  prognosis  unfavorable  are  re- 
pugnance to  food,  vomiting,  pallor  of  countenance,  and  general  ausemia, 
with  progressive  weakness  and  emaciation,  indicating  blood-poisoning ;  a 
large  amount  of  albumen,  with  casts,  in  the  urine,  showing  uraemia,  to  which 
the  irritability  of  the  stomach  is  often  due ;  an  abundant  irritating  discharge 
of  muco-pus  from  the  nostrils,  or  occlusion  of  them  by  membranous  exuda- 
tion or  inflammatory  thickening,  showing  that  the  Schneiderian  membrane 
is  seriously  involved  ;  hemorrhage  from  the  nostrils,  buccal  cavity,  or  fauces, 
showing  an  altered  state  of  the  blood,  or  of  the  walls  of  the  capillaries,  or 
plugging  of  the  capillaries  by  masses  of  microbes  or  leucocytes.  Diphthe- 
ritic laryngo-tracheitis,  or  pseudo-membranous  croup,  largely  increases  the 
aggregate  of  deaths  from  diphtheria,  whether  it  ba  treated  by  improved 
inhalations,  intubation,  or  tracheotomy.  Some  of  the  above  symptoms 
have  been  present  in  most  of  the  fatal  cases  which  I  have  observed.  On 
the  other  hand,  the  prospect  of  recovery  improves  in  proportion  to  their 
absence. 

Preventive  Treatment. — Diphtheria  is  so  highly  contagious,  and  when 
epidemic  it  is  so  likely  to  spread  from  one  household  to  another,  and  its 
severe  forms  are  fatal  in  so  large  a  proportion  of  cases,  that  preventive 
measures  are  of  the  greatest  importance.  The  area  of  contagiousness  of 
diphtheria  is  small.  Dr.  Lancry  cites  cases  to  show  that  it  is  limited  to  a 
few  feet.  Dumez  also  relates  an  instance  showing  that  the  contagious  area 
is  of  small  extent.  In  a  school  the  boys  and  girls  in  the  same  hall  were 
separated  by  an  open  space  a  few  yards  wide.  Diphtheria  prevailed  among 
tlie  girls,  but  did  not  affect  the  boys.  In  this  respect,  as  in  so  many  others, 
diphtheria  resembles  scarlet  fever,  and  is  unlike  pertussis  and  measles. 

The  most  efficient  method  of  preventing  diphtheria  is  the  isolation  and 
disinfection  of  patients,  the  prompt  and  thorough  disinfection  of  the  apart- 
ments in  which  patients  have  been  treated,  and  of  the  bedding  and  furniture 
in  these  apartments,  and  the  exclusion  or  prevention  of  all  noxious  gases, 
especially  those  ascending  from  the  sewers  and  from  filthy  accumulations  of 
all  kinds. 

Dr.  H.  B.  Baker,  of  Lansing,  has  published  statistics  showing  that  in 
102  outbreaks  of  diphtheria  the  average  number  of  cases  where  disinfection 
and  isolation,  one  or  both,  were  neglected  was  16,  and  the  average  deaths 
3.26,  Avhile  in  116  outbreaks  in  which  isolation  and  disinfection  were 
enforced,  the  average  number  of  cases  per  outbreak  was  2.86,  and  the 


652  DIPHTHERIA. 

average  deaths  .Q6.  Therefore  these  precautionary  measures  prevented  13 
cases  and  2.57  deaths  for  each  outbreak;  in  the  total,  1545  cases  and  298 
deaths.     These  statistics  related  to  only  one  year.^ 

It  is  obvious  that,  in  order  to  prevent  the  spread  of  diphtheria,  wherever 
a  case  has  occurred  prompt  and  efficient  personal  and  domiciliary  disinfection 
should  be  practised  so  far  as  the  condition  of  the  patient  will  allow.  But 
there  is  reason  to  think  that  disinfection  as  commonly  practised  is  inade- 
quate. In  the  winter  of  1887-88  and  the  following  spring,  an  epidemic  of 
diphtheria  occurred  in  the  New  York  Infant  Asylum,  and  it  extended  to 
the  maternity  ward.  In  this  ward  five  of  the  new-born  infants  contracted 
diphtheria,  and  two  of  these  five  had  at  the  same  time  umbilical  phlegmons 
in  addition  to  the  usual  diphtheritic  exudate  upon  the  fauces.  It  was 
evident  from  the  occurrence  of  these  cases  that  the  maternity  ward  was 
infected  to  such  a  degree  that  subsequent  patients  could  not  be  safely  ad- 
mitted without  its  thorough  disinfection.  The  ward  was  therefore  vacated, 
the  windows,  doors,  and  crevices  closed,  and  forty  pounds  of  sulphur,  or 
two  pounds  to  the  hundred  cubic  feet  of  air,  were  burnt  until  it  was  con- 
sumed. After  some  hours  the  windows  and  doors  were  opened,  and  Drs. 
Prudden  and  Cheeseman  immediately  raised  a  dust  from  the  floor  and  bed- 
ding and  allowed  it  ..to  settle  in  culture-media.  All  other  sources  of  in- 
fection were  excluded  from  the  media.  The  cultures  produced  so  large  a 
number  of  microbes  that  they  overlay  each  .other ;  but  the  observers  were  able 
to  distinguish  the  streptococcus  pyogenes  in  the  media,  identical  in  form  and 
appearance  with  the  streptococcus  which  they  had  previously  discovered  in 
the  umbilical  phlegmon.  Although  more  sulphur  Avas  employed  than  is 
recommended  by  the  New  York  Health  Board,  and  employed  in  the  manner 
recommended  by  this  Board,  it  was  inadequate  to  destroy  the  microbes.  It 
was  evident  that  some  more  efficient  mode  of  domiciliary  disinfection  was 
required. 

Since  the  ordinary  mode  of  disinfection  was  apparently  futile  in  the 
maternity  ward,  it  seemed  to  me  advisable  to  obtain  the  views  of  so 
eminent  an  authority  as  Dr.  E.  R.  Squibb,  of  Brooklyn ;  and  he  has  kindly 
favored  me  with  the  following  note : 

"  Within  the  past  ten  years  the  efficacy  of  sulphur-fumigation  against 
infectious  material  has  been  repeatedly  denied  and  reaffirmed  upon  very 
good  authority,  and  observations,  apparently  made  with  accuracy  and  care, 
have  been  reported  from  time  to  time  to  prove  both  sides  of  the  question : 
so  that  all  that  can  now  be  said  is  that  burning  sulphur  is  of  doubtful 
efficacy,  with  the  weight  of  the  higliest  authorities  in  bacteriology  against 
it.  But  to  this  it  must  be  added  that  it  is  still  largely  used  by  very  intelli- 
gent bodies  in  large  institutions,  boards  of  health,  etc.,  where  it  would  not 
be  likely  long  to  maintain  an  unearned  confidence, 

"  How  often  the  fumes  are  applied  dry,  and  how  often  moist,  no  one 


1  American  Lancet.     (See  Ann.  Univ.  Med.  Sci.,  1888.) 


DIPHTHERIA.  653 

can  tell  from  the  current  record ;  and  how  many  of  the  failures  of  the  dry- 
gas  would  be  successes  in  the  presence  of  moisture,  there  is  no  means  of 
knowing. 

"  Formerly,  when  sulphur  was  burned  in  closed  chambers  as  a  disin- 
fectant, the  surfaces  were  all  wetted,  and  the  pot  of  burning  sulphur  was  set 
in  water  or  wet  sand,  that  the  heat  might  evaporate  off  a  constant  supply  of 
watery  vapor. 

"  These  conditions  are  now  frequently,  if  not  generally,  neglected ;  and 
where  this  is  the  case,  failure,  on  principle,  should  be  the  rule. 

"  Nearly  all,  if  not  all,  chemical  disinfectants  are  in  a  state  of  tension, 
ready  to  change  on  coming  in  contact  with  the  matter  to  which  they  are 
applicable ;  and  these  changes  are  either  by  oxidation  or  deoxiclatiou,  and 
the  moment  of  greatest  power  or  activity  is  the  moment  of  change,  when 
they  by  reacting  on  infectious  matter  pass  from  a  state  of  tension  to  a  state 
of  rest  under  new  relations.  The  agency  through  which  these  changes 
almost  universally  become  operative  is  the  vapor  of  water. 

"  When  sulphur  is  burned  in  a  close  chamber,  the  dioxide  is  formed  by 
condensing  two  molecules  of  oxygen  from  the  air  upon  each  molecule  of  the 
sulphur,  and  a  heavy  gas  is  the  result,  which  tends  to  settle  at  the  bottom 
of  the  chamber  and  to  run  out  through  the  lower  cracks.  Any  moisture 
present  is  at  once  seized  by  this  rather  inactive  anhydride,  first  forming 
sulphurous  acid,  and  then,  by  oxidation  from  the  air,  sulphuric  acid.  The 
dry  gas,  or  anhydride,  not  only  seizes  with  avidity  all  watery  vapor  in  the 
air,  but  also  the  water  held  in  the  surfaces  of  all  bodies  with  which  it  comes 
in  contact,  and  in  the  presence  of  this  moisture  only  is  it  ready  for  further 
oxidation.  Then  it  is  by  this  oxidation  that  it  deoxidizes  the  matters  with 
which  it  is  in  moist  contact,  filling  the  surfaces  of  these  matters  first  with 
sulphurous  acid,  then,  by  the  change,  with  sulphuric  acid ;  and  it  is  during 
these  changes  that  its  power  is  exerted. 

"  If  there  be  no  moisture  supplied  to  the  burning  sulphur,  that  which 
was  present  in  the  air  and  the  surfaces  of  the  chamber  is  soon  used  up,  and 
the  dry  gas  remains  indefinitely  in  a  comparatively  inactive,  ineffective  con- 
dition. The  dry  passive  anhydride  would  necessarily  destroy  all  organisms 
wliich  breathed  in  any  degree,  because  breathing-surfaces  are  moist.  But 
in  embryonic  life  protected  by  shell,  as  in  seed,  if  the  shell  be  dry  the  gas 
would  be  impotent.  Mai^y  bacteriologists  have  admitted  that  burning 
sulpliur  would  kill  bacteria,  but  not  germs." 

It  seems  probable  that  the  apparently  negative  effect  of  burning  sulphur 
for  the  purpose  of  destroying  the  microbes  in  the  maternity  ward,  as  stated 
above,  was  due  to  the  absence  of  moisture,  for  it  was  burnt  dry.  The  above 
note  from  Dr.  Squibb  conveys  very  important  information.  If  the  facts  as 
stated  by  him  were  more  generally  known  and  acted  on  by  Health  Boards 
and  by  physicians  in  family  practice,  the  results  of  domiciliary  disinfection 
Avould  probably  ho  better.  It  is  so  important  that  the  specific  princi])le 
of  diphtheria  should  be  destroyed  wherever  this  disease  appears,  in  order 


654  DIPHTHERIA. 

to  prevent  its  propagation,  that  any  safe  measures  which  will  aid  in  pro- 
ducing this  result  should  be  employed  in  addition  to  suliDhur-fumigation. 
To  accomplish  this  purpose,  Dr.  Llewellyn  Eliot  recommends  during  the 
continuance  of  a  case  the  constant  evaporation  of  turpentine  over  a  water- 
bath,  so  that  the  vapor  fills  the  room.  In  every  instance  in  which  he  has 
employed  this  treatment,  no  second  case  of  the  disease  has  occurred.^  I  have 
employed  the  following  prescription  for  the  purpose  of  disinfection  during 
my  attendance  on  cases,  with  apparently  so  good  a  result  that  I  am  encour- 
aged to  continue  its  use  : 

B  Acidi  carbolici,  ^i ; 
01.  eucalypti,  ^i  ; 
Spts.  terebinth.,  ^viii. 

Misce. 

Add  two  tablespoonfiils  to  one  quart  of  water  in  a  pan  with  broad  sur- 
face, and  maintain  in  a  constant  state  of  ebullition  or  simmering,  in  the 
room  occupied  by  the  patient.  This  disinfecting  vapor  was  employed  in 
the  quarantine  wards  of  the  Infant  Asylum,  in  which  diphtheritic  patients 
were  treated,  and  to  a  certain  extent  in  the  other  wards,  and  no  subsequent 
cases  have  occurred. 

In  Bellevue  Hospital,  where  pyaemia  had  been  prevalent.  Prof.  E. 
Ogden  Doremus  employed  chlorine  gas  mingled  with  steam  to  secure  disin- 
fection, in  the  following  manner.  Strips  of  paper  having  been  pasted  over 
the  crevices  around  the  doors  and  windows,  equal  parts  of  common  salt 
and  black  oxide  of  manganese  (about  two  hundred  pounds)  were  placed  in 
troughs  formed  of  sheet  lead,  the  edges  being  turned  up  to  make  receptacles. 
A  carboy  of  sulphuric  acid  was  emptied  into  small  basins  and  other  vessels 
and  placed  beside  the  troughs.  The  floors  were  moistened  with  water,  and 
abundant  steam  was  allowed  to  escape  from  the  heaters  into  the  ward.  With 
the  aid  of  assistants,  the  sulphuric  acid  was  quickly  poured  upon  the  mix- 
ture in  the  troughs,  and  the  room  hastily  vacated,  the  door  being  nailed  up 
to  prevent  accidental  entrance,  for  the  large  quantities  of  chlorine  evolved 
would  have  been  fatal.  The  following  day  the  windows  were  opened  from 
without,  and,  after  ventilation,  the  contents  of  the  troughs  were  stirred  and 
sulphuric  acid  added  as  before.  In  the  ward  most  infected,  this  process  was 
repeated  once,  fresh  salt  and  manganese  being  used.  No  further  cases  of 
pyaemia  occurred  in  these  wards. 

In  order  to  prevent  as  far  as  possible  the  spread  of  diphtheria,  stringent 
measures  should  be  taken  to  prevent  propagation  of  the  disease  by  walking 
cases,  by  children  mildly  affected  who  are  allowed  to  attend  school  aud  ride 
in  public  conveyances.  I  have  in  a  number  of  instances  seen  children  Avith 
diphtheria  sitting  with  other  children  in  the  clinics  at  Bellevue.  Recently 
I  saw  in  consultation  a  child  with  fatal  diphtheria,  which  apparently  was 
contracted  in  the  street  by  embracing  a  playmate  who  had  been  allowed  to 

1  Medical  Bulletin. 


DIPHTHEKIA.  655 

go  out  for  the  first  time  after  an  attack  of  the  disease.  In  another  instance 
a  child  went  with  its  parent  to  a  Sunday  mission-school  in  one  of  the  tene- 
ment-house sections  of  New  York.  Four  or  five  days  subsequently  it  had 
diphtheria,  which  was  communicated  to  other  children  of  the  family,  and 
one  of  them  died.  The  philanthropic  endeavor  to  benefit  the  poor  children 
of  Xew  York  by  conveying  them  to  rural  localities  in  midsummer  has,  it  is 
said,  resulted  in  the  occurrence  of  diphtheria  in  farming  sections  where  it 
was  previously  unknown.  I  have  now  under  treatment  a  family  with  diph- 
theria, and  the  child  first  attacked  states  that  a  school-mate  sitting  near  her 
in  the  school  complained  of  sore  throat  a  few  days  previously.  Certainly 
the  safety  of  the  public  requires  that  all  children  with  sore  throats  should 
be  excluded  from  the  schools  whenever  diphtheria  is  prevalent,  and  it  should 
be  the  duty  of  teachers,  acting  under  the  direction  of  Health  Boards,  to  see 
that  this  is  done. 

In  a  paper  relating  to  the  therapeutics  of  diphtheria,  read  before  the 
Philadelphia  County  Medical  Society,  May  23,  1888,  and  printed  in  its 
Transactions,  Dr.  A.  Jacobi  remarks  that  the  well  children  in  a  family 
where  diphtheria  is  occurring  should  not  go  to  church  or  school,  and  that 
schools  should  be  closed  during  an  epidemic  of  diphtheria,  or,  if  not  closed, 
that  teachers  should  every  morning  inspect  the  throats  of  the  pupils  and 
send  home  those  with  sore  throats.  He  recommends  also  the  disinfection 
of  coaches  and  railroad-cars  at  regular  intervals  during  an  epidemic.  He 
also  states  that  a  patient  recovering  from  diphtheria  may  contract  it  anew 
from  the  curtains,  carpets,  and  furniture  which  he  has  infected  during  his 
sickness,  so  as  to  have  a  renewal  of  the  disease.  He  has  seen  patients  die 
from  these  renewals,  and  has  seen  other  patients  improve  immediately  when 
removed  to  other  apartments.  He  also  states  that  an  irritated  surface  is 
more  likely  to  contract  diphtheria  than  one  that  is  healthy,  and  therefore 
buccal,  faucial,  and  nasal  catarrhs  should  be  promptly  treated,  the  cure  of 
these  diminishing  the  liability  to  diphtheria.  Chronic  nasal  catarrh,  he  says, 
should  be  treated  with  two  or  three  daily  injections  of  a  solution  of  salt  (1  to 
130),  to  which  a  one-per-cent.  solution  of  alum  may  be  profitably  added, 
and  the  same  may  be  gargled  in  the  treatment  of  faucial  catarrh.  A  nasal 
spray  of  nitrate  of  silver  (1  to  500  or  1  to  1000)  also  hastens  the  cure. 
The  inflamctl  buccal  surface  should  be  treated  by  the  potassium  chlorate  or 
sodium  chlorate.  Enlarged  tonsils,  which  may  harbor  the  diphtheritic  virus, 
should  be  reduced  by  the  galvano-cautery,  and  enlarged  cervical  glands  should 
also  be  treated  as  a  preventiv^e  measure.  Very  similar  views  were  expressed 
in  a  paper  read  before  the  New  York  Academy  of  Medicine  in  January, 
1888,  by  Dr.  A.  Caille,  who  believes  that  he  has  prevented  the  recurrence 
of  diphtheria  in  those  who  have  suffered  repeated  attacks  of  it  by  prolonged 
daily  antiseptic  treatment  of  their  exposed  surfaces,  which  harbored  the 
poison  or  constituted  a  nidus  favorable  for  its  lodgement  and  propagation. 
These  somewhat  novel  views  of  Drs,  Jacobi  and  Caille  certainly  require 
consideration  and  experimental  testing. 


656  DIPHTHERIA. 

Treatment. — Although  diphtheria  has  been  one  of  the  most  common 
of  the  severe  infectious  maladies  in  Europe  and  America  during  the  last 
thirty  years,  physicians  are  far  from  agreeing  in  reference  to  the  proper 
mode  of  treatment.  The  diversity  of  opinions  in  regard  to  the  use  of 
therapeutic  agents  is  due  in  part  to  a  variation  in  the  type  of  the  malady  in 
different  epidemics  and  localities,  in  part  probably  to  the  fact  that  other 
forms  of  inflammation  of  a  severe  type  have  been  mistaken  for  the  diph- 
theritic, but  more  to  the  fact  that  different  theories  have  been  held  respect- 
ing the  cause  and  nature  of  diphtheria.  Hence  one  physician  recommends 
with  confidence  a  medicine  or  mode  of  treatment  as  eminently  successful  in 
his  hands,  of  which  another  speaks  disparagingly. 

The  germ  theory,  as  described  in  the  foregoing  pages,  according  to 
which  diphtheria  is  produced  by  micro-organisms,  has  had  a  marked  influ- 
ence upon  the  mode  of  treatment.  The  question  has  been  much  discussed, 
whether  diphtheria  is  primarily  a  constitutional  or  a  local  malady.  Accept- 
ance of  the  germ  theory  does  not  require  us  to  believe  that  diphtheria  is 
primarily  local,  for  the  specific  microbe  might  enter  and  infect  the  blood 
through  the  lungs  before  any  symptom  occurred,  and,  as  we  have  stated 
elsewhere,  the  long  incubative  period  of  six  or  seven  days  in  certain  cases 
harmonizes  with  the  theory  of  a  primary  blood-disease,  rather  than  with 
the  theory  that  diphtheria  is  in  the  beginning  strictly  local,  its  seat  being 
upon  one  of  the  exposed  surfaces,  where  the  microbe  has  effected  a  lodge- 
ment. But  the  latter  theory  is,  as  we  have  seen,  more  generally  accepted, 
and  certain  facts  lend  strong  support  to  it.  But  if  diphtheria  be  primarily 
local  there  can  be  no  doubt  that,  as  in  the  vaccine  disease,  the  system 
becomes  quickly  infected  in  cases  of  ordinary  severity,  so  that  successful 
treatment  requires  the  use  of  both  constitutional  and  local  remedies. 
Acceptance  of  the  germ  theory  evidently  leads  to  the  employment  of  germi- 
cide remedies,  the  so-called  antiseptics  or  anti-ferments,  externally  and 
internally,  in  order  to  destroy  the  specific  principle  of  the  disease.  Hence, 
in  proportion  as  this  doctrine  was  accepted,  carbolic  acid,  the  chlorine  prepa- 
rations, bromine,  the  sulphites,  salicylic  acid,  and  the  most  prompt  and 
efficient  agent  of  this  class,  corrosive  sublimate,  came  into  use. 

Hygienic  Treatment. — The  patient  should  be  placed  in  an  airy  room, 
and  the  evacuations  should  be  promptly  disinfected  by  chlorine,  carbolic  acid, 
or  other  disinfectant,  and  removed  from  the  room.  Purity  of  the  air  in  the 
apartment  is  required ;  but  in  the  ventilation,  draughts  of  air  through  the 
room  should  be  avoided,  on  account  of  the  liability  to  diphtheritic  croup, 
which  produces  about  one-third  of  the  deaths  from  diphtheria.  M.  Jules 
Simon  recommends  that  the  windows  of  the  apartment  be  constantly  closed, 
and  that  ventilation  be  obtained  through  the  open  window  of  the  adjoining 
apartment.  In  bathing  the  patient,  care  must  be  taken  that  he  be  not 
chilled.  Bathing  should  be  performed  expeditiously  in  a  warm  room,  with 
perliaps  some  increase  of  the  stimulants  administered,  Tlie  patient  should 
be  constantly  in  bed,  and  the  temperature  of  the  apartment  should  be  from 


DIPHTHEEIA.  657 

70°  to  75°  F.     A  imiform  temperature  of  the  apartment  at  about  73°  F.  is 
safest. 

All  physicians  of  experience  recognize  the  importance  of  the  use  of  the 
most  nutritious  and  easily-digested  food,  and  the  preserv^ation  of  the  appe- 
tite, for  dijDhtheria  produces  rapid  destruction  of  the  red  corpuscles  and  loss 
of  flesh  aud  strength,  and  it  may  soon  produce  a  state  of  dangerous  weak- 
ness. Beef  tea  or  the  expressed  juice  of  meat,  milk  with  farinaceous  food, 
etc.,  should  be  administered  every  two  or  three  hours,  or  to  the  full  extent 
without  overtaxing  digestion.  I  have  sometimes  employed  the  pepsin 
preparations  before  each  feeding,  with  apparently  good  results,  as  in  the 
follo\ving  formula : 

R  Pepsini  puri,  in  lamellis,  ^i ; 

Acidi  muriat.  dilut.,  ^ii ; 

Glycerinse,  gi ; 

Aqu£e  purse,  ^iv. 
Misce. 
Dose,  one  teaspoonful  before  each  feeding. 

In  cases  of-  feeble  digestion  the  predigested  foods  are  often  veiy  usefal, 
as  the  beef  peptonoids  of  Reed  aud  Carnrick,  the  sarco-peptones  of  the 
Rudisch  Company,  and  peptonized  milk.  Failure  of  the  appetite,  and 
refusal  to  take  food,  are  justly  regarded  as  very"  unfavorable  signs.  Trous- 
seau says,  "  AUmentation  occupies  the  first  place  in  the  general  treatment ; 
and  I  have  observed  that  the  severer  the  attack  the  more  imperative  is  the 
necessity  to  sustain  the  jDatients  with  nourishing  food.  Loss  of  appetite — 
that  is,  disgust  for  every  kind  of  food — is  one  of  the  most  alarming  prog- 
nostic signs.  We  must  tiy  to  overcome  this  loathing  of  food  by  every 
possible  means ;  and  to  get  nourishment  taken  I  sometimes  do  not  hesitate, 
in  the  case  of  children,  to  threaten  punishment.  When  the  patient  retains 
his  appetite  for  food,  there  is  good  hope  of  recovers'."  ^  Occasionally,  when 
great  dysphagia  is  present,  whether  from  the  severity  of  the  pharyngitis  or 
from  palatal  paralysis,  it  is  necessary  to  resort  to  rectal  alimentation.  The 
rectum  absorbs  but  does  not  digest,  aud  it  is  capable  of  absorbing  peptonized 
food  to  such  an  extent  that  life  may  be  sustained  for  an  indefinite  time  with- 
out stomach-digestion  and  solely  by  rectal  alimentation.  For  the  purpose  of 
rectal  alimentation  I  have  usually  employed  peptonized  milk  containing  in 
sohition  peptonized  beef,  as  tlie  sarco-peptones  of  the  Rudisch  Company. 
If  this  is  administered  through  a  Xo.  12  to  Xo.  14  elastic  catheter  intro- 
duced far  enough  to  reach  the  sigmoid  flexure,  and  retained  for  half  an 
hour  by  a  compress  jiressed  closely  against  the  anus  by  the  fingers,  the 
result  is,  I  think,  better  than  when  we  dei^end,  as  Trousseau  did  entirely, 
on  stomach-digestion.  One  objection  to  the  use  of  the  brush,  instead  of 
spraying  the  fauces  with  tlie  atomizer,  is  that  it  is  more  likely  to  cause 
vomiting,  by  which  nutriment  that  is  so  much  required  is  lost.  In  malig- 
nant cases  of  diphtheria,  as  in  scarlet  fever  of  a  similar  type,  patients  are 

1  American  Lancet. 
Voz.  I.— 42 


658  DIPHTHERIA. 

sometimes  allowed  to  slumber  too  long  without  nutriment.  It  is  the 
slumber  of  toxaemia,  and  should  be  interrupted  at  stated  times  in  order  to 
give  food  and  stimulants. 

Stimidants. — M.  Sanne,  in  his  treatise  on  diphtheria,  says,  "  De  tons  les 
antiseptiques  donnes  a  I'interieur,  Falcool  est  de  beaucoup  le  plus  sur.  Plus 
Finfection  est  prononc^e,  plus  il  faut  insister  sur  les  composes  alcooliques." 
He  states  that  Bricheteau  reports  the  history  of  a  patient  who  took  daily 
during  diphtheria  a  bottle  and  a  half  of  the  wine  of  Bordeaux,  without  the 
least  symptom  of  intoxication  or  headache.  A  similar  case  was  related  to 
me,  in  which  nearly  one  and  a  half  pints  of  brandy  were  given  in  twenty- 
four  hours,  without  any  ill  effect,  and  with  an  apparent  good  result  on  the 
general  course  of  the  disease.  The  same  rule  holds  true  in  diphtheria  as  in 
other  acute  infectious  maladies,  that  while  mild  cases  do  well  without  alco- 
holic stimulants,  they  are  required  in  cases  of  a  severe  type,  and  should  be 
administered  in  large  and  frequent  doses  whenever  pallor  and  loss  of  appe- 
tite or  of  strength  and  flesh  indicate  danger  from  the  diphtheritic  or  septic 
infection.  It  matters  little  how  the  stimulant  is  administered,  whether 
milk  punch  or  wine  whey,  provided  that  the  proper  quantity  is  employed. 
If  given  early  and  frequently  in  grave  cases,  as,  for  example,  one  tea- 
spoonful  every  half-hour  of  brandy  or  Bourbon  whiskey,  it  does  seem  to 
have  a  tendency  to  render  the  disease  more  tractable;  but  to  be  instru- 
mental in  saving  life  in  malignant  cases  it  must  be  given  boldly  from  the 
start.  If  there  be  marked  diphtheritic  toxaemia  when  its  use  is  commenced, 
it  will  not  save  life,  but  it  may  prolong  it.  Although  the  liberal  employ- 
ment of  alcohol  is  apparently  useful,  it  cannot  be  regarded  as  a  specific. 
In  the  quarantine  wards  of  the  I^ew  York  Foundling  Asylum  in  May, 
1878,  were  four  children,  between  the  ages  of  three  and  five  years,  who  had 
been  sick  a  few  days  with  severe  diphtheria,  and  it  was  evident  at  a  glance 
that  they  must  soon  perish  with  the  ordinary  mild  sustaining  remedies. 
Quinine,  iron,  the  most  nutritious  food,  and  a  moderate  amount  of  alcoholic 
stimulants  were  being  given,  and  we  determined  to  increase  the  Bourbon 
whiskey  to  a  teaspoonful  every  twenty  to  thirty  minutes  day  and  night. 
Nevertheless,  whatever  the  result  might  have  been  with  the  earlier  com- 
mencement of  this  treatment,  the  blood-poisoning  was  now  too  profound, 
and  one  after  the  other  died.  That  intoxication  is  almost  never  produced 
in  this  disease  by  large  and  frequent  doses  of  the  alcoholic  stimulants  is 
probably  in  part  due  to  its  quick  elimination  from  the  system,  but  more  to 
the  nature  of  diphtheria. 

In  fulfilling  the  indication  of  sustaining  treatment,  the  vegetable  tonics 
have  been  long  used,  especially  cincliona  and  its  alkaloid  principle  quinine. 
The  compound  tincture  of  cinchona,  and  the  fluid  extract,  have  been  used 
and  recommended  by  physicians  of  experience,  but  of  vegetable  agents 
quinine  has  been  and  is  still  more  frequently  prescribed  than  any  other. 
But  the  doses  employed  vary  greatly  in  size  and  frequency  in  the  practice 
of  difFerent  physicians.     It  is  administered  for  its  antipyretic  effect  in  large 


DIPHTHERIA.  659 

doses,  so  that  twenty  or  thirty  grains  are  given  daily,  and  in  small  doses, 
as  one  or  two  grains  every  fonrtli  hour,  for  its  tonic  effect.  That  there  is 
nothing  antagonistic  in  the  action  of  quinine  to  the  diphtheritic  virus,  and 
that  it  is  beneficial  in  the  same  way  as  in  the  other  acute  infectious  dis- 
eases, and  no  further,  is,  I  think,  generally  admitted  by  physicians.  Large 
and  frequent  doses  do  not,  apparently,  produce  any  controlling  action  on 
the  course  of  the  disease  or  diminish  the  blood-poisoning.  Cases  might  be 
cited  in  illustration.  In  the  case  of  a  child  of  four  years  with  malignant 
diphtheria,  forty-eight  grains  administered  daily  had  no  appreciable  effect  in 
staying  the  fatal  progress  of  the  disease. 

Quinine  in  doses  of  three  to  five  grains  has  been  employed  as  an  anti- 
pyretic in  diphtheria,  as  also  in  the  other  infectious  diseases ;  but  as  an 
antipyretic  it  is  not  very  efficient,  and  the  temperature  after  the  first  two 
or  three  days  in  diphtheria  is  not  often  so  elevated  that  an  antipyretic  is 
required.  As  a  tonic  in  doses  of  one  to  two  grains  it  is  probably  to  a  cer- 
tain extent  beneficial,  and  it  has  been  highly  recommended  by  good  ob- 
servers for  its  local  action  upon  the  fauces  when  used  by  insufflation.  The 
late  Prof  Rochester,  of  Buffalo,  recommended  and  practised  in  the  treat- 
ment of  diphtheria  the  insufflation  of  sulphate  of  quinine,  in  powders  of 
two  grains,  upon  the  faucial  surface,  every  two  hours.^  It  is  not  improb- 
able that  benefit  may  result  from  its  local  action,  for  used  in  this  manner 
it  is  antiseptic.  But  the  employment  of  this  agent  by  insufflation  is  very 
unpleasant  to  the  child,  and  is  likely  to  be  resisted.  Given  in  solution  in 
doses  of  two  grains,  as  in  the  following  formula,  it  produces  some  local 
action  on  the  fauces,  if  drinks  be  withheld  subsequently  for  a  few  minutes, 
and  at  the  same  time  some  tonic  effect  probably  results  from  its  use  in  this 
manner : 

R    Quinias  sulphat.,  gss; 

Syr.  pruni  Virginiani 
seu 

Elix.  tarax.  comp.,  ^ii. 
Misce. 

Give  one  teaspoonful  every  two  to  four  hours  to  a  child  of  five  years. 
I  have  often  prescribed  quinine  in  this  manner,  with  apparent  benefit,  in 
the  treatment  of  diphtheria. 

Tindura  Ferri  Chloridi. — All  physicians  who  are  familiar  with  diph- 
theria have  noticed  the  pallor,  and  loss  of  appetite,  flesh,  and  strength, 
which  commence  before  the  close  of  the  first  week  in  severe  cases,  and 
which  are  always  unfavorable  symptoms,  indicating,  as  they  do,  rapid  and 
progressive  deterioration  of  the  blood.  The  use  of  iron  is  at  once  sug- 
gested as  the  proper  medicinal  agent  to  arrest  this  blood-change,  from  its 
known  effect  in  increasing  the  number  of  red  blood-corpuscles  and  the 
amount  of  coloring  matter  in  these  corpuscles.  By  its  effect  on  the  red  cor- 
puscles, which  are  the  carriers  of  oxygen,  it  increases  the  functional  activity 

^  New  York  Medical  Journal.    • 


660  DIPHTHEEIA. 

of  organs  and  improves  the  general  nutrition.  The  ferruginous  prepara- 
tions, therefore,  hold  an  important  place  in  the  therapeutics  of  diphtheria. 
The  one  which  has  stood  the  test  of  experience  and  is  now  commonly  em- 
ployed is  the  tincture  of  the  chloride  of  iron.  It  should  be  given  in  large 
and  frequent  doses,  as  five  drops  hourly  to  a  child  of  three  years. 

Ferffuson^  reg-ards  the  tincture  of  the  chloride  of  iron  as  the  most 
valuable  of  all  the  remedies  for  diphtheria.  He  examined  the  blood  daily 
or  every  second  day  in  twenty  cases  of  diphtheria,  and  was  astonished  to 
observe  how  rapidly  the  red  blood-corpuscles  were  reduced  in  number, 
those  remaining  presenting  an  unhealthy  appearance.  He  believes  that  the 
iron  partially  arrests  the  blood-change.  He  administers  as  much  as  can  be 
tolerated.  To  a  child  of  ten  years  he  gives  hourly  one  teaspoonful  of  the 
following  mixture  in  water : 

R   Tinct.  ferri  chloridi,  ^i; 

Syr.  simplic,  ^iii. 
Misce. 

If  the  stomach  do  not  tolerate  this  dose,  half  a  teaspoonful  is  adminis- 
tered every  half-hour.  An  infant  of  seven  months,  greatly  prostrated,  took 
every  hour  one  teaspoonful  of  the  following : 

R   Tinct.  ferri  chloridi,  jii; 
Syr.  simplic,  ^iv. 

Misce. 

A  lady  of  twenty-two  years,  greatly  prostrated,  having  an  excessive 
formation  of  pseudo-membrane  and  a  very  fetid  breath,  took  daily  one  and 
a  half  fluidounces  of  the  iron  for  ten  days. 

M.  Jules  Simon  says,^  "  For  internal  treatment,  from  three  to  six  drops 
of  the  tincture  of  the  chloride  of  iron  should  be  given  in  a  little  water  every 
two  or  three  hours ;  but  it  should  not  be  given  with  milk  or  gum-water,  or 
from  a  metallic  spoon,  on  account  of  the  decomposition  which  occurs,  which 
may  produce  digestive  troubles."  Dr.  Whittier  believes  that  this  medicine, 
given  so  as  to  saturate  the  system,  is  the  best  that  can  be  employed.  In 
thirty-six  consecutive  cases  in  which  the  fauces  were  covered  with  the  exu- 
date, all  recovered  under  the  use  of  the  iron  as  the  principal  medicine.^ 
Dr.  S.  Baruch,  of  New  York,  prescribes  hourly  doses  of  this  remedy  in 
quantities  varying  from  eight  to  twenty-five  drops  mixed  with  glycerin 
and  water.  Food  and  stimulants  are  administered  before  the  iron,  but  not 
immediately  afterwards,  so  that  the  iron  may  have  a  local  action  upon  the 
faucial  surface.*     Dr.  Billington  recommends  hourly  teaspoonful  doses  of 

the  following  mixture : 

R   Tinct.  ferri  chloridi,  f^i; 

Glycerint¥, 

Aqune,  aa  51. 
Misce, 

1  Canadian  Practitioner.  ^  Le  Progres  Medical. 

^  Bo.ston  Medical  and  Suro-ical  Journal.  *  New  York  Medical  Eecord. 


DIPHTHERIA.  661 

Prof.  Joseph  E.  Winters  says  that  he  has  given  two  drachms  of  the 
tinctnre  of  the  chloride  of  iron  every  half-hour  for  forty-eight  hours,  with 
manifest  benefit,  to  a  child  of  eight  years.^  But  it  is  only  in  the  most 
severe  or  malignant  form  of  the  disease,  the  form  described  by  Sanne  as 
septic  phlegmonous,  that  such  large  doses  are  proper  or  are  required.  In 
mild  cases  from  three  to  five  drops  given  hourly  or  oftener  suffice.  This 
is  the  dose  recommended  by  Jules  Simon,  of  Paris. 

Several  recent  writers  make  the  plausible  statement  that  the  indication 
of  treatment  by  the  iron  is  to  saturate  the  system  as  soon  as  possible,  em- 
ploying for  this  purpose  as  large  and  frequent  doses  as  can  be  tolerated  by 
the  stomach.  The  tolerance  of  a  drug  depends  largely  on  the  manner  in 
which  it  is  employed.  The  best  vehicle  for  the  tincture  of  the  chloride  of 
iron  is  glycerin  and  water.  It  may  be  conveniently  prescribed  with  two  or 
three  times  its  quantity  of  glycerin,  and  a  certain  number  of  drops  admin- 
istered in  water.  The  advice  of  Simon  should  be  borne  in  mind,  not  to 
give  it  with  gum-water,  nor  with  milk,  nor  from  a  metallic  spoon. 

That  now  after  nearly  half  a  century  of  the  constant  use  of  iron  in 
diphtheria  in  both  hemispheres  there  is  an  almost  unanimous  verdict  in  its 
favor,  renders  it  probable  that  the  few  who-  have  not  observed  its  good 
eifects  have  treated  unusually  bad  cases  or  have  given  the  medicine  in  small 
and  inadequate  doses.  We  shall  see  that  the  opinions  of  physicians  have 
not  remained  equally  favorable  in  regard  to  the  use  of  the  agent  with  wliich 
the  iron  has  been  commonly  combined,  the  potassium  chlorate. 

Potassium  Chlorate. — This  agent  produces  a  curative  effect  on  buccal 
inflammations,  and  its  beneficial  action  when  employed  for  the  various 
forms  of  stomatitis  has  led  to  its  extensive  use  in  pharyngitis.  When 
taken  internally,  it  is  eliminated  in  part  by  the  salivary  glands,  so  that  it 
continues  to  exert  in  part  a  local  action  on  the  surface  of  the  mouth  and 
fauces  until  it  is  entirely  eliminated.  This  medicine,  the  potassium  chlo- 
rate, has  of  late  years  become  also  a  domestic  remedy ;  but  the  laity  should 
be  cautioned  in  reference  to  its  use.  It  is  an  irritant  to  the  kidneys  in 
large  doses,  producing  intense  inflammatory  congestion  of  these  organs  and 
arresting  their  function.  The  melancholy  fate  of  Dr.  Fountaine,  of  Daven- 
port, Iowa,  in  1861,  whose  life  was  sacrificed  by  an  experimental  dose  of 
potassium  chlorate,  is  remembered  by  the  older  physicians.  Fountaine  took 
half  an  ounce  in  a  gobletful  of  warm  water  at  eight  a.m.  Free  diuresis 
occurred,  which  ceased  at  four  p.m.  Though  fatigued  and  pallid,  he  ate 
a  hearty  supper.  During  the  following  night  he  was  in  collapse,  with 
vomiting  and  purging,  and  severe  a])dominal  pain.  Early  in  the  following 
morning  he  voided  two  ounces  of  dark  urine,  after  which  no  urinary  secre- 
tion occurred.  The  choleraic  symptoms  returned,  with  collapse,  but  he 
again  rallied.  He  had  vomiting  and  intense  and  constant  abdominal  pain 
during  the  subsequent  six  days,  when  death  occurred.     The  total  cessation 

1  Diphtheria  and  its  Management,  1885.     (See  Ann.  Univ.  Med.  Sci.,  1888.) 


662  DIPHTHEEIA. 

of  fsecal  and  urinary  evacuations  for  six  days  was  a  notable  fact.  At  the 
autopsy  the  lesions  of  an  intense  and  general  gastro-intestinal  inflanamation 
were  present,  the  mucous  membrane  hanging  in  shreds  and  patches;  the 
bladder  was  emjDty,  and  its  mucous  membrane  presented  a  similar  appear- 
ance to  that  of  the  stomach  and  intestines.  The  condition  of  the  kidneys 
is  not  stated,  except  that  there  was  liquid  resembling  urine  under  the  cap- 
sule of  one  kidney,  and  crystals  of  the  chlorate  were  in  the  pelves  of  the 
kidneys.  A  few  years  since,  in  my  practice,  a  child  of  three  years  with 
active  diphtheritic  pharyngitis  was  allowed  to  quench  its  thirst  by  drinking 
water  from  a  small  pitcher  in  which  three  drachms  of  potassium  chlorate 
had  been  dissolved,  and  which  had,  been  ordered  as  a  gargle.  In  the  morn- 
ing I  was  summoned  in  haste,  and  found  the  surface  of  the  patient  cold  and 
blue,  and  pulse  feeble.  The  urine  was  totally  suppressed,  and  instead  of  it 
a  few  drops  of  blood  passed  from  the  urethra.  Death  occurred  before  night. 
Jules  Simon  ^  says  that  potassium  chlorate,  acting  wonderfully  well  in 
diseases  of  the  mouth,  produces  no  beneficial  effect  in  diseases  of  the  fauces, 
and  it  weakens  the  little  patient  when  given  in  large  doses.  Dr.  J.  P.  Esch 
says  that  he  has  observed  that  the  potassium  chlorate  used  internally  in 
diphtheria  almost  invariably  produces  symptoms  of  nephritis.  Ferguson^ 
totally  condemns  its  use  in  any  dose  or  mode  of  administration  in  diph- 
theria. In  every  case  in  which  he  employed  it,  if  albuminuria  were  present 
it  increased  the  amount  of  albumen.  Von  Focke^  believes  that  any  benefit 
which  may  be  derived  from  the  potassium  chlorate  in  diphtheria  results 
from  the  oxygen  in  it.  To  render  the  oxygen  more  efficient,  he  adds  hydro- 
chloric acid.  He  prepares  a  two-per-cent.  solution  of  the  chlorate,  with  a 
one-and-a-half-per-cent.  solution  of  the  acid,  and  administers  a  half-tea- 
spoonful  to  two  teaspoonfuls,  according  to  the  age,  every  one  to  two  hours. 
All  the  benefit  obtained  from  this  mixture  may  be  derived  from  a  prescrip- 
tion long  used  and  favorably  known  in  New  York,  and  probably  more 
frequently  written  than  any  other  prescription  for  diphtheria.  The  tincture 
of  iron  in  the  mixture  contains  one  minim  of  free  muriatic  acid  in  each 
drachm,  but  a  small  amount  of  this  acid  is  added  to  the  mixture  in  addi- 
tion. The  prescription,  with  some  variations  in  its  proportions  in  the 
practice  of  different  physicians,  is  as  follows  : 

U   Tinct.  ferri  chloridi,  ^ii-iii; 

Potas.  chlorat.  ,31; 

Acidi  muriat.  dilut. ,  gtt.  x  ; 

Syr.  simplic,  ^iv. 
Misce. 
Dose,  one  teaspoonful  hourly  or  each  second  hour. 

After  such  an  extensive  use  of  potassium  chlorate  during  nearly  half  a 
century,  its  therapeutic  uses  should  be  clearly  defined,  and  any  ill  effects 

1  Le  Progres  Medical.  *  Canadian  Practitioner. 

'  Wien.  Med.  Wochenschr. 


DIPHTHEEIA.  663 

which  may  result  fully  determined.  From  what  is  now  known  of  its  action, 
it  would  probably  be  better  to  abandon  its  use  in  diphtheria,  since  it  is  a 
remedy  of  doubtful  efficacy  for  throat-affections.  If  it  be  employed,  it 
should  certaiuly  be  administered  in  small  doses  sufficiently  diluted.  If  it 
be  prescribed,  it  should  not,  I  think,  be  in  larger  quantity  than  half  a 
drachm  in  twenty-four  hours  for  a  child  of  five  years. 

The  remedies  mentioned  above  are  those  which  have  been  most  largely 
employed  for  internal  medication  by  physicians  of  the  present  and  the  pre- 
ceding generation ;  but  the  belief  that  diphtheria  has  a  microbic  origin, 
that  the  action  of  the  microbes  gives  rise  to  poisonous  ptomaines,  and  that 
the  virulence  of  the  disease  is  due  to  these  organisms  and  chemical  products, 
has  during  the  last  few  years  brought  into  prominence  the  germicide  and 
antiseptic  treatment.  The  attempt  is  now  made,  and  apparently  with  con- 
siderable success,  to  cure  the  patient  by  antagonizing  and  destroying  the 
cause  of  diphtheria.  We  look  with  interest  and  for  enlightenment  to  the 
results  of  treatment  by  the  antiseptics,  and  compare  them  with  the  results 
obtained  by  the  use  of  tonics,  stimulants,  and  alimentation,  which  have  been 
heretofore  employed. 

Among  the  most  useful  of  the  statistics  bearing  upon  the  action  of  germi- 
cide and  antiseptic  remedies  in  the  treatment  of  diphtheria  are  the  follow- 
ing, made  by  N.  Lunin  in  the  hospital  of  Oldenburg  in  1882.^  In  this 
hospital  two  hundred  and  ninety-six  children  had  diphtheria,  and  one 
hundred  and  sixty-four,  or  55  per  cent.,  died.  The  treatment  by  corrosive 
sublimate  consisted  in  brushing  the  pharynx  every  two  hours  with  a  solu- 
tion of  1  part  to  1000,  or  in  spraying  by  the  irrigator  of  Rauchfuss  with  a 
solution  of  1  part  to  5000.  The  patients  subjected  to  this  treatment  num- 
bered fifty-seven.  Forty-three  of  them  had  the  fibrinous  form  of  the  dis- 
ease, and  fourteen  the  septic  phlegmonous  form.  Thirteen  of  each  class 
died,  or  45  per  cent,  of  the  whole  number.  The  tincture  of  the  chloride  of 
iron  Lunin  employed  in  small  doses,  only  one  drop  every  quarter-hour,  or 
two  drops  every  half-hour,  in  ninety-four  cases,  forty-three  having  the 
fibrinous  form  and  fifty-one  the  septic  phlegmonous  form.  The  total  mor- 
tality was  56.3  per  cent.  Irrigation  of  the  fauces  was  also  employed  in 
these  cases  with  a  three-per-cent.  solution  of  boric  acid.  Lunin  made  use 
of  chinoline  in  twenty-eight  cases, — nineteen  of  the  fibrinous  form  and  nine 
of  the  septic  phlegmonous  form.  Fifteen  died,  or  53  per  cent.  This  agent 
was  prescribed  in  a  five-per-cent.  solution,  the  medium  being  half  water  and 
half  alcohol.  Twenty-nine  children  were  treated  by  resorcin,  a  solution  of 
ten  per  cent,  being  applied  by  the  brush  twice  hourly,  and  irrigation  with  a 
one-per-cent.  solution  once  hourly.  Sixty-five  per  cent.  died.  A  solution 
of  bromine  and  bromide  of  potassium  was  applied  from  one  to  three  times 
hourly  to  the  fauces  in  thirty-three  patients,  but  69.7  per  cent.  died. 

Finally,  twenty-three  infants  were  treated  by  turpentine,  a  tablespoonful 

1  Archiv  fiir  Kinderheilk.,  1886. 


664 


DIPHTHERIA. 


twice  daily,  and  in  some  of  tlie  cases  au  additional  hourly  dose  during  two 
or  three  days.  The  mortality  was  43.4  per  cent.  In  the  fibrinous  form  the 
percentage  of  deaths  from  the  diiferent  modes  of  treatment  was  as  follows : 


Percentage.  Percentage. 


By  turpentine 8.30 

"  resorcin '  .    .    .    20.00 

"  corrosive  sublimate 30.20 


By  chinoline 31.60 

"  tinct.  ferri  chloridi 82.60 

"  bromine '  .    .    46.70 


In  the  septic  form  the  deaths  were  as  follows 


Percentage. 

By  tinct.  ferri  cbloridi 76.5 

"   turpentine 81.0 

"  bromine 88.9 


Percentage. 


By  resorcin 89.5 

'•  corrosive  sublimate 92.9 

"   cbinoline 100.0 


Therefore,  according  to  Lunin's  statistics,  turpentine  was  the  most  useful 
agent  in  the  fibrinous  form  of  diphtheria,  and  the  tincture  of  the  chloride 
of  iron  in  the  septic  phlegmonous  form. 

Hydrargyri  Chloridum  Corrosivum  {Hydrargyri  PerGhloridum,  Br. 
Phar.). — The  use  of  this  agent  in  the  treatment  of  diphtheria  is  based  on 
the  theory  of  the  microbic  origin  of  this  disease.  Corrosive  sublimate  is 
the  most  active  and  certain  of  the  germicide  agents  employed  in  medicine, 
w^hether  used  locally  or  internally.  It  quickly  destroys  all  micro-organisms 
with  which  it  comes  in  contact,  and  in  safe  medicinal  doses  it  is  believed  to 
penetrate  all  parts  of  the  system.  The  employment  of  corrosive  sublimate 
in  the  treatment  of  diphtheria  is  not  new,  since  it  appears  that  the  late  Dr. 
Tappan,  of  Steubenville,  Ohio,  prescribed  it  with  apparent  benefit  in  1860- 
61 ;  but  it  was  seldom  prescribed  as  a  remedy  in  this  disease  until  within 
the  last  four  or  five  years.  The  establishment  of  the  theory  of  the  microbic 
origin  of  diphtheria,  and  a  knowledge  of  the  fact  that  the  sublimate  is  the 
most  efficient  germicide,  have  made  it  the  favorite  remedy  with  many  phy- 
sicians. Of  course  its  employment  demands  caution,  and  is  justified  only 
by  the  fact  that  the  disease  for  which  it  is  prescribed  has  hitherto  been 
very  fatal  with  other  modes  of  treatment.  Though  this  agent  is  now  widely 
used  for  diphtheria,  medical  journals  thus  far  contain  very  few  rej^orts  of 
its  supposed  toxic  or  injurious  action,  wdiile  many  physicians  believe  that 
it  diminishes  the  virulence  of  diphtheria  and  increases  the  percentage  of 
recoveries. 

In  ordinary  cases  the  following  may  perhaps  be  regarded  as  about  the 
proper  quantities,  w^hich  should  be  administered  in  divided  doses,  in  twenty- 
four  hours.  For  a  child  of  two  years,  gr.  ^  (gr.  -^^  every  two  hours) ;  for 
a  child  of  four  years,  gr.  ^  (gr.  ^  every  two  hours) ;  for  a  child  of  six 
years,  gr.  J  (gr.  -^  every  two  hours) ;  and  for  a  child  of  ten  years,  gr.  |- 
(gr.  2V  every  two  hours).  Thus,  if  we  employ  the  vehicle  which  Dr.  Tap- 
pan  used  one-quarter  of  a  century  ago,  the  following  prescription  might  be 
written  for  a  child  of  six  years  : 


DIPHTHEEIA.  665 

R    Hydrarg.  chlor.  corros.,  gr.  i ; 

Alcoholi,  ^ii ; 

Elix.  bismuthi  et  pepsinii,  q.  s.  ad  3! v. 
Misce. 
Dose,  one  teaspoonful  every  two  hours. 

According  to  the  statement  of  physicians,  considerably  larger  doses  have 
been  administered  with  safety  and  apparent  benefit,  and  in  severe  cases, 
attended  by  profound  blood-poisoning,  such  as  Lunin  designates  septic 
phlegmonous,  certainly  the  maximum  medicinal  dose  is  required,  if  we  de- 
pend on  the  sublimate  as  the  main  remedy.  Dr.  Grant  (Bey)  administered 
to  a  child  of  four  years  one-half  grain  every  half-hour  till  six  doses  were 
taken,  and  then  hourly  during  the  first  day,  every  second  hour  on  the  second 
day,  and  on  subsequent  days  at  longer  intervals.  Dr.  A.  Jacobi  states  that 
an  infant  a  year  old  may  take  one-half  grain  every  day  for  many  days  in 
succession,  with  very  little  if  any  intestinal  disorder,  and  with  no  stomatitis. 
Although  certain  children  may  tolerate  doses  so  large  as  those  recommended 
by  Dr.  Grant  (Bey),  safer  doses  are  those  which  we  have  recommended 
above,  and  they  seem  to  be  sufficient  for  protracted  use.  Dr.  P.  Werner  ^ 
recommends  in  the  treatment  of  dijjhtheria  the  sublimate  dissolved  in  dis- 
tilled water,  in  half-hourly  doses  or  at  a  little  longer  interval,  so  that  the 
following  quantities  are  taken  in  twenty-four  hours.  For  an  infant  of  one 
and  oue-half  years,  0.015  (grain  0.231)  of  the  sublimate  in  120.0  (4  fl.  oz.) 
of  water;  for  a  child  at  the  age  of  six  to  seven  years,  0.3  in  180  (grain 
0.45  to  6  oz.)  of  water.  This  quantity  is  to  be  given  in  divided  doses  in 
the  twenty-four  hours.  At  night,  if  the  child  sleep,  the  doses  should  be 
less  frequent  and  proportionately  larger  than  in  the  daytime.  Dr.  I.  N. 
Love,  of  St.  Louis,  states  that  he  has  employed  the  sublimate  in  doses  of 
one  one-hundredth  to  one-fiftieth  grain  every  hour  or  second  hour,  accord- 
ing to  the  age,  preceded  by  large  draughts  of  water.  Its  action  as  thus  used 
seemed  to  be  both  local  and  constitutional. 

Those  who  denounce  the  use  of  mercurials  in  diphtheria,  like  Jules 
Simon  and  one  at  least  of  our  distinguished  American  writers,  grouping 
together  calomel,  the  oleate,  the  unguentum,  the  cyanide,  the  biniodide,  and 
corrosive  sublimate,  condemning  them  in  a  body,  on  the  ground  that  they 
enfeeble  the  system,  do  injustice  to  the  therapeutic  virtues  of  the  sublimate. 
Medicines  having  the  same  base  often  differ  widely  in  their  action  upon 
the  system ;  and  it  is  the  common  and  probably  correct  belief  that  the  sub- 
limate in  safe  medicinal  doses  does  not  enfeeble  the  system,  but  in  some 
instances  acts  rather  as  a  tonic. 

In  my  practice  excellent  results  have  apparently  occurred  from  the 
local  use  of  corrosive  sublimate, — its  use  by  the  atomizer.  If  fhe  sublimate 
be  administered  internally  at  the  same  time,  care  must  be  taken  not  to  em- 
ploy too  much.     The  solution  which  I  have  employed  with  the  atomizer 

1  St.  Petersburg.  Med.  Wochenschr.,  1886. 


666  DIPHTHEEIA. 

consists  of  two  grains  of  the  sublimate  to  one  pint  of  water,  and  in  spray- 
ing the  fauces  the  bulb  of  the  atomizer  is  compressed  from  three  to  five 
times.  In  ordinary  cases  the  spray  is  used  every  second  hour.  Oatman,  of 
Nyack,  New  York,  has  lost  but  one  patient  in  twenty-three  by  the  follow- 
ing local  treatment.  Cotton  is  firmly  wound  around  the  end  of  a  stick 
about  the  size  of  a  lead-pencil,  being  drawn  out  as  it  is  wound,  and  made 
to  project  beyond  the  end.  This  is  dip23ed  into  a  solution  of  the  bichloride 
of  mercury,  two  grains  to  the  pint  (1  to  3840),  and  passed  into  the  throat 
until  it  touches  the  posterior  wall  of  the  pharynx.  It  is  then  instantly 
withdrawn  and  burnt.  This  treatment  is  repeated  hourly  with  a  new  swab 
each  time,  until  the  inflammation  begins  to  subside,  which  is  usually  in 
forty-eight  hours.  Jules  Stiimf  ^  treated  thirty-one  cases,  with  two  deaths, 
by  inlialation  of  the  sublimate,  using  the  apparatus  of  Richardson.  For 
infants  under  the  age  of  two  years  he  employs  1  pai't  to  4000 ;  from  five  to 
six  years,  1  part  to  2000  ;  for  those  over  six  years,  1  part  to  1000.  Dr. 
Thomas  Welcher  recommends  in  the  treatment  of  diphtheria,^  used  as  a 
gargle  or  employed  as  a  spray,  a  solution  of  corrosive  sublimate  of  1  to  1000. 
In  most  instances,  when  this  local  treatment  had  been  employed  a  few 
times  at  intervals  of  one  to  two  hours,  the  pharyngeal  disease  began  to 
abate,  and  the  general  condition  improved.  Dr.  Welcher  also  employs 
small  doses  of  the  sublimate  internally.  It  is  evident  from  the  experience 
of  other  physicians  that  when  this  agent  is  used  as  a  spray  in  so  strong  a 
solution  as  1  to  1000,  it  should  be  used  with  caution.  Two  or  three  com- 
pressions of  the  bulb  will  be  sufficient.  Prof.  A.  Jaeobi  recommends  for 
washing  the  nares  a  solution  of  corrosive  sublimate  1  part  to  2000  to  1 
part  to  10,000,  with  or  without  10  to  50  parts  of  table-salt  or  60  to  300 
parts  of  boracic  acid. 

The  medical  journals  during  the  last  three  or  four  years  contain  abun- 
dant testimony  to  the  beneficial  results  of  both  the  internal  and  the  local 
use  of  corrosive  sublimate  in  diphtheria.  An  important  question  evidently 
arises,  to  wit,  how  to  use  this  active  agent  internally  and  locally  at  the  same 
time  without  administering  too  large  a  quantity.  Some  physicians  admin- 
ister the  amount  that  can  safely  be  employed  in  twenty-four  hours,  dissolved 
in  water  and  in  frequent  doses  (every  hour  or  second  hour),  and  if  no  drinks 
be  given  subsequently  for  a  few  minutes  the  local  effect  upon  the  fauces  is 
to  a  considerable  extent  obtained.  Perhaps  this  is  the  safest  and  best  mode 
of  employing  this  very  efficient  and  usefid  antiseptic  agent  in  the  treatment 
of  diphtheria. 

Calomel. — Dr.  Simon  Baruch  begins  the  treatment  of  all  cases  of  diph- 
theria not  attended  by  diarrhoea  by  a  dose  of  four  to  eight  grains  of  calomel, 
followed,  if  necessary,  by  a  laxative.^  He  cites  the  experience  of  Dr. 
Coester,  who    administered,   in   the  preliminary  treatment  of  diphtheria, 

^  Miinch.  Med.  Wochenschr.  ^  Deutsche  Med.  Zeit. 

^  New  York  Medical  Eecord. 


DIPHTHERIA.  667 

calomel  in  sixty-uine  cases  aud  lost  only  one.  Prof.  Simon,  of  Paris,  in 
the  treatment  of  diiihtheria  discards  (1)  blisters,  which  are  always  followed 
bv  the  reproduction  of  pseudo-membrane,  (2)  bleeding  aud  mercurials, 
which  enfeeble  the  patient,  (3)  preparations  of  opium,  which  produce  rapid 
depression  of  the  vital  powers,  and  (4)  potassium  chlorate  in  large  doses. 
Tlie  reference  of  Simon  to  mercurials  is  probably  more  particularly  to 
calomel."^ 

On  the  other  hand.  Dr.  Geo.  B.  Fowler  considers  calomel  the  best 
remedy  with  which  to  combat  diphtheria.  AVheu  croupy  symptoms  super- 
vene, he  increases  the  dose  from  gr.  ^  to  gr.  ^  or  even  one  grain  every 
hour.^  Dr.  I.  X.  Love  remarks  that  the  most  marked  recent  recommenda- 
tion of  the  use  of  calomel  in  diphtheria  is  from  the  pen  of  Dr.  AVm.  H. 
Daly,  chairman  of  the  Laryngological  Section  of  the  Ninth  International 
Medical  Congress.^  Dr.  Daly's  method  is  to  administer  the  calomel  two  to 
five  grains  every  one,  two,  or  three  hours  until  free  catharsis  follows,  and 
then  at  longer  intervals,  but  so  that  three  or  four  daily  evacuations  are  pro- 
duced. The  editor  of  the  Therapeutic  Gazette  writes,  "  We  have  so  frequently 
seen  an  apparently  severe  attack  of  diphtheria  abruptly  aborted  in  its  incep- 
tion under  the  influence  of  large  doses  of  calomel,  that  we  can  scarcely 
believe  that  the  drug  has  no  pronounced  effect.  A  grain  of  it  should  be  put 
dry  in  the  mouth  of  the  child  every  hour  or  two,  until  frequent,  very  loose, 
liquid  evacuations  are  produced." 

In  addition  to  those  already  mentioned,  other  physicians  of  ample  expe- 
rience have  recommended  calomel  in  the  treatment  of  diphtheria,  some  in 
laxative  doses  and  only  at  the  beginning  of  the  attack,  and  others  in  doses 
of  the  fractional  part  of  a  grain  every  two  to  four  hours  during  the  sickness. 
The  majority  of  physicians,  very  properly  in  my  opinion,  discourage  the 
employment  of  calomel  in  laxative  doses  during  the  sickness,  believing  that 
it  tends  to  weaken  the  patient  and  increase  the  anaemia,  which  in  all  cases 
of  severe  diphtheria  soon  becomes  very  manifest,  whatever  the  treatment ; 
but  a  single  laxative  dose  is  perhaps  sometimes  useful.  It  may  do  good,  as 
in  other  infectious  diseases,  to  unload  the  primse  vise  in  the  commencement 
of  the  attack,  so  that  the  remedies  to  be  employed  arc  more  readily  absorbed 
and  without  alteration  by  admixture  with  chemical  products  in  the  intestinal 
tract.  What  change  calomel  undergoes  so  that  it  can  be  absorbed  has  not 
been  clearly  ascertained. 

Turpentine. — This  has  been  highly  recommended  recently  by  physicians 
of  experience,  when  used  locally  as  well  as  internally,  for  its  prompt  action 
in  arresting  the  formation  and  extension  of  the  pseudo-mombranc,  and  as 
an  antidote  to  the  diphtheritic  virus.  Dr.  Rewentauer  states  that  an  infant 
of  two  years  treated  by  other  remedies  began  to  have  symptoms  indicating 
invasion  of  the  larynx  on  the  fourth  day.     Tracheotomy  was  resolved  upon, 

'  Jour,  de  Med.  de  Paris.  ^  New  York  Medical  Record. 

*  Weekly  Medical  Review. 


668  DIPHTHEEIA. 

but  previous  trial  was  made  of  pure  turpeutine  in  a  teaspoouful  dose.  The 
croupiness  ceased,  other  symptoms  improved,  and  the  patient  recovered 
without  tracheotomy.^ 

Dekhil,  and  following  him,  Schenker  employed  a  mixture  of  coal-tar 
and  turpentine,  which  was  burnt  in  the  room  occupied  by  the  patient 
either  constantly  or  several  times  through  the  day.  Schenker's  observations 
led  him  to  believe  that  the  benefit  from  this  treatment  occurred  chiefly  from 
the  turpentine,  and  largely  from  its  general  effect  on  the  system.  He  there- 
fore decided  to  employ  turpentine  internally,  in  doses  of  ten  minims  to  one 
teaspoouful,  one  to  three  times  daily,  in  milk,  sugar-water,  .or  gruel.  At 
the  same  time  he  employed  it  as  a  spray.  Alcoholic  stimulation,  cleanliness, 
and  a  diet  of  beef  tea,  milk,  and  egg  were  enjoined.  Of  thirty-six  cases 
which  Dr.  Schenker  treated  by  turpentine,  thirty-one  recovered. 

Rose,  of  Hamburg,  employed  turpentine  in  teaspoouful  doses  mixed 
with  spirit  of  ether  (ether  one  part,  alcohol  three  parts)  three  times  daily, 
A  teaspoonfal  of  a  two-per-cent.  solution  of  salicylate  of  sodium  was  also 
given  every  two  hours.  Under  this  treatment  the  temperature  and  pulse 
diminished,  other  symptoms  improved,  and  in  fifty-eight  cases  thus  treated, 
95  per  cent,  recovered.^  Sigel  also  employed  turpentine  in  teaspoonful 
doses  in  forty-seven  cases,  in  fourteen  of  which  the  question  of  tracheotomy 
arose.  A  manifest  reduction  of  temperature  followed  the  use  of  the  turpen- 
tine. The  percentage  of  deaths  in  all  thus  treated  was  14.9,  while  of  those 
treated  by  corrosive  sublimate,  salicylic  acid,  potassium  chlorate,  etc.,  32.5 
per  cent.  died.  Dr.  Llewellyn  Eliot  also  reports  good  results  from  the 
vaporization  of  turpentine. 

The  recent  recommendation  of  turpentine  in  the  treatment  of  diphtheria 
by  many  physicians  of  large  experience  and  sound  judgment,  among  whom 
we  may  mention  Drs.  S.  Baruch  and  A.  Jacobi,  has  extended  and  established 
the  use  of  this  agent.  Its  supposed  efficacy  depends  on  the  fact  that  it  is 
antiseptic  and  germicidal,  and  that  when  vaporized  and  inhaled,  or  taken  by 
the  stomach,  it  penetrates  all  parts  of  the  system.  The  descriptions  long 
given  in  the  text-books  of  the  physiological  action  of  turpentine  have  had 
the  tendency  to  induce  physicians  to  employ  it  in  small  doses.  But  I  am 
not  aware  that  any  writer  has  recorded  ill  effects  from  the  use  of  turpentine 
in  diphtheria,  although  it  has  been  employed  by  a  considerable  number 
of  physicians  in  the  last  year  or  two,  and  in  quantities  which  exceed  the 
medicinal  doses  mentioned  in  text-books. 

It  is  well  known  that  the  constitutional  effects  of  the  oleum  terebin- 
thinse,  even  to  impaired  vision,  strangury,  and  bloody  urine,  may  be  ob- 
tained by  the  prolonged  inhalation  of  its  vapor  ;^  and  I  have  employed  the 
vapor  of  the  oil  of  turpentine  during  the  last  two  or  three  years  with  such 
apparent  good  results  that  I  confidently  recommend  this  mode  of  using  the 
turpentine. 

1  Centralbl.  f.  Klin.  Med.  ^  Therap.  Monatschr.  ^  Stille  and  Maisch- 


DIPHTHERIA.  669 

The  accompanving  prescription  is  mixed  with  water  in  the  proportion 
of  two  tablespoonfuls  to  one  quart  of  water.  R  Acidi  carbolici,  ol.  euca- 
lypti, aa  oi ;  spts.  terebinth.,  Sviii.  This  is  placed  in  a  shallow  vessel  or 
vessels  with  a  broad  surface,  and  maintained  in  a  constant  ebullition  or 
simmering,  upon  a  gas  or  other  stove.  The  vapor,  which  is  not  unpleasant, 
soon  fills  the  room,  and  even  adjoining  rooms.  As  regards  the  effect  on 
the  patient,  the  turpentine  vapor  passing  over  the  inflamed  surfaces,  which 
are  the  seat  of  the  exudate,  with  every  inspiration  jDrobably  produces  more 
or  less  local  disinfection,  apart  from  the  systemic  disinfection  which  it  may 
cause  by  entering  the  blood  and  the  tissues  generally.  Thus  employed,  the 
turpentine  is  also  apparently  a  useful  domiciliary  disinfectant,  affording 
protection  in  a  measure  to  other  members  of  the  family,  and  to  the  physi- 
cian and  nurses,  as  we  have  stated  elsewhere.  The  oil  of  turpentine  will 
probably  in  the  future  be  a  very  important  remedy  in  the  treatment  of 
diphtheria,  whether  taken  by  the  stomach  or  received  as  a  spray. 

Pilocarpine. — Certain  physicians  have  recommended  pilocarpine  in  the 
treatment  of  diphtheria,  because  it  is  supposed  that  the  salivary  and  mucous 
secretions  which  it  produces  aid  in  throwing  off  the  pseudo-membrane. 
Dr.  Lax  states  that  ten  patients  treated  by  him,  some  of  them  severely 
sick,  all  recovered.^     He  employed  the  following  prescription  : 

R   Pilocarpini  hydrochlorat. ,  gr-  5  to  | ; 
Acidi  hydrochlorici,  gtt.  ii-iii ; 
Pepsini,  gr.  x-sii ; 
Aquae  destillat. ,  ^xviiss. 
Misce. 
Dose,  a  teaspoonful  or  tablespoonful  in  wine. 

Guttmanu  treated  in  a  year  and  a  half  eighty-one  cases  by  this  remedy 
without  a  death.  Gelsner  and  Delewsky  also  report  good  results.  On  the 
other  hand,  I  have  seen  the  most  disastrous  effects  from  the  use  of  pilocar- 
pine in  diphtheria,  the  secretions  filling  the  bronchial  tubes  and  being  ex- 
pectorated insufficiently  and  with  great  difficulty.  Death  resulted.  The 
symptoms  which  occurred  were  like  those  in  extreme  cedema  of  the  lungs. 
I  cannot,  therefore,  recommend  its  use.  Its  employment  aj)pears  too  hazard- 
ous, especially  in  young  and  feeble  children. 

Sodiiuii  Benzoate. — Dr.  I.  N.  Love  recommends  the  sodium  benzoate 
in  five,  ten,  or  fifteen  grain  doses.^  He  remarks  that  Salkowski  in  1879 
noticed  tluit  this  drug  largely  increased  the  secretion  by  the  kidneys  of  nitro- 
genous and  sulphurous  compounds,  and  concludcHl  that  it  would  aid  in  de- 
purating the  blood  of  noxious  matters.  Salkowski,  Fleck,  and  Buckholtz 
ascertained  that  the  benzoate  arrested  the  growth  of  micro-organisms  in 
putrid  liquid,  and  Graham  Brown  that  diphtheritic  liquids  became  non- 
contagious by  the  addition  of  the  benzoate.  Helferich,  Graham  Brown, 
and  Sann6,  from  experiments  made  on  animals,  consider  the  benzoate  of 

^  Medical  News.  *  Weekly  Medical  Keview. 


670  DIPHTHERIA. 

sodium  a  specific  against  the  virus  of  diphtheria.^  On  the  other  hand,  M. 
Dumas,  surgeon  to  the  Hopital  de  Cette,  has  not  derived  any  marked  benefit 
from  its  use,  and  Prof.  A.  Jacobi  says  that  it  does  not  deserve  the  eulogies 
bestowed  upon  it  from  theoretical  reasonings.^ 

Such  are  the  more  important  remedies,  used  internally,  which  have  been 
up  to  the  present  time  employed  in  the  treatment  of  diphtheria.  The 
number,  it  is  seen,  is  large,  and  most  of  them  are  no  doubt  useful  in  certain 
cases.  Diphtheria,  being  a  disease  of  variable  type,  must  be  treated  accord- 
ing to  the  indications  in  each  case.  The  internal  remedies  which,  in  my 
opinion  have  been  most  useful  and  which  should  be  most  frequently  em- 
ployed are  the  tincture  of  the  chloride  of  iron,  quinine,  corrosive  sublimate, 
turpentine,  and  the  alcoholic  preparations. 

Among  the  other  remedies  which  have  been  recommended  by  good  ob- 
servers, we  may  mention  the  following.  Copaiba  and  cubebs  are  employed 
and  recommended  by  distinguished  French  physicians.  Jules  Simon  pre- 
scribes copaiba  and  cubebs  for  patients  over  the  age  of  five  or  six  years.^ 
Dr.  I.  H.  Fruitnight  has  employed  the  sodium  hyposulphite  in  eight  cases, 
giving  hourly  drachm  doses  of  the  following:  R  Sodii  hyposulph.,  5i;  aquse, 
fgii.  The  result  was  favorable.  Illingworth  *  recommends  the  biniodide  of 
mercury.  Dr.  C.  B.  Galentine  recommends  the  internal  use  of  hydrate  of 
chloral,  given  with  the  potassium  chlorate  to  a  child  of  six  years  in  about 
two-and-a-half-grain  doses.  Herbert  L.  Snow  recommends  sulphurous  acid, 
Dr.  Hofmokl  the  hydrogen  dioxide,  and  E.  S.  Smith  the  oil  of  eucalyptus 
and  Warburg's  tincture.  In  diphtheria,  therefore,  as  in  other  diseases  which 
in  a  large  proportion  of  cases  end  favorably,  whatever  the  treatment,  the 
number  of  recommended  remedies  is  large. 

Local  Treatment. — Solvents. — The  belief  is  becoming  prevalent  in  the 
profession  that  the  early  destruction  and  removal  of  the  exudate  from  the 
faucial  or  nasal  surface  is  not  an  imperative  duty,  as  was  formerly  practised 
under  the  teachings  of  Bretonneau  and  Trousseau,  provided  that  thorough 
disinfection  of  the  pseudo-membrane  and  the  surrounding  and  underlying 
tissues  be  effected.  Patients  are  injured  by  irritating  lotions  or  instru- 
mental treatment  designed  to  remove  the  pseudo-membrane,  which  imme- 
diately reappears  in  greater  extent  and  thickness  than  at  first,  on  account 
of  the  increase  in  the  inflammation  in  consequence  of  the  severe  measures 
employed.  The  employment  at  short  intervals  of  mild  but  efficient  anti- 
septic applications  in  place  of  the  stronger  and  irritating  lotions  formerly 
used  has  been  a  great  improvement  in  the  treatment  of  diphtheria.  But 
antiseptic  lotions,  vapors,  or  sprays  are  inadequate  to  produce  complete 
disinfection,  if  the  pseudo-membrane  have  great  thickness.  Its  under  sur- 
face, which  is  in  immediate  relation  with  the  lymphatics  and  blood-vessels, 
and  from  which  systemic  poisoning  occurs,  from  absorption  of  the  cliph- 

1  La  France  Medicale.  ^  New  York  Medical  Record. 

^  Le  Progres  Medical.  ■*  British  Medical  Journal. 


DIPHTHERIA.  671 

tlieritic  germ,  septic  matter,  or  ptomaines,  is  probably  not  reached  by  the 
antiseptic  sprays  or  lotions  as  commonly  employed.  Any  painless  and  un- 
irritating  application  which  diminishes  the  thickness  of  the  pseudo-membrane 
by  its  solvent  action,  or,  better,  entirely  dissolves  and  removes  it,  is  there- 
fore useful.  Of  the  unirritating  solvents,  alkalies,  pepsin,  trypsin,  and 
papayotin  have  been  chiefly  used,  and  have  in  the  highest  degree  the  confi- 
dence of  the  profession.  The  efficiency  of  solvent  treatment  depends  largely 
on  the  manner  in  which  it  is  employed,  the  kind  of  instrument  used,  and  the 
frequency  of  the  application.  The  solvent  agent  heretofore  most  largely 
used  has  been  lime-water  or  the  spray  of  slacking  lime.  Its  solvent  action 
is  probably  due  chiefly  to  its  alkalinity,  but  its  alkalinity  and  its  solvent 
action  can  be  greatly  increased  by  adding  to  it  the  sodium  bicarbonate. 
From  observing  its  effects  in  a  considerable  number  of  cases,  the  writer 
recommends  with  confidence  the  following  formula  : 

R   01.  eucalypti,  gii; 

Sodii  benzoat. ,  5  i ; 

Sodii  bicarbonat.,  gii; 

Glycerinas,  ^  ii ; 

Aquae  calcis,  Oi. 
Misce. 

To  be  used  with  the  hand-atomizer  from  three  to  five  minutes  every  half- 
hour,  or  with  the  steam  atomizer  almost  constantly.  This  alkaline  spray 
not  only  exerts  a  solvent  action  on  the  pseudo-membrane,  but  also  renders 
the  muco-pus  thinner,  less  viscid,  and  therefore  so  changes  its  character  by 
diminishing  its  viscidity  that  it  is  more  easily  expectorated. 

The  use  of  pepsin  as  a  solvent  is  suggested,  from  its  well-known  action 
in  digesting  nitrogenous  substance.  It  has  been  employed  with  varying 
results.  It  is  well  known  that  some  of  the  preparations  in  the  shops  are 
much  more  active  than  others,  and  hence  perhaps  a  chief  reason  for  the 
difference  in  the  results  claimed.  It  is  well  to  remind  the  reader  that  it 
should  be  employed  alone  or  with  an  acid,  for  it  is  comparatively  inert  if 
used  with  an  alkali.  It  may  not  be  improper  to  state  that,  in  comparative 
tests  of  the  pepsins  in  the  shops  made  by  Dr.  George  B.  Fowler  and  related 
before  the  Pediatric  Section  of  the  Academy  of  Medicine,  the  solvent  action 
of  the  pepsin  prepared  by  Parke,  Davis  &  Co.,  of  Detroit,  was  especially 
noticeable. 

Rossbach  states  ^  that  he  has  used  a  solution  of  papayotin,  or  vegetable 
pepsin,  frequently  applied  to  the  fauces.  In  young  children  a  few  minims 
may  be  placed  on  the  tongue  every  five  minutes.  If  the  drug  be  good,  he 
states  that  the  membrane  is  dissolved  in  two  or  three  hours.  Prof.  Jacobi 
says  that  this  agent  is  readily  dissolved  in  twenty  parts  of  water.^  It  may, 
he  says,  be  brushed  over  the  surface  or  used  as  a  spray.     Mixed  with  water 

1  St.  Petersburg.  Med.  Wochenschr.,  1886. 
^  New  York  Medical  Kecord. 


672  DIPHTHERIA. 

and  glycerin  in  greater  concentration  (1  to  4-8),  it  has  been  used  by  bim 
with  fair  results.  Dr.  J.  K.  Bauduy,  Jr.,  also  writes  favorably  of  the 
solvent  action  of  papayotin  on  the  pseudo-membrane.^ 

Trypsin,  unlike  pepsin,  is  an  active  solvent  in  an  alkaline  medium,  and 
it  may  be  added  to  the  alkaline  mixture  described  above.  Dr.  F.  C.  Fer- 
nald  relates  the  case  of  a  boy  of  six  and  a  half  years,  who  had  perforation 
of  each  membrana  tympani  and  began  to  complain  of  sore  throat.  A 
pseudo-membrane  appeared  upon  the  tonsillar  portion  of  the  fauces,  and 
the  right  auditory  canal  was  covered  with  a  diphtheritic  exudate,  entirely 
occluding  it,  so  that  liquids  did  not  flow  from  the  external  ear  to  the  fauces 
as  formerly.  The  ear  was  filled  every  half-hour  with  the  following  mix- 
ture :  R  Tripsin.,  gr.  xxx,  sodii  bicarb.,  gr.  x,  aquse  destillat.,  ii.  The 
pseudo-membrane  gradually  dissolved  and  disappeared,  the  passage  through 
the  ear  and  Eustachian  tube  became  open,  and  the  patient  recovered.^  Dr. 
E.  N.  Liell  also  relates  a  case  in  which  trypsin  apparently  produced  a  sol- 
vent action  on  the  pseudo-membrane.  Probably,  therefore,  in  the  present 
state  of  our  knowledge  we  can  apply  no  better  solvent  mixture  upon  the 
diphtheritic  pseudo-membrane  than  trypsin  added  to  the  alkaline  solution 
described  above. 

Albuminuria. — This  being  due  to  septic  nephritis,  patients  have  seemed 
to  me  to  be  more  benefited  by  the  tincture  of  the  chloride  of  iron,  in  fre- 
quent and  rather  large  doses,  than  by  any  other  remedy.  If  while  this  is 
being  used  a  marked  diminution  in  the  quantity  of  urine  occurs,  it  may  be 
necessary  to  employ  diuretics  and  laxatives,  as  in  scarlatinous  nephritis. 
The  potassium  bitartrate  or  acetate,  and  perhaps  the  more  laxative  salines, 
may  be  needed  under  such  circumstances.  But  marked  diminution  of 
urine,  and  especially  anuria,  in  diphtheria,  end  fatally,  with  few  exceptions, 
according  to  my  observations,  whatever  the  treatment. 

Paralysis. — The  loss  of  the  tendon  reflexes,  and  palatal  and  multiple 
paralyses,  require  the  same  stimulating  and  sustaining  remedies  which  are 
appropriate  for  the  primary  disease  diphtheria.  Iron  and  other  tonics, 
nutritious  and  easily-digested  diet,  massage,  and,  in  some  instances,  elec- 
tricity, suffice  to  restore  the  use  of  the  aflected  muscles ;  but  sometimes 
weeks  and  even  months  elapse  before  their  use  is  fully  restored.  So  long 
as  the  paralysis  does  not  aifect  any  vital  organ,  a  favorable  prognosis  may 
be  expressed,  although  recovery  may  be  slow. 

On  the  other  hand,  it  is  evident  from  its  nature,  and  from  the  cases 
which  have  been  related,  that  cardiac  paralysis  is  exceedingly  dangerous, 
and  must  be  treated  promptly  and  by  the  most  active  remedies.  As  we 
have  seen,  the  attack  of  cardiac  i)aralysis  is  usually  sudden,  with  little  fore- 
warning, and  is  often  fatal  before  the  physician,  promptly  summoned,  is 
able  to  arrive.  The  patient  should  be  as  quiet  as  possible  in  bed,  with  the 
head  low,  and  alcoholic  stimulants  should  be  administered  at  once.     In  the 

1  Medical  Weekly  Keview.  ^  Medical  News. 


DIPHTHERIA.  673 

sudden  seizures  such  as  have  been  related  above,  hypodermic  injections  of 
brandy  act  most  promptly  in  sustaining  the  heart-action.  Ammonia,  cam- 
phor, musk,  and  the  electrical  current  may  be  useful  auxiliaries.  The  pre- 
digested  beef  preparations,  peptonized  milk,  and  other  concentrated  foods 
designed  for  those  with  feeble  digestion,  are  useful.  If  the  urgent  symp- 
toms are  relieved  by  these  measures,  such  remedies  should  be  employed  as 
are  useful  in  other  forms  of  diphtheritic  paralysis.  The  patient  is  ordinarily 
feeble,  anaemic,  and  with  poor  digestion.  The  beef  extracts  and  concen- 
trated foods  should  be  continued.  Iron,  quinine  in  moderate  doses,  and 
alcoholic  stimulants  are  indicated.  The  use  of  the  electric  current  is  sug- 
gested by  the  nature  of  the  attack.  Many  physicians  believe  that  they 
have  obtained  benefit  from  its  use  in  the  treatment  of  the  more  common 
forms  of  diphtheritic  paralysis,  while  others  speak  doubtfully  of  its  efficacy. 
If  there  be  reason  from  the  symptoms  to  suspect  the  presence  of  central 
lesions  in  the  nervous  system,  the  galvanic  current  in  short  sittings  has  been 
recommended,  and  not  the  faradic.  In  ordinary  cases  either  the  direct  or 
the  induced  current  may  be  employed. 

Strychnine  is,  however,  regarded  by  good  observers  as  the  most  efficacious 
nerve-stimulant  in  the  various  forms  of  diphtheritic  paralysis.  Oertel's 
objection  expressed  twenty  years  ago  to  the  use  of  strychnine  in  this  disease, 
that,  acting  as  an  excitant  of  the  spinal  cord,  it  is  likely  to  aggravate  cen- 
tral lesions,  was  founded  on  a  wrong  understanding  of  the  pathology  of  the 
paralysis.  Prof.  Henoch  cured  diphtheritic  paralysis  in  three  weeks  by 
hypodermic  injections  of  strychnine.  W.  Reinard  ^  states  that  a  boy  three 
and  a  half  years  of  age  fifteen  days  after  the  appearance  of  the  diph- 
theritic patches  on  the  tonsils  had  paralysis  of  the  inferior  extremities  and 
the  velum  palati,  a  tottering  gait,  nasal  voice,  and  difficult  deglutition.  At 
the  end  of  twelve  days  death  seemed  imminent,  the  paresis  of  the  lower  ex- 
tremities had  become  a  complete  paraplegia,  and  the  paralysis  of  the  upper  ex- 
tremities, and  of  the  muscles  of  the  nucha,  larynx,  and  thorax,  was  complete. 
He  was  unable  to  sustain  himself  in  the  sitting  posture,  his  head  falling 
heavily  on  his  chest.  He  had  also  dyspnoea,  hoarse  cough,  tracheal  rales, 
and  aphonia,  probably  from  cardio-pulmonary  paralysis.  Reinard  made  a 
hypodermic  injection  each  day  of  one  milligramme  (about  one-sixty-fifth 
of  a  grain)  of  sulphate  of  strychnine,  in  the  nucha.  Improvement  occurred 
in  twenty-four  hours  in  the  tonicity  of  the  muscles.  On  the  third  day  the 
cardiac  and  pulmonary  paralysis  had  so  improved  that  the  tracheal  rale  had 
ceased.  The  respiratif)n  was  more  normal,  and  deglutition  possible.  On 
the  fifteenth  day  of  this  treatment,  and  after  fifteen  injections,  the  patient 
was  considered  cured.  Dr.  Gerasimow^  relates  the  case  of  a  child  six  years 
of  age  who  had  paralysis  of  the  velum,  pharynx,  larynx,  and  lower  ex- 
tremities. Six  weeks  after  the  commencement  of  paralytic  symptoms, 
subcutaneous  injections  of   strychnine,  two  centigrammes  (or  about  oue- 


1  Deutsche  Med.  Wochenschr.,  1885,  No.  19.  ^  ^l^.a.  Obosr.,  No.  20. 

YOL.  I.— 43 


674 


DIPHTHEEIA. 


thirty-first  of  a  grain),  were  given  daily.  With  this  treatment  the  patient 
improved,  and  after  seven  injections  of  this  strength,  followed  by  twelve  of 
one-twenty-second  of  a  grain,  the  cure  was  complete. 

With  such  strong  testimony  in  favor  of  the  use  of  strychnine,  it  is  perhaps 
remarkable  that  physicians  of  experience  state  that  they  have  not  observed 
any  marked  benefit  from  its  use  in  the  treatment  of  diphtheritic  paralysis. 
At  a  meeting  of  the  New  York  Clinical  Society,  held  December  23,  1887,^ 
Dr.  Holt  stated  that  he  was  yet  to  be  convinced  that  strychnine  possessed 
any  specific  value  in  this  disease,  though  it  was  of  much  value  as  a  general 
tonic.  At  the  same  meeting  Dr.  A.  A.  Smith  stated  his  belief  that  tonics 
and  time  did  more  for  diphtheritic  paralysis  than  anything  else.  He  had 
used  electricity  and  strychnine,  and  had  never  been  able  to  satisfy  himself 
that  electricity  did  any  good,  and  the  effects  of  strychnine  seemed  to  be  not 
specific,  but  those  of  a  general  tonic.  On  the  other  hand.  Dr.  Thatcher, 
of  New  York,  has  reported  a  case  in  Avhich  galvanism  was  employed  on 
the  two  paralyzed  upper  extremities  alternately,  on  each  for  a  week  at 
a  time.  It  was  invariably  found  that  the  arm  receiving  the  electricity 
gained  more  rapidly  than  the  one  untreated,  the  strength  being  tested  by 
the  dynamometer.  This  test  seems  to  have  been  conclusive  as  showing 
the  efficacy  of  galvanization. 

Note. — In  the  preparation  of  this  article  I  have  availed  myself  of  extracts  from  former 
publications  of  my  own,  whenever  my  present  views  coincided  with  those  already  presented. 

1  New  York  Medical  Journal,  Jan.  14,  1888. 


MEASLES. 

By  F.  E.  WAXHAM,  M.D. 


Synonymes. — Rubeola,  Morbilli. 

Definition. — Measles  is  an  acute  epidemic,  contagious  disease,  charac- 
terized by  a  peculiar  papular  eruption,  occurring  usually  on  the  fourth  day 
of  the  attack,  preceded  by  catarrhal  symptoms  and  followed  by  slight 
desquamation. 

History. — This  disease  was  described  with  sraall-pox  by  Rhazes,  a.d. 
900,  who  undoubtedly  recognized  the  difference  between  them.  Before  that 
date  there  is  no  authentic  account  of  the  disease. 

It  continued  to  be  confused  with  scarlatina  and  small-pox  until  1670— 
74,  when  Sydenham  and  Morton  declared  the  former  to  be  a  distinct 
disease. 

While  the  origin  of  measles  is  buried  in  obscurity,  at  present  it  is  dis- 
seminated nearly  all  over  the  world,  seemingly  following  the  footsteps  of 
civilization.  Only  in  those  distant  countries  where  civilization  has  not 
penetrated  is  the  disease  unknown. 

Etiology. — Measles  is  due  to  a  specific  poison  that  has  not  yet  been 
isolated.  It  is  both  epidemic  and  contagious.  All  authorities  agree  that  it 
cannot  originate  de  novo. 

That  it  is  epidemic  is  manifest  from  the  fact  that  the  disease  is  far  more 
common  during  certain  seasons  or  years  than  others.  A  community  may 
be  comparatively  free  from  the  disease  for  a  time,  when  at  length  it  will 
sweep  over  it  like  a  cyclone  and  but  few  will  escape.  A  period  of  im- 
munity will  then  prevail,  lasting  for  a  longer  or  shorter  time,  Avhen  it  will 
again  make  its  appearance. 

That  it  is  highly  contagious  needs  no  argument  to  prove.  It  indeed 
ranks  with  small-pox  in  this  regard.  The  contagiousness  begins  with  the 
catarrhal  symptoms  and  continues  until  after  desquamation.  The  contagious 
princi]>le  exists  in  the  breath,  the  exhalations  from  the  skin,  the  blood,  the 
tears,  the  nasal  and  bronchial  secretions,  and  undoubtedly  in  the  urine  and 
faecal  discharges.  Tlio  poison  of  the  disease  gains  access  to  the  system  in 
the  great  majority  of  cases  tlirough  the  mucous  membrane  of  the  respiratory 
tract,  the  inspired  air  carrying  the  active  contagious  principle.  The  disease 
is  equally  prevalent  in  both  sexes.     Although  a  disease  of  childhood,  the 


676  MEASLES. 

adult  is  noway  exempt  from  it.  The  great  majority  of  children,  having 
suffered  from  the  disease  in  early  life,  escape  it  later,  but  those  who  do  not 
receive  such  immunity  are  susceptible. 

The  infant  under  six  months  is  generally  exempt  from  the  disease, 
although  there  are  many  notable  exceptions. 

In  speaking  of  the  etiology  of  measles,  it  must  be  mentioned  that  micro- 
cocci have  been  discovered  in  the  breath  and  in  the  blood  of  patients  suffer- 
ing from  the  disease ;  but  it  is  not  yet  clear  whether  these  micrococci  are 
post  hoe  or  propter  hoc. 

Pathological  Anatomy. — The  morbid  anatomy  varies  considerably, 
and  is  influenced  in  a  great  measure  by  the  complications  which  are  so 
frequently  the  cause  of  death.  The  blood  is  sometimes  bluish  or  brownish 
red,  sometimes  thin  and  deficient  in  coagulability,  and  sometimes  thick. 
The  mucous  membranes  usually  present  evidences  of  catarrhal  inflamma- 
tion, and  should  death  result  from  some  complication,  which  is  usually  the 
case  when  the  termination  is  fatal,  we  will  observe  the  lesions  characteristic 
of  such  complications. 

Symptomatology. — The  disease  may  be  divided  into  four  stages  :  first, 
the  stage  of  incubation ;  second,  the  stage  of  invasion ;  third,  the  stage  of 
eruption ;  and  fourth,  the  stage  of  decline. 

While  some  claim  that  after  infection  the  poison  of  the  disease  lies 
dormant  in  the  system  for  a  certain  length  of  time  before  manifesting  its 
presence,  the  majority  of  authorities  believe  that  the  disease  commences, 
that  is  to  say,  the  active  contagious  principle  exerts  its  influence,  the  moment 
it  enters  the  system,  and  when  it  has  attained  sufficient  force  to  upset  the 
equilibrium  of  the  system  we  get  the  characteristic  symptoms. 

The  period  between  exposure  and  the  commencement  of  the  manifest 
symptoms  constitutes  the  first  stage,  or  that  of  incubation.  This  period 
varies  from  seven  to  twenty-one  days,  with  an  average  of  about  twelve. 

Stage  of  Invasion. — This  stage  may  be  ushered  in  abruptly  by  vomit- 
ing, chills,  fever,  and  pain  in  the  head,  back,  and  limbs,  accompanied  by 
symptoms  of  a  catarrhal  nature.  Usually,  however,  the  onset  is  gradual, 
and  loss  of  appetite,  malaise,  and  mild  catarrhal  symptoms,  with  slight 
fever,  are  first  observed. 

The  catarrhal  symptoms  rapidly  develop,  and  soon  become  the  most 
prominent  feature  of  this  stage.  The  mucous  membranes  of  the  eyes,  nose, 
throat,  larynx,  trachea,  and  bronchial  tubes  become  implicated.  The  con- 
junctivae become  reddened  and  congested,  and  increased  lachrymation  is 
observed,  the  eyes  being  suffused  with  tears.  The  mucous  membrane  of 
the  nasal  passages  becomes  reddened  and  swollen  with  at  first  a  thin  wateiy 
discharge,  which  soon  becomes  abundant  and  muco-purulent  in  character. 
As  a  result  of  the  irritation  in  the  nasal  cavities,  frequent  sneezing  occurs 
and  is  a  common  symptom. 

The  inflammation  of  the  mucous  membrane  of  the  larynx  and  bronchial 
tubes  gives  rise  to  a  frequent  troublesome  cough.     Sometimes  the  cough 


MEASLES.  677 

becomes  decidedly  croupy  and  the  respiration  embarrassed  from  the  swell- 
ing of  the  mucous  membrane  of  the  larynx.  Occasionally  alarming  symp- 
toms result  from  oedema  of  the  glottis.  At  times  the  inflammation  of 
the  pharynx  assumes  a  diphtheritic  type,  which  may  extend  into  the  larynx. 
This  dangerous  complication,  however,  is  not  frequently  observed.  Nausea 
and  vomiting  are  often  present,  and  indicate  disturbance  of  the  digestive 
system.  Diarrhoea  occurs  in  a  small  proportion  of  cases,  and  would  seem 
to  indicate  irritation  of  the  mucous  membrane  of  the  intestinal  tract. 
Convulsions  rarely  occur,  but  when  they  are  present  they  are  of  very 
serious  import. 

Epistaxis  occasionally  results,  but  seldom  becomes  alarming. 

The  fever  that  may  have  preceded  the  catarrhal  symptoms  increases  in 
intensity  with  the  development  of  these  symptoms,  and  the  temperature 
usually  ranges  from  102°  to  104°  F. 

The  symptoms  that  have  been  enumerated  as  characteristic  of  the  stage 
of  invasion  vary  greatly  in  intensity.  In  some  cases  they  are  so  mild  that 
the  child  is  supposed  to  be  suffering  only  from  a  slight  cold,  while  in  other 
cases  they  are  so  severe  as  to  make  the  patient  quite  ill,  and  occasionally 
they  assume  a  dangerous  character. 

Stage  of  Eruption. — About  the  fourth  day  the  catarrhal  symptoms 
have  reached  their  height,  and  upon  this  day  in  the  great  majority  of  cases 
the  eruption  first  begins  to  make  its  appearance.  The  eruption  first  appears 
upon  the  forehead,  temples,  and  cheeks,  soon  extending  to  the  face,  breast, 
extremities,  and  trunk.  At  first  the  eruption  appears  in  the  form  of  minute 
red  spots ;  these  rapidly  increase  in  number  and  size,  and  become  distinctly 
papular  and  perceptible  to  the  touch.  These  papules,  of  a  dark-red  color, 
are  in  many  cases  surrounded  by  areas  of  skin  of  normal  color,  but  on 
certain  portions  of  the  body,  esj^ecially  the  face,  neck,  and  forearms,  they 
become  confluent,  and  these  portions  present  a  peculiar  blotched  and  swollen 
appearance.  By  the  end  of  the  sixth  day  of  the  disease,  or  the  second  from 
the  first  appearance  of  the  eruption,  the  disease  is  at  its  height.  The  erup- 
tion is  now  fully  developed,  and  has  extended  to  all  parts  of  the  body, 
although  more  marked  in  some  portions  than  in  others.  The  catarrhal  symp- 
toms and  the  fever  which  were  present  during  the  stage  of  invasion  continue 
unabated,  and  diarrhoea,  if  not  present  before,  frequently  occurs  at  this  stage. 
The  tongue  continues  moist  throughout  the  attack,  and  covered  with  a  light 
coating.  Enlargements  of  the  submaxillary  and  anterior  cervical  glands  are 
common. 

The  disease,  having  reached  its  height  by  the  end  of  the  sixth  day,  re- 
mains stationary,  all  the  symptoms  persisting,  but  not  increasing  in  severity, 
for  two  days,  when  tlic  eruption  rapidly  fades,  the  fever  diminislies,  and  the 
catarrhal  symptoms  abate.     We  now  reach  the  last  stage  of  the  disease. 

Stage  of  Decline. — Tliis  stage  is  characterized  by  tlie  diminution  of 
all  the  symptoms.  Although  the  eruption  rapidly  fades  and  the  fever  sub- 
sides, yet  a  bronchitis  remains  for  some  days  and  is  the  last  symptom  to 


678  MEASLES. 

disappear.  As  the  active  symptoms  disappear,  the  appetite  and  natural 
disposition  of  the  child  return,  and  the  patient  is  soon  in  ordinary  health. 

The  stage  of  decline  terminates  with  a  fine,  furfuraceous  desquamation, 
which  begins  about  the  tenth  or  eleventh  day.  It  is  most  marked  when  the 
eruption  has  been  the  most  intense. 

Atypical  Course. — The  regular  course  of  measles  may  be  interrupted, 
or  the  disease  may  present  variations  from  the  typical  course  just  described. 
We  may  meet  occasionally  with  those  cases  styled  morbilli  sine  catarrho,  in 
which  the  catarrhal  symptoms  are  wanting  or  very  slight,  and  where  the 
eruption  occurs  with  scarcely  any  premonitory  symptoms.  Again,  cases  are 
occasionally  met  with  styled  morbilli  sine  exantliemate,  where  the  catarrhal 
symptoms  are  well  pronounced,  but  where  the  eruption  is  very  scant  or  en- 
tirely absent.  Other  cases,  again,  are  met  with  where  the  eruption  is  long- 
continued,  and  still  others  where  the  eruption  is  of  very  light  color,  in  strong 
contrast  to  others,  where  the  eruption  is  of  a  deep  dark  red  and  confluent,  at 
times  livid,  with  evidences  of  extravasation. 

The  disease,  again,  is  sometimes  modified  or  suddenly  interrupted  by 
intercurrent  affections. 

The  so-called  black  or  malignant  hemorrhagic  measles  presents  a 
series  of  symptoms  somewhat  dissimilar  from  those  enumerated.  Evidences 
of  great  depression  occur  early  in  the  attack.  The  pulse  becomes  extremely 
rapid  and  feeble,  the  temperature  high,  the  extremities  cold,  the  patient 
anxious  and  restless  or  somnolent,  with  a  tendency  to  convulsions  or  coma. 
The  eruption  may  scarcely  make  its  appearance,  and  death  may  occur  before 
it  is  developed,  or  it  may  occur,  usually  in  the  confluent  form,  and  the 
papules  assume  a  dark  livid  or  even  black  color,  as  they  fade  leaving 
dark-yellowish  stains.  This  type  of  measles  is  extremely  fatal,  and  occurs 
most  frequently  in  broken-down  subjects,  those  suifering  from  some  con- 
stitutional dyscrasia,  or  those  whose  hygienic  surroundings  are  unfavorable. 

Diagnosis. — During  the  stage  of  invasion  it  is  difficult  to  distinguish 
measles  from  a  severe  attack  of  coryza  or  bronchial  catarrh. 

Known  exposure  to  the  disease  would  be  the  strongest  evidence  of  its 
real  character.  After  the  appearance  of  the  eruption  we  may  confuse  the 
disease  with  rubella,  or  German  measles,  scarlet  fever,  variola,  varicella, 
or  typhus  fever. 

In  rubella  we  have  catarrhal  symptoms,  but  they  are  slight.  In 
rubella  the  eruption  appears  within  twelve  or  twenty-four  hours  after 
invasion,  and  very  frequently  tlie  premonitory  symptoms  are  so  slight  that 
the  patient  is  not  considered  sick  until  the  eruption  is  discovered.  The 
eruption,  instead  of  being  a  deep  dark  red  as  in  measles,  is  of  a  lighter 
color,  and  the  papules  are  much  finer,  and  we  do  not  see  the  swollen  and 
blotched  surface  that  is  so  characteristic  of  measles.  The  temperature  does 
not  run  so  high,  the  pulse  is  less  rapid,  and  the  disease  runs  a  much  shorter 
and  milder  course. 

The  differential  diagnosis  between  measles  and  scarlet  fever  is  based 


MEASLES.  679 

upon  the  shorter  period  of  invasion  in  scarlet  fever,  the  presence  of  sore 
throat,  the  absence  of  catarrhal  symptoms,  and  the  difference  in  the  appear- 
ance of  the  eruption.  In  measles  the  period  of  invasion  is  four  days,  in 
scarlet  fever  two.  In  scarlet  fever  the  initial  symptoms  are  sore  throat  and 
nausea  or  vomiting.  In  measles  these  symptoms  are  absent,  and  in  their 
place  we  have  the  catarrhal  symptoms.  In  scarlet  fever  the  eruption  occurs 
in  the  form  of  minute  points  of  a  brick-red  color,  which  coalesce,  forming 
a  more  or  less  uniform  erythematous  redness  quite  different  from  the 
papular  eruption  of  measles. 

Measles  undoubtedly  has  been  more  frequently  confused  with  variola 
than  with  any  other  disease.  We  often  have  catarrhal  symptoms  in  variola, 
but  they  are  not  usually  so  marked  as  in  measles.  During  the  first  twenty- 
four  hours  of  variola  the  eruption  often  resembles  very  closely  that  of 
measles ;  but  if  there  is  any  uncertainty  a  delay  of  a  few  hours  will  usually 
make  the  diagnosis  clear.  A  very  important  consideration  in  the  differential 
diagnosis  is  the  fact  that  in  variola  with  the  aj)pearance  of  the  eruption  all 
the  active  symptoms  abate ;  the  pain  in  the  back,  the  headache,  the  high 
fever,  all  disappear ;  but  not  so  in  measles.  In  variola  the  eruption  soon 
becomes  more  markedly  papular,  presenting  the  shotty  feeling  when  the 
hand  is  passed  over  the  surface.  In  the  course  of  the  disease  these  papules 
become  vesicles,  and  then  pustules.  In  measles,  however,  the  eruption 
remains  papular  throughout  its  whole  course,  aud  these  papules  are  but 
slightly  elevated  above  the  surface. 

There  should  be  little  or  no  difficulty  in  distinguishing  measles  from 
varicella.  In  the  latter  disease  the  absence  of  catarrhal  symptoms  and 
the  rapid  development  of  the  eruption  into  vesicles  should  be  sufficient  to 
render  the  diagnosis  easy. 

In  typhus  fever  we  meet  with  a  petechial  eruption  somewhat  resembling 
that  of  measles,  but  it  does  not  become  confluent,  as  is  frequently  the  case 
in  the  latter  disease.  The  eruption  does  not  appear  until  the  seventh  day, 
while  in  measles  it  occurs  on  the  fourth,  and  there  is  almost  an  entire 
absence  of  the  catarrhal  symptoms  that  are  so  characteristic  of  measles. 

Complications. — The  most  common  complications  of  measles  are  in- 
flammations of  the  mucous  membranes.  These  inflammations  exist  during 
the  natural  course  of  the  disease  to  a  greater  or  less  extent,  and  are  not 
properly  complications  unless  so  intensified  as  to  give  rise  to  grave  or  dan- 
gerous symptoms.  Thus,  conjunctivitis  is  present  and  constitutes  a  promi- 
nent symptom,  but  when  so  intensified  as  to  become  purulent,  or  Avhen  in- 
volving the  cornea  in  purulent  inflammation,  it  may  be  properly  considered 
a  complication. 

Stomatitis  is  a  common  complication,  varying  greatly  in  severity.  It 
may  range  from  a  simple  inflammation  to  ulceration,  or  even  to  cancmm 
oris  or  noma.  Gangrenous  inflanniiation  of  the  mouth,  however,  more 
frequently  follows  as  a  sequel  than  as  a  complication. 

Diphtheritic  inflammation  of  the  fauces  not  infrequently  occurs,  and 


680  MEASLES. 

becomes  a  source  of  great  danger,  especially  when  it  invades  the  larynx. 
There  is  a  diiFerence  of  opinion  as  to  whether  this  complication  is  diph- 
theria engrafted  upon  the  pharyngitis  of  measles,  or  whether  the  membrane 
which  is  observed  is  due  directly  to  the  intensity  of  the  inflammation.  In- 
flammation or  oedema  of  the  larynx  independent  of  membrane-formation 
occasionally  constitutes  a  grave  complication,  that  calls  for  surgical  treat- 
ment. 

Bronchitis,  when  so  severe  as  greatly  to  increase  the  rapidity  of  respira- 
tion, elevating  the  temperature,  increasing  the  rapidity  of  the  pulse,  and 
giving  rise  to  fine  bronchial  rales,  adds  greatly  to  the  danger,  and  consti- 
tutes a  true  complication. 

Pneumonia  is  one  of  the  most  common  as  well  as  one  of  the  most  fatal 
complications  of  measles.  Catarrhal  pneumonia  will  be  indicated  by  the 
expiratory  moan,  rapid  respiration,  short  painful  cough,  elevation  of  tem- 
perature, increased  rapidity  of  pulse,  crepitant  rales,  and  slight  dulness  on 
percussion.  Lobar  pneumonia  will  present  much  the  same  series  of  symp- 
toms, with  the  exception  that  the  dulness  on  percussion  is  much  more 
marked.     The  dyspnoea,  however,  is  not  so  great  as  in  the  catarrhal  form. 

Enteritis  and  colitis  not  infrequently  occur  as  complications,  while  deaf- 
ness, otalgia,  or  suppurative  inflammation  of  the  middle  ear  often  results 
from  the  extension  of  the  inflammation  from  the  pharynx  through  the 
Eustachian  tube  to  the  drum  of  the  ear. 

Prognosis. — The  prognosis  will  depend  very  greatly  upon  the  previous 
state  of  health  of  the  patient,  the  surroundings,  and  the  care  and  attention 
the  patient  will  receive.  In  private  practice,  where  patients  will  receive 
good  and  careful  attention  and  where  the  surroundings  are  healthful,  but 
little  danger  may  be  anticipated. 

It  must  be  remembered,  however,  that  there  are  exceptions  to  this  rule. 
The  writer  well  remembers  a  notable  example.  A  yoTing  man  attending 
college,  and  in  the  very  prime  of  early  manhood,  was  taken  with  malignant 
measles,  and,  notwithstanding  that  the  surroundings  were  perfect  and  that 
the  attention  and  care  were  all  that  wealth  could  secure,  a  fatal  termination 
followed  in  a  few  days. 

Measles  occurring  in  crowded  tenement-houses,  where  the  most  careless 
nursing  is  usually  given,  in  camps,  where  patients  are  exposed  to  inclement 
weather,  or  in  crowded  hospitals,  is  a  disease  to  be  justly  dreaded.  Under 
such  circumstances  the  prognosis  must  be  very  guarded,  for  it  is  there 
that  fatal  complications  are  most  liable  to  occur. 

In  some  epidemics  the  death-rate  is  much  higher  than  in  others,  and 
the  tendency  to  fatal  complications  mucli  greater.  The  prognosis  is  favor- 
able in  those  cases  that  pursue  au  even  and  regular  course,  but  in  all  cases 
of  great  severity,  bordering  upon  malignancy,  or  that  pursue  an  irregular 
course,  or  that  develop  complications,  it  sliould  be  most  guarded.  The 
development  of  diphtheritic  pharyngitis  adds  greatly  to  the  danger,  and 
the  prognosis  is  generally  unfavorable.     The  development  of  membranous 


MEASLES.  681 

laryngitis  involves  still  greater  danger,  although  a  few  will  survive  after 
surgical  measures.  The  occurrence  of  capillary  bronchitis,  or  of  catarrhal 
or  lobar  pneumonia,  also  involves  the  case  in  great  danger.  Entero-colitis 
and  dysentery  add  greatly  to  the  distress  and  danger,  but  these  complica- 
tions can  generally  be  overcome.  The  occurrence  of  convulsions  during  the 
premonitory  stage  or  at  the  onset  of  the  eruptive  stage,  while  increasing  the 
dano-er,  does  not  necessarily  indicate  a  fatal  termination  ;  occurring,  how- 
ever, later  in  the. disease,  almost  invariably  a  fatal  termination  follows. 

The  continuance  of  high  fever  after  the  disappearance  of  the  eruption 
is  generally  an  unfavorable  indication,  denoting,  as  it  does,  the  presence  of 
some  complication. 

Treatraent. — The  treatment  of  measles  should  be  preventive,  hygienic, 
and  therapeutic. 

Preventive  treatment  consists  in  the  prompt  isolation  of  the  patient  on 
the  first  occurrence  of  the  catarrhal  symptoms,  thorough  disinfection  of  the 
apartment  and  of  all  clothing,  and  the  use  of  antiseptics  applied  to  the  body 
of  the  patient  in  the  form  of  ointments. 

As  the  disease  is  not  generally  recognized  during  the  catarrhal  stage, 
isolation  is  not  usually  eifective,  as  measles  is  highly  contagious  during 
this  early  period.  In  case,  however,  of  known  exposure,  the  patient  should 
be  isolated  on  the  appearance  of  the  earliest  symptoms,  either  by  sending 
the  well  children  from  home  or  by  removing  the  patient  to  a  distant  room 
in  the  house.  The  attendant  should  not  mingle  with  the  other  members  of 
the  household  without  first  changing  the  dress  and  washing  the  face,  hands, 
and  head  with  some  antiseptic  solution.  All  discharges  should  be  at  once 
disinfected,  and  soiled  clothing  placed  in  some  antiseptic  solution  and  then 
thoroughly  boiled.  Daring  the  illness  antiseptic  solutions  may  be  applied 
directly  to  the  body  of  the  patient  two  or  three  times  daily,  thus  preventing 
the  diifusion  of  the  poison.  For  this  purpose  carbolized  oil,  and  cold  cream 
or  vaseline  with  carbolic  acid,  may  be  employed.  After  recovery  the  patient 
should  receive  a  warm  bath  before  mingling  with  the  other  members  of  the 
family. 

The  room  should  be  thoroughly  fumigated  by  burning  sulphur  moistened 
with  alcohol,  and  all  playthings  used  by  the  patient  should  be  burned. 

Inoculation  as  a  preventive  measure  has  been  employed,  but  the  disease 
is  not  sufficiently  modified  by  this  means  to  justify  the  operation. 

The  hygieniG  treatment  is  of  great  importance  in  measles.  As  the 
disease  cannot  be  aborted  or  abridged  by  any  known  treatment,  we  must 
endeavor  by  careful  nursing  and  by  hygienic  measures  to  j)rcvent  complica- 
tions and  conduct  the  case  to  a  successful  issue.  The  jiaticnt  sliould  be 
placed  in  a  large,  well-ventilated  apartment,  which  should  be  shaded  from 
briglit  light,  but  not  completely  darkened,  and  the  temperature  should  be 
uniform.  The  covering  should  be  light  and  comfortable,  and  an  abundance 
of  water  given  when  the  patient  is  thirsty.  It  is  a  mistake,  too  frequently 
made,  to  bundle  a  child  in  heavy  blankets  and  give  nothing  but  hot  drinks. 


682  MEASLES. 

When  the  eruption  is  tardy  in  making  its  appearance,  a  warm  bath  and 
an  occasional  drink  of  hot  lemonade  may  be  useful ;  but  to  cover  a  patient 
almost  to  suffocation  and  to  give  nothing  but  hot  drinks  adds  greatly  to  the 
discomfort  of  the  child  and  accomplishes  little  good.  Little  food  is  re- 
quired, especially  during  the  first  few  days,  and  that  which  is  given  should 
be  simple  and  easily  digested.  The  patient  should  be  placed  in  bed  at 
the  onset  of  the  catarrhal  symptoms,  and  should  remain  there  until  the 
entire  disappearance  of  the  eruption.  If  this  rule  were  always  enforced,  we 
should  far  less  frequently  meet  with  dangerous  complications. 

TJierapeutiG  Treatment. — Little  medication  is  required  in  an  ordinary 
attack  of  measles.  There  is  no  specific  or  known  remedy  that  will  cut 
short  the  disease.  We  must  be  content  with  warding  off  complications  or 
meeting  them  promptly  when  they  occur.  In  case  the  cough  is  trouble- 
some, an  occasional  Dover's  powder  may  be  given,  or  a  soothing  expecto- 
rant mixture.  In  case  of  great  restlessness,  an  occasional  dose  of  bromide 
of  potassium  is  indicated.  In  the  early  eruptive  stage,  if  nausea  and 
vomiting  occur,  a  sinapism  should  be  placed  over  the  pit  of  the  stomach, 
and  equal  parts  of  lime-water  and  milk,  with  the  white  of  one  egg  to  each 
cupful,  should  be  given  in  small  quantities  and  at  frequent  intervals.  In 
case  of  constipation,  an  injection  is  preferable  to  a  cathartic ;  for  we  must 
remember  the  tendency  to  intestinal  irritation. 

Personally,  in  treating  measles  the  writer  employs  a  soothing  expec- 
torant mixture,  alternating  with  moderate  doses  of  quinine.  The  former 
quiets  the  frequent  harassing  cough  and  gives  comfort  to  the  patient,  while 
the  latter  acts  as  a  tonic,  supporting  the  system  against  the  disease  and 
assisting  in  controlling  the  febrile  action.  As  indications  arise  for  special 
treatment,  they  are  properly  met.  In  case  the  temperature  runs  above 
103°  F.  it  is  controlled  by  autipyrin,  ten  grains  in  a  teaspoonful  of  warm 
water,  injected  per  rectum  and  repeated  every  hour  until  it  is  reduced. 

In  case  there  is  a  tendency  to  malignancy,  characterized  by  the  peculiar 
appearance  of  the  eruption  and  by  rapid  and  feeble  pulse,  whiskey  is  given 
in  large  and  frequently-repeated  doses.  Keating  has  very  clearly  pointed 
out  the  fact  that  in  malignant  measles  micrococci  are  found  in  the  blood 
in  ffreat  abundance.  In  culture-solutions  it  is  well  known  that  alcohol  is 
one  of  the  most  active  destroyers  of  these  micrococci ;  and  the  benefit  derived 
from  the  administratfon  of  this  agent  in  malignant  measles  would  indicate 
that  it  has  the  same  effect  upon  these  micrococci  in  the  blood.  When  the 
patient  remains  pale  and  anaemic  after  the  attack,  arsenic  and  iron  are  espe- 
cially indicated.  When  complications  arise,  they  should  be  promptly  met 
and  treated  the  same  as  if  occurring  independently  of  the  disease  under 
consideration. 

Owing  to  the  bronchitis,  and  the  involvement  of  the  gastro-intestinal 
mucous  membrane,  which  accompany  this  disease,  the  greatest  care  should 
be  taken  during  convalescence  that  the  patient  be  not  exposed  to  sudden 
changes  of  temperature  or  to  draughts.     The  patient  should  be  sponged. 


MEASLES.  683 

off  daily  with  cool  water  aud  thoroughlj  dried,  so  that  the  functional 
activity  of  the  skin  shall  be  maintained.  It  should  be  insisted  upon  that 
flannel  be  worn,  however  light  it  may  be  in  weight.  If  it  irritates  the 
skin,  a  fine  linen  garment  may  be  worn  beneath.  Especially  should  the 
chest,  abdomen,  aud  feet  be  protected  against  cold.  Just  as  in  scarlet  fever 
the  greatest  precaution  must  be  taken  during  convalescence  to  prevent  renal 
congestion,  so  in  measles  a  pulmonary  disease  may  subsequently  terminate 
fatally  a  case  neglected  during  convalescence  in  one  who  is  constitutionally 
weak. 


RUBELLA. 

(EOTHELJv\) 
By  WILLIAM  A.  EDWAEDS,  M.D. 


Definition. — Rubella  is  a  specific,  epidemic,  and  contagious  eruptive 
fever,  occurring  independently  of  the  existence  of  either  measles  or  scarlatina, 
and  possessing  characteristic  symptoms  in  its  incubation,  invasion,  eruption, 
and  period  of  duration.  Furthermore,  it  will  reproduce  itself  only  in  those 
exposed  to  its  contagion.  One  attack  usually  protects  from  subsequent 
invasion,  but  will  not  afford  immunity  from  either  measles  or  scarlatina. 
Children  are  most  susceptible.  An  almost  constant  manifestation  of  the  dis- 
ease— indeed,  it  may  be  considered  a  prodromal  symptom — is  enlargement 
and  induration  of  the  cervical,  submaxillary,  auricular,  and  sub-occipital 
glands.     At  times  other  glands  are  affected  ;  but  suppuration  never  occurs. 

Synonymes. — The  disease  has  been  most  unfortunate  in  the  number 
of  synonymes  and  various  titles  that  have  been  applied  to  it, — a  fact  that 
has  much  retarded  its  proper  study  and  classification  and  has  also  caused  a 
vast  amount  of  confusion  in  its  recognition.  The  Germans  use  the  terms 
"  rubeola"  and  "  rotheln"  interchangeably,  and  the  French  "  rub^ole," 
whereas  many  English  and  American  writers  have  adopted  the  term 
"  rubella"  advanced  by  Veale,^  accepted  by  Squire,  and  further  receiving 
the  sanction  of  Dunglison's  Dictionary.  A  recent  writer  (Griffith)  objects 
to  the  term  rotheln,  because  it  is  usually  mispronounced  and  for  its  proper 
pronunciation  we  have  no  equivalent  vowel-sound  in  English;  advocating 
the  title  rubella  as  being  a  diminutive  of  rubeola  and  expressing  at  once  the 
usually  slight  import  of  the  disease  and  its  relationship  to  measles,  akin  to 
that  existing  between  varicella  and  variola. 

As  a  further  illustration  of  the  multiplicity  of  terms,  we  cite  :  German 
measles ;  French  measles ;  false,  bastard,  or  hybrid  measles ;  rubeola  sine 
catarrho ;  rubeola  epidemica,  morbillosa,  scarlatinosa,  notha ;  roseola ; 
roseola  epidemica;  rosalia;  rosalia  idiopathica;  hybrid  scarlatina;  and 
many  more,  which  space  forbids  us  to  mention. 

History. — Not  until  about  the  middle  of  the  eighteenth  century^  did 

1  Edin.  Med.  Jour.,  Nov.  18G6. 

*  Hoffmann,  De  Bergen,  and  Orlow,  who  published  their  papers  between  1740  and  1758. 
684 


EUBELLA.  685 

rubella  receive  separate  recognition  and  description  as  a  distinct  eruptive 
fever,  and  from  that  time  almost  until  the  present  day  medical  opinion  has 
been  somewhat  divided  upon  the  effect  of  its  distinctive  character  or  of 
its  being  a  combination  of  measles  and  scarlatina.  Indeed,  as  late  as  1865 
Kostlein^  held  rubella  to  be  a  variety  of  measles.  Within  the  last  two 
decades,  however,  a  consensus  of  opinion  has  been  secured,  and  at  the 
present  time  it  is  a  rarity  to  observe  a  writer  advocating  the  hybrid  nature 
of  the  disease.  Striimpel,  indeed,  goes  so  far  as  to  say  that  the  existence 
of  the  disease  can  be  denied  only  by  those  who  have  never  seen  it.  In  the 
latter  part  of  the  eighteenth  century  papers  were  published  by  German 
writers  (Selle,  Ziegler,  Stark,  and  others)  giving  accounts  of  epidemics 
more  or  less  severe  in  character  and  maintaining  the  specific  nature  of  the 
disease:  indeed,  Formey^  states  that  between  the  years  1784  and  1796 
eleven  hundred  and  eighty  persons  died  of  it  in  Berlin,  while  during  the 
same  interval  there  were  but  two  hundred  and  three  deaths  from  scarlatina 
and  one  hundred  and  three  from  measles.  Thomas,^  however,  gives  these 
figures  very  differently,  stating  that  according  to  Formey  there  died  between 
1784  and  1794  in  Berlin  four  hundred  and  fifty-seven  from  rubeola,  one 
hundred  and  seventy-two  from  scarlet  fever,  and  fifty-three  from  measles. 
Opportunity  has  not  been  afforded  me  of  consulting  the  original,  and  I  am 
unable  to  decide  which  is  correct.  In  1840,  Patterson*  wrote  advocating 
the  distinct  character  of  the  disease ;  and  his  views  for  a  time  received  sup- 
port, particularly  from  Balfour^  and  Tripe.''  Many,  however,  did  not  believe 
at  all  in  its  separate  existence.  Goden^  and  Jahn^  were  of  this  class,  the 
former  confounding  it  with  scarlatina,  and  the  latter  denying  its  existence ; 
Heim^  regarded  it  as  an  anomalous  scarlatina,  more  dangerous  than  that 
disease  itself,  and  he  was  supported  in  this  view  by  Reil,  Hufeland,  and 
Frank.  Other  writers  declared  that  it  was  measles,  and  attributed  its  pecu- 
liarity to  a  "  certain  individuality :"  these  are  the  writers  who  describe  a 
"  rubeola  morbillosa  et  scarlatinosa,"  to  give  this  view  a  terse  expression. 
Hildebraud  and  Schonlein  discussed  an  hermaphrodite  form  of  measles  and 
scarlatina,  maintaining  that  in  rubella  we  had  a  disease  which  was  a  hybrid 
of  the  other  two  fevers.  This  "  hybrid"  disease  for  a  time  took  fast  hold 
upon  professional  opinion,  and  was  advocated  by  Geertsema,  Busche,  Paasch, 
Gelmo,  and  many  others,  as  stated  by  Griffith.^  Copland  and  Aitken  both 
agreed  that  it  was  a  liybrid,  Gintrac,  Hebra,  and  others  also  sliariug  in  this 
view.  Indeed,  as  late  as  the  present  decade  a  writer  has  denied  the  speci- 
ficity of  the  disease.  But,  on  the  other  hand,  the  overwhelming  mass  of 
testimony  is  in  fixvor  of  its  distinct  character,  as  we  before  stated  :  indeed, 

^  Wiener  Med.  Presse,  1868,  xiii.  (Atkinson). 

2  Quoted  by  Griffith,  Med.  Kec.,  July,  1887. 

'  Ziemssen's  Cyc,  vol.  ii.,  Amer.  edit.,  p.  131. 

♦  W.  A.  Edwards,  Amer.  Jour.  Med.  Sci.,  Oct.  1884. 

5  Edin.  Med.  Jour.,  1857,  p.  718. 

6  Medical  Times,  1852,  v.  457.  ''  Ibid. 


686  RUBELLA. 

not  to  recognize  it  as  a  separate  and  distinct  disease  is  almost  a  confession 
of  not  having  witnessed  a  series  of  cases/ 

Let  us  review  for  a  moment  the  grounds  upon  which  we,  in  common 
with  most  writers  for  the  last  twenty  years,^  decide  that  rubella  is  an  inde- 
pendent disease.  First,  rubella  is  a  disease  sui  generis,  and  is  in  no  way 
related  to  either  measles  or  scarlatina ;  it  is  not  a  combination  of  these,  nor 
is  it  a  hybrid ;  it  has  never  given  rise  to  any  disease  but  itself  in  those 
exposed  to  its  contagion. 

Epidemics  of  rubella  prevail  without  any  regard  to  the  existence  of 
cases  or  epidemics  of  either  measles  or  scarlatina.  An  attack  of  rubella 
will  not  jjrotect  from  either  of  these  diseases ;  the  converse  of  this  propo- 
sition is  also  well  established  by  clinical  experience.  One  attack  probably 
protects  from  a  second.  In  my  own  experience  of  over  two  hundred  cases 
I  have  never  observed  a  second  attack  in  the  same  individual,  excluding,  of 
course,  relapses,  which  we  will  consider  later. 

To  conclude,  its  symptomatology,  invasion,  eruptive  course,  and  dura- 
tion differ  much  from  those  of  either  of  the  other  forms  which  it  is  said  to 
resemble.  There  is  no  dearth  of  clinical  material  to  show  that  rubella  does 
attack  those  who  have  had  either  measles  or  scarlatina  or  both  :  many  of  my 
cases  had  had  these  diseases ;  some,  in  fact,  were  just  recovering  from  them 
when  prostrated  by  rubella.  The  literature  presents  many  similar  instances, 
to  which  I  have  before  referred.  Since  then  recent  writers  have  further 
strengthened  the  statements  by  the  citation  of  additional  examples :  for 
instance,  Griffith  states  that  quite  a  number  of  the  cases  reported  in  his 
article  had  previously  had  measles  or  developed  it  afterwards ;  of  Hatfield's 
one  hundred  and  ten  cases  many  had  had  measles  and  scarlatina ;  Atkinson 
observes  the  same  condition ;  most  of  the  one  hundred  cases  reported  by 
Park  had  had  measles ;  Riggs's  cases  had  previously  suffered  from  measles 
or  scarlatina ;  out  of  sixty-three  cases  reported  by  Clement  Dukes,  thirty- 
nine  had  had  measles,  one  had  rubella,  and  measles  three  weeks  afterwards, 
another  measles  twenty-two  days  later ;  and  of  Shuttleworth's  twenty-seven 
cases,  fifteen  had  had  measles  and  scarlatina,  and  five  had  both  diseases  in 
later  years. 

A  most  interesting  case,  as  bearing  on  the  point  at  issue,  to  which  I 
have  already  referred,  is  that  reported  by  Tompkins,  in  which  a  girl  was 

^  The  independent  nature  of  this  disease  has  been  and  is  now  accepted  by  the  follow- 
ing writers  :  Alibert,  Arnold,  Atkinson,  Barthez  and  Rilliet,  Balfour,  Behrend,  Bourne- 
ville  and  Bricon,  Brown,  Cheadle,  Collin,  Cotting,  Cuomo,  Damaschino,  Davis,  Delastre, 
De  Man,  Dukes,  Earle,  Emminghaus,  Edwards,  Faber,  Fleischmann,  Gerhardt,  Green, 
Griffith,  Grove,  Hatfield,  Hardaway,  Hennig,  Homans,  Kingsley,  Kiister,  Liveing,  Lind- 
wurm,  Longuet,  Lubanski,  Maton,  Mettenheimer,  Murchison,  McLeod,  Xymann,  Oester- 
reich.  Park,  Patterson,  Roger,  Roth,  Salzmann,  Schwarz,  Smith,  Striimpel,  Steiner,  Shuttle- 
worth,  Squire,  Thomas,  Thierfelder,  Tonge-Smith,  Trastour,  Tripe,  Trousseau,  Yeale,  Yogel, 
Wagner,  "Wilson. 

^  The  following  recent  writers  deny  its  specificity :  Fagge,  Goodhart,  Henoch,  Stewart, 
Oxley.     Descroizilles  does  not  acknowledge  its  existence  at  all. 


RUBELLA.  687 

attacked  by  rubella,  lasting  five  days;  three  days  after  recovery  she  wa.s 
attacked  by  scarlatina,  as  she  had  been  sent  to  the  hospital  as  a  scarlatinous 
case  and  there  exposed  to  it. 

Etiology. — There  is  but  little  doubt  that  rubella  is  directly  contagious; 
it  is  also  more  prone  to  be  epidemic  than  its  congeners,  and  its  contagiousness 
seems  to  depend  greatly  upon  the  exposure  and  amount  of  the  contagium 
absorbed,  be  it  what  it  may,  which  appears  to  come  off  in  the  cutaneous 
exhalations  and  the  breath  and  to  be  conveved  bv  fomites,  clothing,  etc. 
Many  of  my  earlier  cases — indeed,  quite  seventy-five  per  cent. — could  be 
distinctly  traced  to  infected  ships,  particularly  the  "  bunks"  of  steerage- 
passengers,  an  environment  which  Avould  also  present  heat  and  moisture, 
potent  factors  in  its  production.  For  example,  in  the  island  of  Malta, 
after  the  rainy  season  the  disease  prevails  to  its  greatest  extent.  My  own 
experience  leads  me  to  conclude  that  rubella  is  one  of  the  most  contagious 
of  all  the  eruptive  fevers,  more  particularly  when  occurring  in  large  institu- 
tions, as  in  my  first  one  hundred  cases  in  the  Philadelphia  Hospital.  Still, 
it  must  be  remembered  that  these  cases  were  particularly  virulent,  show- 
ing a  mortality  of  four  and  a  quarter  per  cent.,  and  occurred  among  chil- 
dren who  had  just  passed  through  the  experience  of  an  immigrant  aboard 
the  large  ocean-steamers,  an  experience  which  is  certainly  not  conducive  to 
a  very  high  state  of  health  in  young  children  who  left  the  vessels  to  become 
inmates  of  a  large  city  hospital.  Some  writers,  however,  doubt  the  fact  of 
its  contagiousness.  Atkinson  believes  that  it  is  not  violently  contagious, — 
far  less  so  than  measles.  Steiner  goes  further,  and  denies  its  contagious- 
ness altogether.  Nymann  and  Klaatsch  consider  it  very  feebly  contagious, 
and  Picot,  Mettenheimer,  Arnold,  De  Man,  and  Lindwurm  think  that  it 
is  probably  contagious.  Thomas,  Liveing,  Tonge-Smith,  Bourneville,  and 
others  consider  it  less  contagious  than  measles,  whereas  Jacobi,  Dukes,  and 
Squire  consider  it  very  contagious,  the  latter  stating  that  this  contagiousness 
is  marked  even  before  the  appearance  of  the  rash,  and  persists  for  two  or 
three  weeks  after  its  disappearance.  Griffith  concludes  from  his  own  expe- 
rience that  the  contagious  nature  of  rubella  is  very  decided  :  for  example, 
out  of  about  one  hundred  children  in  a  "  home"  which  he  attended,  thirty- 
seven  took  the  disease  in  spite  of  the  most  prompt  and  careful  isolation ; 
out  of  approximately  the  same  number  in  another  institution,  twenty-six 
were  attacked.  In  Hatfield's  experience,  one  hundred  and  ten  of  the  one 
hundred  and  ninety-six  inmates  of  the  asylum  suffered  from  the  disease. 

Let  us  for  a  moment  consider  the  question  of  its  infectiousness.  Many 
of  my  first  cases  could  be  directly  traced  to  infection  from  the  bunks  in 
ships.  Emminghaus  considers  this  proved  ;  Thomas,  Veale,  and  others  are 
of  a  similar  opinion. 

The  disease  is  more  prone  to  be  epidemic  than  cither  measles  or  scarla- 
tina. Liveing  and  Thomas  are  of  a  similar  opinion ;  and  J.  F.  Meigs,  in  a 
personal  communication  to  Griffith,  considers  it  more  apt  to  be  epidemic  than 
contagious.     My  own  experience  leads  me  to  agree  entirely  with  Squire  in 


688  EUBELLA. 

that  the  disease  is  contagious  throughout  its  entire  course,  from  the  period 
of  incubation,  during  and  well  into  the  stage  of  convalescence. 

As  stated  in  an  earlier  paper  (1884),  the  specific  cause  of  the  disease  had 
not  been  isolated,  nor  has  any  advance  in  this  particular  been  made  since 
then.  An  examination  of  the  blood  in  my  Philadelphia  Hospital  cases 
(one  hundred  in  number)  proved  the  presence  of  micrococci  in  the  blood, 
liquor  sanguinis,  and  white  corpuscles,  although,  as  then  stated,  I  was  unable 
to  trace  any  direct  relation  between  these  bodies  and  the  disease  under  con- 
sideration.^ Opportunity  has  not  offered  itself  for  me  to  pursue  the  subject 
further,  and,  so  far  as  I  know,  other  observers  have  not  taken  up  the  in- 
vestigation, either  to  verify  or  to  disprove,  with  the  exception  of  Hatfield, 
who  considers  the  virulence  of  the  epidemic  to  be  due  to  the  ravages  of  the 
rubella-microbe.  Steeves  makes  the  somewhat  remarkable  statement  that 
under  certain  constitutional  conditions  the  contagion  of  scarlet  fever  may 
be  the,  exciting  factor  in  producing  such  a  poison  in  the  system  as  shall 
determine  the  specific  disease  in  question,  thus  showing  that  even  in  the 
present  decade  a  writer  will  occasionally  assert  the  now  wholly-disproved 
hybrid  nature  of  the  disease. 

Age. — Rubella  is  pre-eminently  a  disease  of  childhood,  most  cases  oc- 
curring at  or  before  the  fifth  year.  Hatfield  considers  that  the  liability 
increases  in  inverse  proportion  to  the  age ;  Sholl  has  seen  it  transmitted 
from  the  pregnant  mother  (seven  months)  to  the  unborn  child  and  devel- 
oped a  few  days  after  the  birth  of  the  child ;  many  of  Smith's  and  Hard- 
away's  cases  were  infants.  Roth  and  Steiner  record  a  case  in  a  babe  of  six 
months.  On  the  other  hand,  Griffith  considers  early  infancy  as  almost  ex- 
empt. The  majority  of  cases  occur  between  five  and  fifteen  years  of  age, 
but  adults  are  often  attacked.  I  have  witnessed  several  severe  and  pros- 
trating attacks  in  adults  from  twenty  to  thirty  years  of  age.  That  more 
adults  are  not  attacked  is  caused  by  the  fact  that  they  are  not  so  much  ex- 
posed, as  the  described  outbreaks  are  usually  in  children's  asylums,  and  not 
in  general  hospitals.  I  do  not  recognize  the  fact  that  adults  possess  any 
special  immunity  from  the  disease,  but  rather  the  fact  that  they  are  not 
often  exposed,  or  that  they  are  protected  by  a  previous  attack.  This,  how- 
ever, is  not  Griffith's  experience,  as  there  were  many  adults  connected  with 
the  institutions  for  children  in  which  one  hundred  of  his  cases  occurred, 
yet  but  one  of  the  number  was  attacked.  Kassowitz  noted  but  five  adults 
among  sixty-four  cases  in  private  practice.  As  illustrating  the  extremes  of 
age  attacked,  Seitz  reports  a  case  in  a  woman  aged  seventy-three. 

Sex. — Sex  is  not  an  etiological  factor  worthy  of  consideration.  Of  three 
hundred  and  thirty-one  cases,  one  hundred  and  fifty-one  were  males  and  one 
hundred  and  eighty  females  (Hatfield).  In  my  own  experience  more  adult 
females  were  attacked  than  males ;  but  a  moment's  reflection  ^^'ill  explain 

^  A  similar  though  more  marked  appearance  was  seen  in  the  blood  in  cases  of  malignant 
measles,  in  which  we  were  able  to  show  a  definite  relation  between  the  cocci  and  the  disease. 
—Keating,  Trans.  Coll.  Phys.  Phila.,  June  7,  1882. 


EUBELLA.  689 

this,  since  they  were  more  exposed  to  the  contagion  than  the  male  members 
of  the  family. 

Stage  of  Incubation. — This  is,  of  course,  most  difficult  to  decide  posi- 
tively, as  symptoms  are  almost  entirely  absent  during  this  time.  Squire, 
however,  states  that  epistaxis  and  enlargement  of  the  post-cervical  glands 
may  be  noted,  also  that  the  throat  may  be  a  little  sore, — symptoms  that  we 
should  be  now  inclined  to  class  among  those  of  invasion  rather  than  of  in- 
cubation. 

As  nearly  as  I  have  been  able  to  ascertain,  the  duration  of  this  stage 
is  about  ten  days, — certainly  between  ten  and  twelve  :  the  shortest  period 
recorded  was  six  days,  and  the  longest  twenty-one.  The  duration  of  this 
period,  however,  must  be  very  variable,  as  almost  every  observer  has 
allotted  a  different  time :  for  example,  Griffith,  five  to  eleven  days ;  Mus- 
ser,  six  days ;  Atkinson,  fourteen  to  twenty-one  days ;  Hatfield,  ten  days ; 
James  Robinson,  six  to  seven  days ;  Glaister,  four  to  five  days  or  longer ; 
Duckworth,  sixteen  days;  James  Pollock,  six  to  sixteen  days;  L.  A. 
Clausen,  seventeen  to  twenty  days ;  J.  L.  Smith,  seven  to  twenty-one 
days ;  Earle,  seventeen  to  twenty-one  days ;  Bourneville  and  Bricon,  eight 
to  ten  days ;  Jacobi,  fourteen  to  twenty-one  days ;  Squire,  eight  to  twenty- 
one  days, — generally  two  weeks  ;  Sholl,  five  to  twenty-one  days  ;  Cheadle, 
eleven  to  twelve  days ;  Dukes,  twelve  to  twenty-two  days, — average,  fif- 
teen to  sixteen  days ;  Steiner,  ten  to  fourteen  days ;  Cuomo,  seventeen  days, 
— never  less.  Many  observers  place  it  at  "two  weeks  or  longer;"  several 
at  "  two  to  three  weeks ;"  some  at  two  and  one-half  to  three  weeks ;  and 
one  observer  (Cotting)  at  three  weeks.  Hardaway  remarks  that,  "taken 
as  a  whole,  it  is  probably  longer  than  is  observed  in  measles." 

Griffith  considers  this  varying  period  of  incubation  to  be  of  diagnostic 
value,  thus  differentiating  from  the  fixed  period  of  measles. 

Stage  of  Invasion. — In  most  cases  this  stage  is  apt  to  be,  at  least  in  its 
incipiency,  without  any  very  characteristic  symptoms.  Indeed,  excluding 
hospital  cases,  and  referring  to  those  in  private  practice,  I  may  say  that 
it  is  almost  without  any  symptoms  until  a  few  hours  before  the  eruption 
appears.  More  extended  experience  has  convinced  me  that  epidemics  of 
rubella  occurring  in  asylums,  nurseries,  hospitals,  and  the  like  differ  in 
many  essential  characters  from  those  that  we  see  in  private  practice  and 
among  the  better-housed  and  better-fed  class  of  children.  For  example, 
my  Philadelphia  Hospital  cases  were  of  the  most  severe  type,  j^rcsenting 
many  symptoms  during  the  period  of  invasion,  whereas  those  outside  of  the 
hospital  were  comparatively  exempt  from  symptoms  at  this  time. 

]\Iy  notes  record  the  following  symptoms :  chilliness,  languor,  faintness, 
headache  more  or  less  severe,  pain  in  the  back  and  limbs,  coryza,  red  and 
watery  eyes,  sore  throat,  cough,  and  occasionally  a  hoarse,  husky  voice.  As 
illustrating  the  more  severe  character  of  some  of  the  first  one  hundred  cases, 
we  note  a  rise  of  temperature  during  this  period.  Many  of  the  patients 
did  not  show  a  higher  registration  than  100°  F.,  others  varied  from  this 
Vol.  I.— 44 


690  EUBELLA. 

point  to  103°  F. ;  nausea  and  von-iiting,  delirium  and  convulsions,  and  epis- 
taxis  in  three  cases.  Other  observers  have  noted  marked  prodromal  symp- 
toms during  the  invasion  :  two  cases  of  hemorrhage  from  the  eyes  and  ears 
have  been  recorded  by  Prioleau ;  convulsions  by  Smith  and  others ;  delirium 
by  Hardaway  and  Cuomo ;  urticaria  by  Cullingworth  in  four  cases ;  rigors  by 
Nymann  and  dizziness  by  Squire ;  Mettenheimer  notes  fainting,  and  Balfour 
a  croupy  condition ;  Earle,  Kingsley,  and  Thierfelder  report  a  prodromal 
rash,  and  Cuomo  and  myself  an  erythema  preceding  the  specific  rash. 

In  a  former  paper  I  have  considered  the  average  duration  of  the  in- 
vasion stage  as  three  days.  Again  in  this  particular  do  we  find  a  great 
difference  of  opinion,  some,  as  Griffith,  McLeod,  Murchison,  and  Berens, 
placing  the  duration  at  two  days  (twenty-four  to  forty-eight  hours) ;  other 
periods  recorded  are  as  follows:  one  to  three  days;^  two  to  three  days;^ 
three  days;^  three  to  four  days;*  four  days;^  a  few  hours  to  five  days;® 
two  to  six  clays;^  six  to  seven  days;^  twelve  hours  to  three  days;^  one 
day  ;^''  two  hours  to  a  half-day  ;"  about  a  week.^^ 

Most  cases,  except  those  in  a  severe  epidemic,  will  have  the  shorter 
period  of  invasion  and  present  but  few  symptoms. 

Stag"e  of  Eruption.— After  the  existence  of  prodromal  symptoms  which 
have  lasted  a  variable  period,  from  a  few  hours  to  a  week,. the  characteristic 
eruption  appears.  In  some  cases  the  prodromal  symptoms  have  been  so 
slight  that  apparently  the  eruption  appears  without  them,  and,  as  Thomas 
tells  us,  the  child  is  found  covered  with  it  after  a  quiet  night's  sleep.  Rapid 
extension  of  the  eruption  progressively  downwards,  about  in  the  following 
order,  Avas  most  frequently  noted  in  my  cases  :  face,  neck,  chest,  arms,  back, 
groin,  and  lower  extremities.  Many  writers  have  observed  the  same  course 
in  the  eruption.  Some,  however,  have  noted  other  points  for  its  first  ap- 
pearance. For  example,  Earle  observed  it  first  on  the  neck  and  chest,  but 
adds  that  the  exanthem  may  be  preceded  some  hours  by  a  redness  of  the 
forehead  and  cheeks,  really  an  erythema,  and  then  the  spots  make  their 
appearance.  Willcocks  and  Carpenter  state  that  the  eruption  first  appears 
on  the  face  at  the  margin  of  the  hair.  Morris  and  Liveino;  reo;ard  its  first 
appearance  to  be  on  the  back  and  chest ;  whereas  Murchison  and  Balfour 
state  that  it  is  first  seen  on  the  breast  and  arms.  Patterson  and  Copland 
are  of  the  opinion  that  it  comes  out  all  over  the  body  at  once. 

In  considering  this  subject  we  must  bear  in  mind  that  the  eruption  of 
rubella  is  by  no  means  uniform,  and  that  it  differs  in  various  epidemics  and 
in  isolated  cases. 

In  some  of  Griffith's  cases  the  eruption  appeared  on  the  brow,  the  body 
of  the  lower  jaw,  and  the  neck,  but  not  on  any  other  part  of  the  body. 

1  Mettenheimer,  Henderson,  Emminghaus,  Koth,  Thierfelder,  Kingsley. 
"^  Cuomo,  Chcadlc,  Copland.  ^  Cullingworth  and  myself. 

*  Aitken,  Patterson.  ^  Lindwurm.  ^  Hemming.  '  Balfour. 

8  Clau.'^en.  »  Eoth.  "  Veale,  Day.  "  Thomas. 

^2  Willcocks  and -Carpenter. 


RUBELLA.  691 

Park  has  observed"  that  the  eruption  is  often  seen  first  on  the  roof  of  the 
mouth,  then  appears  on  the  neck.  Heim  is  further  of  the  opinion  that 
there  may  be  in  this  disease  a  local  eruption ;  and  the  case  recorded  bv  Reed, 
in  which  the  eruption  appeared  only  upon  the  tonsils  and  velum  palati,  no 
rash  whatever  manifesting  itself  on  any  external  part  of  the  body,  give? 
strength  to  the  statement. 

]My  own  experience  is  that  no  part  of  the  body  is  exempt,  not  even  the 
soles  and  palms,  as  stated  by  Emminghaus  and  Smith.  On  the  other  hand, 
I  have  noted  a  local  eruption  confined  to  a  small  part  of  the  brow,  face, 
or  neck,  in  which  the  diagnosis,  unassisted  by  the  known  presence  of  an 
ej)idemic  of  the  disease,  would  have  been  very  difficult  indeed. 

Tonge-Smith  has  noted  the  eruption  within  the  oral  circle. 

In  my  own  cases  the  rash  was  multiform  in  character,  more  or  less  Con- 
fluent, occasionally  ill  defined,  in  color  rosy  or  pale  red.  A  few  cases  of 
the  brightest  scarlet  and  some  purplish  tints  were  observed.  The  rash  was 
punctated ;  small  macu.les  were  noted ;  over  the  more  vascular  parts  the  rash 
was  sometimes  elevated,  producing  a  rough  skin  easily  detected  by  the  touch. 
The  patches  were  very  irregular  in  outline,  shape,  and  size,  the  last  factor 
being  the  most  irregular.  The  centre  of  each  patch  was  much  higher  in 
color  than  any  other  part. 

Much  hypersemia  of  the  intervening  skin  was  present  in  many  cases ; 
itching  was  then  a  more  marked  symptom.  In  rare  instances  the  eruption 
goes  on  to  the  formation,  upon  hypersemic  spots,  of  a  varying  number  of 
vesicles  resembling  miliaria. 

In  my  experience  the  eruption  was  generally  discrete,  and  had  but  little 
tendency  to  become  confluent :  when  confluence  occurred  it  was  most  marked 
on  the  face  or  on  the  extremities,  particularly  the  joint-surfaces  and  those 
parts  warmed  by  contact,  as  the  groin  or  nates.  On  the  posterior  surface 
of  the  body  the  rash  is  paler  and  of  a  diiferent  color, — more  brownish. 

Griffith  states  that  pressure  has  much  to  do  with  the  character  of  the 
eruption,  and  cites  in  illustration  a  patient  in  whom  the  eruption  was  dev^el- 
oped  in  two  circular  bands,  one  around  each  leg,  above  the  knee,  where  the 
garter  had  been  Avorn.     Klaatsch  has  noted  the  same  thing. 

According  to  Thomas,  the  eruption  is  due  to  a  capillary  hyperemia  of 
the  papillary  body  of  the  uppermost  layer  of  the  corion.  Hcim  and  Pat- 
terson compare  the  apjiearance  of  the  eruptive  patch  in  color  to  that  pro- 
duced by  a  writing-quill  dipped  in  red  ink  and  having  its  i)oint  placed  on 
moist  white  paper.  Thomas,  however,  considers  the  eruption  in  color  to  be 
a  pale  rose-red,  not  so  red  as  scarlatina,  nor  so  bluish  as  measles.  I  liave 
never  seen  the  eruption  of  such  an  intense  red  as  indicated  by  the  com- 
parison of  Heim  and  Patterson. 

Elevation  of  the  rash  above  the  skin  has  also  been  noted  by  several  ob- 
servers :  indeed,  Aitken  states  that  it  is  more  elevated  even  than  in  measles. 
Gerhardt  and  Thomas,  with  others,  have  observed  that  the  erui)tion 
has  smooth  or  irregular  indented  edges,  and  that  when  it  occurs  in  the 


692  BUBELLA. 

latter  form  the  lesions  are  sometimes  connected  with  one  another  by  little 
prolongations.  I  have  never  observed  this  character  of  rash,  but  Emming- 
haus  speaks  of  small  blood-vessels  which  are  seen  in  the  skin,  and  Cuomo 
has  observed  a  similar  appearance.  These  observers  also  refer  to  a  marbled 
condition  of  the  skin.  Dunlop  says  that  he  has  seen  petechise ;  Cheadle  has 
noted  the  same  thing,  as  has  also  Erskine,  in  the  uvula  and  soft  palate ; 
and  Glaister  has  observed  a  purpuric  rash.  Griffith  and  Clausen  have  noted 
a  shot-like  sensation  beneath  the  skin.  The  former  observer  states  that  the 
eruption  in  this  particular  case  appeared  on  the  first  day,  and  was  composed 
principally  of  annular  spots,  from  the  size  of  a  pea  to  that  of  a  silver  three- 
cent  piece,  of  a  pale  rose-red  color,  with  a  distinct  yellowish  tinge  in  the 
centre. 

The  eruption  may  seemingly  appear  and  disappear  within  twenty-four 
hours;  but  this  is  probably  because  it  attains  its  maximum  intensity  in 
the  various  parts  of  the  iDody  at  different  times,  and  not  because  the 
eruption  has  totally  disappeared  at  any  one  time.  Griffith,  however,  states 
that  he  has  seen  one  case  in  which  it  was  invisible  during  one  day  and 
returned,  and  mentions  a  case  of  Musser's  in  which  the  rash  was  kept  visi- 
ble only  by  the  repeated  use  of  hot  baths.  This  observer  concludes  from  his 
own  experience  that  there  are  two  easily-recognizable  types  of  anomalies  in 
the  typical  eruption  that  we  have  been  considering,  and  styles  them  (1) 
rubella  morbilliforme,  and  (2)  rubella  scarlatiniforme.  The  former  is  com- 
posed of  spots  nearly  or  fully  the  size  of  a  split  pea,  more  or  less  grouped, 
and  in  this  respect  resembling  measles  very  closely.  I  have  noted  many 
cases  of  this  character,  in  which,  but  for  the  known  presence  of  an  epidemic 
of  rubella,  if  considering  the  skin-appearances  alone,  I  should  have  been 
compelled  to  hesitate  in  my  diagnosis. 

The  latter  form  closely  resembles  the  skin-appearances  of  scarlatina. 
Here  again  the  resemblance  is  close  indeed,  and  we  can  readily  appreciate 
the  confusion  of  the  earlier  writers  which  has  handed  the  disease  down  to 
us  as  a  "  hybrid."  In  these  cases  the  color  is  more  vivid  and  the  redness 
more  uniform,  the  patches  increasing  in  area  and  coalescing  until  the  resem- 
blance to  scarlatina  is  almost  absolute,  Heim  states  that  we  may  isolate 
the  original  lesions  by  pressing  the  surface  firmly  with  the  finger,  when  they 
will  become  less  anaemic  than  the  surrounding  areas.  In  these  cases  of 
scarlatiniform  eruption  macules  and  papules  are  also  present,  but  not  so 
well  marked  as  in  the  other  form.  The  following  observers  have  noted 
the  close  resemblance  which  the  eruption  may  sometimes  have  to  measles  or 
scarlatina.  Harrison,  Klaatsch,  Copland,  and  Goodhart  consider  that  it 
may  resemble  either  measles  or  scarlatina,  and  Byers,  Picot,  and  Hender- 
son have  observed  many  cases  in  which  it  was  morbilliform  in  one  part  and 
scarlatiniform  in  another  portion  of  the  same  patient,  Ladell  adding  three 
cases  of  this  nature  to  those  already  recorded.  Dukes  and  Kassowitz  state 
that  it  may  resemble  measles,  and  Murcliison,  Liveing,  and  Tonge-Smith 
that  it  closely  simulates  scarlet  fever. .  This  list  could  be  almost  indefinitely . 


RUBELLA.  693 

prolonged,  bat  to  no  purpose :  sufficient  has  been  cited  to  show  that  the 
eruption  of  rubella  is  indeed  multifonn  in  character.  To  my  mind,  a  too 
minute  and  restricted  consideration  of  the  conditions  of  the  skin  is  responsi- 
ble for  a  vast  amount  of  the  confusion  which  has  arisen  in  the  recognition 
and  classification  of  this  disease,  and  for  the  various  opinions  that  prevail 
in  regard  to  the  nature  of  the  exanthem.  If  we  pay  more  attention  to  the 
general  constitutional  condition  of  the  patient,  less  confusion  will  arise,  and 
the  literature  will  not  present  the  distinction  made  by  a  recent  Russian 
writer  of  a  rubeola  scarlatinosa  and  a  rubeola  morbillosa.  After  all,  we 
may  agree  with  Maton,  an  early  English  writer,  that  the  true  distinctions 
of  this  disease  are  to  be  founded  on  the  more  general  and  constitutional  con- 
ditions. In  conclusion  I  can  but  refer  to  the  three  forms  of  eruption 
described  by  Thomas,  depending  on  the  size  of  the  spots, — a  classification 
which  to  my  mind  is  decidedly  strained, — and  that  of  Emrainghaus,  who 
describes  a  confluent  and  a  discrete  type,  IvTymann  and  Klaatsch  adding 
their  quota  by  recording  a  punctate  type  and  another  whose  characteristics 
are  large  spots.  The  eruption  does  not  reach  its  height  in  all  parts  of  the 
body  at  the  same  time :  indeed,  it  is  fading  in  one  part  and  appearing  in 
another,  so  that  the  part  first  affected  has  usually  returned  to  the  normal 
by  the  time  the  patches  that  last  appeared  have  reached  their  maximum. 
These  local  areas  of  eruption  have  a  developmental  duration  of  a  few  hours 
to  a  day.  INIy  own  experience  has  been  that  the  face  and  upper  chest  are 
the  regions  of  most  persistent  eruption,  and  that,  while  it  appears  in  these 
regions  usually  first,  it  also  remains  there  the  longest.  INIany  writers  con- 
sider that  the  fact  of  the  eruption  reaching  its  height  in  different  parts  of 
the  body  at  different  times  is  a  diagnostic  sign  of  the  greatest  importance ; 
I,  however,  have  been  unable  to  attach  the  same  value  to  this  matter  as  do 
Emminghaus,  Mettenheimer,  Hardaway,  and  Roth. 

The  total  duration  of  the  rash  is  much  influenced  by  the  character  and 
type  of  the  epidemic,  and  has  been  variously  reported  by  different  observers. 
The  average  duration  in  over  two  hundred  cases  of  my  own  is  five  days.  In 
this  scries  the  shortest  was  scarcely  two  days,  and  the  longest  of  all  the  cases 
was  fifteen.  Writers  have  noticed  the  greatest  variability  in  this  period : 
for  example,  Clausen  and  J.  L.  Smith,  three  days  ;  Emminghaus  and 
Kingslcy,  two  to  four  days ;  Maton  and  Picot,  three  to  four  days ;  Cop- 
land and  Aitken,  four  to  five  days ;  Hatfield,  four  days ;  Willcocks  and 
Carpenter,  one  to  four  days ;  Liveing,  five  to  seven  days ;  Klaatsch,  one  to 
five  days ;  Trousseau,  one  to  two  days.  Alexander  has  observed  the  dura- 
tion to  be  almost  as  long  (fourteen  days)  as  that  recorded  in  one  of  our 
cases.  On  the  other  hand,  Gerhardt  has  seen  it  last  but  from  one-half  to 
one  day,  and  Griffith,  one  to  five  days.  Wc  may  conclude,  from  this  mass 
of  testimony,  first,  that  the  duration  of  the  eruption  of  rubella  is  very 
variable,  from  one  to  fifteen  days,  and,  secondly,  that  its  average  duration 
may  be  placed  at  from  three  to  four  days. 

Desquamation. — The  eruption  in  all  my  cases  was  followed  by  dcsqua- 


694  EUBELLA. 

mation  of  furfuraceous  scales.  In  quite  a  number  of  the  cases  the  des- 
quamation was  well  marked,  in  others  only  on  particular  parts  of  the  body, 
in  these  instances  especially  about  the  nose.  The  buccal  cavity  also  partook 
of  the  general  desquamation ;  it  was  here  best  marked  in  the  throat  proper. 
The  larger  scales  were  those  from  the  hands  and  feet.  Usually  the  peeling 
was  by  furfuraceous  scales,  and  it  always  commenced  in  the  centre  of  an 
eruptive  patch,  thence  extending  to  the  circumference.  There  is  not  entire 
unanimity  among  observers  as  to  the  presence  of  this  desquamation,  but 
Griffith,  Aitken,  Patterson,  Squire,  Sholl,  and  Hemming  have  all  observed 
it.  On  the  other  hand,  it  has  never  been  observed  by  several  writers 
of  acknowledged  worth,  as  Steiner,  Thomas,  Goodhart,  Bourneville,  and 
others.  A  delicate  brownish-yellow  pigmentation  was  not  infrequently 
observed  after  the  eruption  had  subsided :  this  coloring  did  not  appear  to 
bear  any  relation  to  the  color  of  the  eruption  or  its  severity.  This  con- 
dition has  been  noted  by  many  observers, — Griffith,  Thomas,  Rilliet  and 
Barthez,  Emminghaus,  Cheadle,  and  Stone,  who  speak  of  a  staining  of  the 
face  lasting  two  or  three  days,  while  Kassowitz  notes  a  mottling  of  the  skin, 
lasting  about  eight  days  after  recovery.  In  my  own  cases  the  duration  of 
the  desquamation  was  very  indefinite :  in  no  instance,  however,  have  I  seen 
it  last  over  twenty  days,  and  rarely  so  long.  Squire  has  noticed  its  per- 
sistence until  the  third  week,  and  Sholl  until  the  fortieth  day.  A  fair 
average  duration  would  perhaps  be  about  three  days. 

Symptoms  of  the  Stage  of  Eruption. — Superadded  to  the  previously- 
existing  symptoms  which  we  have  already  detailed  under  the  head  of  in- 
cubation, the  eruptive  stage  presented  a  rise  in  temperature  of  from  1°  to 
3°  F. ;  103°  and  104°  F.  are  recorded  in  my  notes,  the  temperature,  as  a 
rule,  being  in  proportion  to  the  extent  and  severity  of  the  eruption.  Davis  ^ 
records  a  temperature  of  106°  F.  in  a  young  boy,  with  livid  eruption  and 
convulsions  and  a  rapid  running  pulse;  Haig-Brown^  one  of  105°  F. 
Once  more  do  we  meet  a  conflict  of  opinion  regarding  the  presence  of  fever. 
Eustace  Smith  recognizes  a  slight  febrile  condition  during  the  invasion  stage, 
but  has  not  observed  that  it  is  increased  by  the  appearance  of  the  eruption. 
Indeed,  other  writers  say  that  it  diminishes  at  this  time.  On  the  other 
hand,  Griffith's  experience  agrees  with  my  own,  noting  a  temperature  of 
103°  F.,  and  in  a  considerable  number  of  cases  100°  F.  is  recorded,  the 
temperature  remaining  at  this  point  in  many  cases  after  the  rash  had  entirely 
disappeared ;  in  other  cases  the  temperature  fell  abruptly  to  normal  while 
the  rash  was  still  apparent.  High  temperatures  are  I'ccorded  by  Fox, 
McLeod,  Cheadle,  and  Patterson,  ranging  from  100°  to  105°  F. 

The  temperature-curve  of  rubella  may  be  very  variable,  sudden  rises 
and  equally  sudden  falls,  or  it  may  rise  but  a  few  fifths  above  the  normal 
throughout  the  entire  case.  Indeed,  some,  as  Wuudcrlich,  Earle,  Picot, 
and  Vogel,  assert  that  there  may  be  no  fever  at  all,  and  others  that  it  lasts 

1  Brit.  Med.  Jour.,  Oct.  8,  1887,  p.  767.  ^  ibid.^  i887. 


EUBELLA.  695 

but  a  few  hours,  at  most  a  day ;  while  others,  again,  do  not  recognize  any 
association  between  the  onset  of  the  fever  and  the  appearance  or  intensity 
of  the  eruption.  Griffith  has  noted  a  wide-spread  eruption  with  complete 
apyrexia. 

Sore  throat  was  always  present  in  my  cases,  and  enlargement  of  the 
tonsils  to  a  great  extent.  Many  of  the  cases  also  presented  marked  pharyn- 
gitis and  dysphagia.  This  is  the  experience  of  almost  every  writer  on  the 
subject.  Park  is  the  only  exception :  he  limits  sore  throat  to  twenty  per 
cent.  The  condition  of  the  throat  in  this  disease  is  of  marked  diagnostic 
importance.  Murchison,  Liveing,  Aitken,  Copland,  Hemming,  Burnie, 
and  many  others  have  noted  its  occurrence.  Thomas  endeavors  to  show 
that  the  anterior  and  posterior  parts  of  the  throat  are  equally  affected  in 
rubella,  while  in  scarlatina  only  the  posterior  parts  are  affected.  I  have 
also  found  in  some  cases  an  eruption  scattered  over  the  throat :  this  has  been 
noted  by  several  other  observers.  Thomas,  Emminghaus,  Griffith,  Aitken, 
Cheadle,  Patterson,  myself,  and  others  have  noted  hoarseness  more  or  less 
severe. 

Many  of  my  little  patients  complained  of  a  sense  of  constriction  of  the 
chest,  and  a  cough  was  generally  present,  increasing  in  frequency  and  se- 
verity and  sometimes  becoming  somewhat  laryngeal.  In  quite  a  large  pro- 
portion of  the  cases  bronchitic  rales  more  or  less  diffused  were  noted.  These 
catarrhal  and  anginose  symptoms  lasted  about  as  long  as  the  eruption,  so 
that,  as  a  rule,  they  had  entirely  disappeared  about  the  fourth  or  fifth  day ; 
although  a  slight  cough  and  some  hypersemia  of  the  throat  may  remain  for 
some  days  longer.  Shoemaker  has  noted  a  case  in  which  sore  throat  lasted 
eighteen  days  from  the  first  appearance  of  the  eruption. 

Enlargement  and  induration  of  the  cervical,  post-cervical,  and  post- 
auricular  glands  were  present  during  the  eruptive  stage :  occasionally  only 
one  or  two  glands  were  affected,  in  other  cases  the  entire  chain.  This 
we  may  consider  one  of  the  most  diagnostic  signs  of  the  disease.  This 
statement  is  supported  by  -the  almost  universal  testimony  of  writers  for 
the  past  seventy-five  years:  indeed,  since  1815  it  has  not  been  disputed. 
Some  writers,  as  we  have  already  stated,  say  that  it  may  be  detected  even 
before  the  eruption  becomes  visible,  and  place  it  under  the  category  of  pro- 
dromal symptoms.  Eustace  Smith  and  Kassowitz  are  the  only  writers  that 
we  have  been  able  to  find  who  do  not  recognize  the  constant  presence  of  this 
symptom,  the  former  noting  it  in  only  some  C])idemics,  and  the  latter  in  but 
thirty-three  per  cent,  of  his  cases. 

The  lymphatic  glands  in  other  parts  of  the  body  may  also  enlarge  and 
become  indurated,  although  I  have  never  noted  tliis  condition ;  but  ISIusser 
has  observed  a  tumefaction  of  the  axillary  and  inguinal  glands,  especially 
the  latter.  .  Thomas,  Klaatsch,  Emminghaus,  ITardaway,  and  others  have 
noted  enlargement  of  the  glands  in  various  parts  of  the  body. 

.  In  a  fair  proportion  of  our  earlier  cases,  vomiting  occurred  as  the 
eruption  was  approaching  its  maximum.     In  five  of  these  cases  it  was 


696  RUBELLA. 

almost  imcoutrollable.  My  experience  in  this  respect  is  somewhat  unique, 
— probably  on  account  of  the  fact  that  these  earlier  cases  occurred  during  a 
severe  hospital  epidemic,  as  I  have  never  observed  the  same  condition 
obtaining  in  private  practice.  This  is  the  experience  of  most  writers,  their 
reports  mentioning  nausea  and  vomiting  in  the  severest  cases  only. 

Pulse. — The  pulse-respiration  ratio  was  in  all  the  cases  maintained,  it 
falling  with  the  temperature,  and  that  with  the  disappearance  of  the  rash. 
Pulses  of  120,  130,  140,  and  150  were  recorded.  Several  of  the  cases 
presented  well-marked  symptoms  of  heart-failure,  which,  however,  was 
successfully  combated. 

Tongue. — The  tongue  in  these  cases  was  coated  as  it  is  in  those  aifected 
with  scarlet  fever,  but  exfoliation  did  not  occur,  as  it  does  in  that  disease. 
The  strawberry-tongue  was  never  met  with.  The  dry  brown  tongue  appears 
in  the  notes  of  the  more  severe  cases.  Balfour,  Hemming,  and  Tripe  have 
noted  strawberry-tongue.  Murchison  and  Burnie  give  testimony  to  the 
same  effect :  the  latter  considers  this  condition  of  the  tongue  to  be  part  and 
parcel  of  the  symptoms  of  the  disease.  It  is,  indeed,  hard  to  reconcile 
these  statements  with  our  own  experience  and  that  of  the  great  host  of 
writers  on  the  subject.  We  can  but  conclude  that  the  cases  seen  by  these 
gentlemen  must  have  been  modified  by  some  peculiar  local  condition.  In 
my  own  experience,  cleaning  in  patches  has  been  the  most  usual  method  of 
return  to  the  normal  appearance. 

Urine. — This  secretion  was  such  as  is  found  in  all  similar  states, — 
"  febrile  urine."  My  first  one  hundred  and  sixty-six  cases  presented  slight 
albuminuria  in  about  thirty  per  cent.,  but  the  next  hundred  cases  showed 
only  three  per  cent,  with  albuminous  arine.  In  the  first  series  nine  cases 
presented  well-marked  albuminous  urine  (one-fifteenth  bulk),  with  dropsy. 
In  none  of  the  cases  could  tube-casts  be  detected. 

Let  us  for  a  moment  consider  the  experience  of  other  observers  in  regard 
to  the  presence  of  albumen.  Hatfield  has  observed  it  twice,  Cuomo  three 
times.  A  case  is  reported  by  each  of  the  following, — Cheadle,  Duckworth, 
Reed,  and  Kingsley.  Emminghaus  records  the  condition  as  a  possibility, 
and  Roberts  states  that  transient  albuminuria  is  not  uncommon,  but  in  very 
rare  instances  does  acute  renal  disease  with  dropsy  arise.  Curtman^  states 
that  he  sometimes  met  nephritic  trouble.  Hardaway,  Squire,  Tonge-Smith, 
and  Mettenheimer  have  never  observed  it :  the  former  goes  so  far  as  to  con- 
sider it  an  anomalous  symptom,  giving  rise  to  a  doubt  in  the  diagnosis. 

CEdema  of  the  face  occurring  coincidently  with  the  eruption  is  recorded 
by  Douglas,  and  has  been  observed  many  times  by  Griffith.  Thierfelder 
notes  a  febrile  oedema  of  the  face.  It  has  never  been  my  good  fortune  to 
see  such  a  case,  neither  have  I  noticed  the  odor  said  by  Heim  to  attend  the 
eruption. 

I  have  met  cases  in  which  the  eruption  caused  severe  itching.     This 

1  St.  Louis  Cour.  of  Med.,  1880,  iii.  53L 


RUBELLA.  697 

symptom  has  been  recorded  by  nine  other  observers.  Elsewhere  I  have 
called  attention  to  a  roughness  of  the  skin  where  the  eruption  appeared  on 
the  more  vascular  parts.  This  condition  has  also  been  observed  by  Shoe- 
maker, Musser,  Griffith,  and  Golson.  In  Griffith's  cases  the  roughness  not 
only  accompanied  the  rash,  but  persisted,  in  severe  cases,  for  days  after  all 
redness  had  disappeared. 

Complications. — By  far  the  most  frequent  seat  of  complications  is  the 
respiratory  apparatus.  Pneumonia  occurred  three  times  in  my  series  of 
cases,  and  twice  in  Griffith's  one  hundred  and  fifty  cases.  A  number  of 
cases  presented  more  or  less  severe  bronchitis.  One  case  of  pleurisy  is  re- 
corded. Ryle  has  also  seen  one  case.  Cheadle,  Smith,  Earle,  Emminghaus, 
and  Park  have  met  severe  bronchitis  and  pneumonia  as  complications. 

Ten  cases  of  enteritis  and  two  of  entero-colitis  occurred  among  my 
hospital  cases.  About  forty  per  cent,  of  these  cases  presented  gastro-intes- 
tinal  irritation.  This  percentage  is  somewhat  out  of  the  common,  and  is 
due,  no  doubt,  to  the  severity  of  the  epidemic.  Cuomo  has  noted  diarrhoea 
under  similar  circumstances.  Earle  has  met  four  cases  of  intestinal  irrita- 
tion. Balfour  regards  colonic  catarrh  as  a  usual  symptom  of  the  disease. 
As  a  rule,  the  bowels  are  but  little  affected,  and  are  generally  in  the  condi- 
tion which  accompanies  a  slight  febrile  state.  Musser  observed  one  case 
of  icterus.  Stomatitis  arose  in  four  of  my  cases,  and  aphthae  in  thirty. 
Instances  of  the  former  are  also  reported  by  Hatfield,  and  of  the  latter  by 
Earle.  Rheumatism  occurred  in  two  instances.  Slagle  has  noted  its  devel- 
opment in  one  case,  and  Earle  has  had  a  similar  experience  in  a  few  cases. 
I  have  observed  in  one  instance  tubercular  meningitis  develop  as  a  compli- 
cation. My  experience  in  this  respect  seems  to  be  unique.  Curtmau  was 
obliged  to  combat  abscesses  in  various  parts  of  the  body ;  he  also  noted 
renal  disturbances.  De  Schweinitz  has  observed  several  cicatrices  in  the 
popliteal  space  break  down  and  ulcerate.  Golson  records  abscesses  in 
the  submaxillary  lymphatic  glands ;  this  observer  also  notes  a  numbness 
following  desquamation,  attended  by  loss  of  motion  in  the  arms  and  legs, 
lasting  for  several  days. 

Alexander  has  met  five  cases  of  facial  erysipelas  as  a  complication 
occurring  within  a  week  after  the  disappearance  of  the  rash. 

Fifty  per  cent,  of  Park's  cases  presented  marked  adenopathy  in  the 
cervical  region  and  under  the  tongue.  Miliaria,  urticaria,  and  pempln'gus 
are  occasionally  met  with.  Thierfelder  observes  febi-ile  oedema  of  the  face, 
and  Emminghaus  a  similar  disturbance  in  the  legs ;  Mettenheimer,  a  naso- 
pharyngeal catarrh,  permanent  swelling  of  tlic  tonsils,  and  inflammation, 
of  the  gums ;  Smith  is  of  the  opinion  that  diphtheria  is  liable  to  follow 
rubella.  Painful  enlargement  of  the  thyroid  gland  has  been  observed  by 
Slagle  in  half  a  dozen  cases.  Rotli  has  remarked  that  mumps  is  apt  to 
follow  rubella.  Ciliary  blepliaritis  and  otorrhoea  liavc  occurred  in  Hard- 
away's  experience.  Cheadle  also  remarks  that  earaclic  may  develop  as  the 
rash  subsides.     De  Schweinitz  has  met  two  cases  of  phlyctenular  keratitis. 


698  BUBELLA. 

Relapse. — I  have  noted  relapse  to  occur  once  on  the  fourth  day  and 
once  on  the  twentieth  day.  Griffith  has  noted  it  in  three  instances,  in  one 
case  after  an  interval  of  eleven  days  and  in  the  other  cases  three  weeks  after 
the  onset  of  the  disease.  Cuomo  seems  to  have  had  a  peculiar  experience, 
as  it  occurred  in  all  of  his  ninety  cases ;  this  series,  however,  was  somewhat 
anomalous  in  many  of  its  manifestations.  Kostlin,  Earle,  Lindwurm,  and 
Golson  have  noted  relapses  in  a  limited  number  of  cases.  Kingsley  is  of 
the  opinion  that  it  occurs  frequently. 

During  the  relapse  the  disease  may  manifest  itself  with  all  its  primary 
vigor,  or  it  may  be  attended  by  a  lesser  degree  of  intensity  of  all  the  symp- 
toms, particularly  the  prodromal. 

Prog-nosis  and  Mortality. — -This  depends  much  upon  the  type  of  the 
disease  and  the  character  of  the  epidemic,  and  also  upon  whether  our  deduc- 
tions are  made  from  hospital  or  private  practice.  My  own  experience  in  about 
the  first  one  hundred  and  fifty  cases,  which  occurred  in  hospitals  and  among 
the  destitute  class,  shows  a  mortality  of  about  four  and  one-quarter  per  cent. 
(five  deaths  in  one  hundred  and  sixty-six  cases),  whereas  in  private  practice, 
and  of  course  outside  of  hospital  or  asylum,  I  have  yet  to  encounter  the 
first  death  from  this  disease.  Hatfield  records  a  mortality  of  nine  per  cent. ; 
Hemming,  Alexander,  Cuomo,  Slagle,  Roberts,  jNIcFarlan,  and  Davis  report 
deaths ;  Aitken,  Patterson,  and  Copland  say  that  the  prognosis  should  be 
guarded.  On  the  other  hand,  Atkinson  says  that  the  disease  almost  invari- 
ably results  favorably.  Tonge-Smith  observed  no  deaths  in  one  hundred 
and  forty-five  cases,  and  Park  none  in  one  hundred  cases.  Nymann,  Oester- 
reich,  Hardaway,  Thomas,  Robinson,  Emminghaus,  and  Steiner  consider  the 
prognosis  altogether  favorable. 

Complications  sometimes  prove  fatal.  Kronenberg,  quoted  by  Klaatsch, 
reports  four  deaths  from  bronchitis,  pneumonia,  and  cerebral  congestion  after 
rubella.  Of  my  own  cases  two  died  of  pneumonia,  one  of  pneumonia  and 
enteritis,  two  of  entero-colitis,  and,  as  before  remarked,  one  of  tubercular 
meningitis.  It  is  to  be  noted  that  the  cause  of  death  in  all  my  cases  was 
verified  by  post-mortem  examination. 

Davis's  case  proved  fatal  during  the  primary  affection  by  broncho- 
pneumonia. 

Diagnosis. — Should  it  be  necessary  to  diagnose  a  single,  individual,  and 
isolated  case  of  rubella,  we  must  indeed  admit  that  some  difficulty  would  be 
encountered,  and  that  we  have  no  diagnostic  guide  that  can  be  considered 
positive,  pathognomonic,  or  characteristic,  but  that  we  are  constrained  to 
rely  upon  the  tout  ensemble.  Should  the  disease  pursue  a  typical  course,  but 
little  difficulty  will  be  met  in  the  diagnosis. 

For  the  purpose  of  comparison  it  is  well  to  tabulate  the  differential 
diagnostic  signs.  In  the  following  table  I  have  endeavored  to  present  a 
consensus  of  opinion  of  the  authorities  quoted  : 


EUBELLA. 


699 


DIFFEEENTIAL   DIAGNOSIS. 

EUBELLA  (ROTHELN).  EUBEOLA   (MEASLES).  SCARLATINA   (SCARLET  FEVER). 


EuBEOLA  (Measles). 
Contagiousness. 
Contagious  and  infectious.        Very  contagious. 


Very  contagious. 


Incubation. 

Very  variable,  from  seven  to     From  nine  to  fourteen  days,     One  to  seven  days,  rarely  less 
twenty-one  days.  rarely  less  or  more.  or  more. 


Often  absent.  Earely  longer 
than  from  twelve  to  sev- 
enty-two hours ;  the  latter 
is  unusual,  and  is  the  ex- 
treme. 

Catarrhal  symptoms  slight ; 
nasal,  faucial,  or  bronchial 
irritation  not  often  pres- 
ent. May  be  slight  con- 
junctival hjfpersemia. 


Sore  throat  always  present. 
May  note  an  eruption  in 
throat  preceding  cutane- 
ous eruption. 

Vomiting  unusual. 

Fever,  slight. 


Enlargement  of  cervical,  oc- 
cipital, auricular,  and  sub- 
maxillary glands.  Occa- 
sionally other  glands  may 
be  painful.  Frequent  dur- 
ing prodromal  stage,  and 
may  last  through  eruption 
period. 

First  on  face  or  over  whole 
body  at  once ;  spreads  rap- 
idly ;  may  fade  in  one  part 
and  appear  in  another. 
Duration,  three  to  four 
days,  never  more,  usually 
less. 

Rose-red  in  color,  rarely  a 
dusky  red. 

Discrete ;  sometimes  diffuse  ; 
rarely  grouped.  Elevated, 
but  smaller  spots  than 
measles. 


Prodromal  Stage. 
About  three  days. 


Catarrhal  symptoms  severe : 
nose  and  eyes  affected. 
Bronchial  cough.  Even 
in  mild  cases  of  measles 
these  are  miore  marked 
than  in  severe  cases  of 
rotheln. 

Sore  throat  occasionally. 
Prodromal  rash  in  throat. 


One  day,  or  less. 


Marked  sore  tQroat. 


Vomiting  usual. 


Vomiting  occasionally. 

Fever,   diagnostic   tempera-  Hyperpyrexia,  rapid,  running 

ture-chart.  pulse.          Nerve-symptoms 

early  and  marked. 

Enlarged  glands  uncommon ;  Below  angle   of  jaw   glands 

if  enlarged,  are  not  pain-  usually  enlarged. 

ful. 


Eruption. 

First  on  face ;  spreads  gradu- 
ally ;  body  covered  by  third 
day.    Duration,  four  dayii. 


Deep  red  or  purplish. 


First  on  lower  neck  and  upper 
chest ;  spreads  moi-e  slowly. 
Duration,  usually  longer; 
may  be  six  days. 


Dusky  or  livid  ;  intense  red. 


Papules  arranged  in  concen-    Confluent,  minute  red  points, 
trie  groups. 


7Q0 


RUBELLA. 


EUEELLA  (IlOTHELK). 


DIFFERENTIAL   DIAG'NOSIS.— Continued. 

Scarlatina  (Scaelet  Fever). 


Rubeola  (Measles). 
Eruption. — (Continued.) 

All  symptoms  increase  with 
appearance  of  eruption. 


Temperature  reaches  its  max- 
imum with  eruption. 


During  eruption  slight  catar- 
rhal symptoms  are  aggra- 
vated, or  appear  for  first 
time. 
Temperature  very  variable. 
No    constant    relation    to 
other  symptoms. 
Pulse   in   direct   relation  to     Pulse  depends  much  on  pres- 
ence  of  respiratory   com- 
plications. 
Tongue  much  coated,  some- 
times    dry,     brown,    and 
cracked,  with  sordes. 
Albuminuria  somewhat  un- 
common. 


fever. 

Tongue      slightly     coated ; 

never  presents  the  "straw- 

beny  tongue." 
Albuminuria  rare,  but  occurs 

during  severe  epidemics. 

Slightly  branny  ;  almost  al- 
ways present. 


Branny. 


Desquamation. 


All  symptoms  increase  durins 
erujJtive  stage. 


Rapid    rise    of    temperature, 
early. 

Pulse  rapid  from  onset. 


"  Strawberry  tongue. 


Albuminuria  almost  always. 


Flakes. 


Treatment. — That  many  authorities  should  dismiss  the  treatment  of  this 
disease  in  a  few  words  seems  to  us  to  be  due  to  an  incorrect  appreciation  of 
the  gravity  of  the  disorder.  Certainly  a  disease  which  presents  a  recorded 
mortality  in  one  epidemic  of  nine  per  cent,  and  in  another  of  four  and  a 
quarter  per  cent. — a  disease  whose  victims  in  some  cases  succumb  as  early 
as  the  fourth  day  of  the  malady — cannot  but  be  of  sufficient  importance  to 
claim  our  best  efforts  in  its  treatment,  the  more  so  as  in  many  cases  we  have 
not  alone  the  disease  itself  to  combat,  but  also  the  serious  and  alarming 
complications  which  may  arise  during  its  course,  the  nature  of  which  Ave 
have  already  fully  considered. 

In  hospital  practice,  at  all  events,  one  cannot  help  being  convinced  that 
rubella  is  a  distinctly  epidemic  and  contagious  disease :  so  that  our  first 
thought  should  be  isolation,  preferably  in  a  large,  airy  room  with  a  tempera- 
ture of  about  6o°~70°  F.  Particular  care  must  be  taken  that  the  patients 
are  not  exposed  to  draughts  or  sudden  chilling  of  the  cutaneous  circulation  : 
this  must  be  our  endeavor  until  all  danger  of  complication  has  passed  away. 
In  some  of  my  own  cases,  those  with  a  tendency  to  marked  catarrh  of  the 
respiratory  apparatus,  with  deficient  secretions  and  harassing  cough,  steam 
was  admitted  to  the  room,  as  is  the  practice  in  the  treatment  of  trache- 
otomy cases. 

As  in  all  the  other  eruptive  fevers,  the  treatment  at  the  onset  should 
be  expectant.  Very  little,  if  any,  medicinal  treatment  is  required.  The 
child  should  be  put  to  bed,  the  room  somewhat  darkened,  and  all  noise 
and  unnecessary  visiting  prohibited.  The  little  ]iaticnt  should  be  allowed 
to  drink  freely,  if  there  be  much  thirst,  milk  well  diluted  with  lime-water, 
barley-water,   or  lithia  water,   whey,   or  weak   lemon-   or   orange- water 


RUBELLA.  ^  701 

flavored  with  glycerin.  An  occasional  cup  of  tea,  made  by  adding  a  small 
quantity  of  tea,  for  flavoring  only,  to  a  cup  of  hot  milk-and-water,  will  fre- 
quently be  of  great  advantage  in  bringing  out  the  eruption.  If  there  be 
headache,  the  head  can  be  kept  cool  by  cloths  wrung  out  in  camphor-water 
or  sprinkled  with  spirit  of  camphor  or  mint-water,  and  a  hot  foot-bath 
administered.  Should  the  child  be  restless,  sweet  spirit  of  nitre  forms 
undoubtedly  the  best  sedative,  and  may  be  given  with  sweetened  water  or 
added  to  the  lemonade.  Should  the  skin  be  dry,  and  the  child  restless  and 
delirious,  a  hot  bath  is  indicated.  A  fever-mixture  may  be  given  at  inter- 
vals, such  as  the  following  : 

U   Tinct.  aconit.  rad.,  n\,i ; 
Spts.  setheris  nitrosi,  ^ss; 
Liq.  ammon.  acetatis,  q.  s.  ad  ^  ii. 
M. 
Dessertspoonful  every  two  hours  p.  r.  n. 

As  has  been  already  noted,  there  are  cases  with  a  tendency  to  intestinal 
catarrh  more  or  less  severe.  These  should  be  carefully  watched,  and,  when 
treatment  is  indicated,  small  and  repeated  doses  of  Dover's  powder  and 
calomel,  or  calomel,  bismuth,  and  pepsin,  administered : 

R   Hydrarg.  chlor.  mitis,  gr.  ss ; 

Pulv.  Doveri,  gr.  vi  ; 

Pulv.  aromat.,  gr.  vi. 
M.  Ft.  chart,  vi. 
One  every  hour,  if  indicated,  for  a  child  a  year  old.  , 

R   Hydrarg.  chlor.  mitis,  gr.  i ; 

Bismuth,  subcarb.,  gr.  xii ; 

Pepsini  sacch.,  gr.  xxiv. 
M.    Ft.  chart,  xii. 

Sig. — One  every  two  hours. 

The  diet  should  receive  careful  supervision  and  be  graded  to  the  re- 
quirements of  each  case.  Mild  aperient  mixtures  should  be  ordered  for 
the  bowels  as  indicated,  and  the  lungs  carefully  examined  daily.  As  soon 
as  a  sense  of  oppression  or  tightness  about  the  chest  is  complained  of,  hot 
poultices  or  fomentations  should  be  applied.  The  more  serious  of  my  cases 
were  painted  with  a  mixture  of  equal  parts  of  chloroform  and  tincture  of 
iodine,  to  which  occasionally  a  few  drops  of  tincture  of  aconite-root  were 
added.  When  the  cough  becomes  troublesome,  it  should  be  treated  by  the 
usual  expectorant  mixtures.'     Patients  presenting  laryngeal  com})lications 

'  I  have  found  the  following  to  be  a  serviceable  combination  : 

R   Ammoniae  muriat.,  ^i; 

Vin.  ipecac,  f.^ii ; 

Tinct.  opii  cainph.,  f^iiss; 

Syr.  senegse,  f  ^  vi  ; 

Aquae,  q.  s.  ad  f,|iv. 
M.  Teaspoonful  every  two  hours. 


702  _  EUBELLA. 

must  be  subjected  to  constaut  steani-inhalatioDs,  together  with  the  application 
of  heat  and  moisture  externally  over  the  larynx. 

Many  cases  will  require,  in  addition,  a  general  stimulant  treatment  by 
digitalis,  carbonate  of  ammonium,  wine,  or  brandy,  and  liberal  liquid 
nourishment  frequently  administered.  I  would  strongly  recommend  the 
use  of  an  oleaginous  preparation  to  the  skin  during  the  stages  of  eruption 
and  desquamation :  in  the  former  stage  for  the  comfort  of  the  patient, 
allaying  itching  and  aiding  in  the  reduction  of  the  temperature ;  in  the 
latter  to  prevent  contagion,  as  it  may  be  by  these  fine  scales  that  the  con- 
tagion is  carried.  For  this  purpose  we  may  use  either  olive  oil,  carbolated 
cold  cream,  or  cod-liver  oil,  in  this  way  contributing  also  to  the  general 
nutrition  of  our  patient. 

Complications  are  to  be  treated  as  they  arise.  During  convalescence 
much  care  should  be  exercised  to  guard  against  colds.  The  patients  should 
be  placed  upon  general  tonics,  quinine,  iron,  and  cod-liver  oil.  Suitable 
clothing  must  be  insisted  upon,  with  flannel  Jiext  to  the  skin. 


PERTUSSIS. 

By  T.  31.  DOLAX,  M.D.,  F.E.C.P. 


Synonynaes. — Whooping-cough,  Hooping-cough,  Chin-cough,  Kin- 
cough  ;  Latin,  Tussis  convulsiva ;  French,  Coqueluche ;  German,  Keuch- 
huisten  ;  Spanish,  Tos  ferina  ;  Italian,  Tusse  convulsiva. 

Definition. — Whooping-cough  may  be  defined  as  a  communicable  dis- 
ease, depending  on  a  specific  poison,  prevailing  ejiidemically  and  sporadi- 
cally. It  is  chai'acterized  by  fever,  malaise,  irritation  of  the  respiratory 
tract,  catarrh,  and  subsequently  by  a  hard,  dry,  convulsive,  paroxysmal 
cough.  It  attacks  both  sexes  and  all  ages,  but  especially  children,  rarely 
occurring  more  than  once.  Usually  it  runs  a  course  varying  from  three 
weeks  to  three  months.  It  may  be  complicated  with  other  lesions,  as  ulcer- 
ation of  the  frsenum  linguse,  enlargement  of  the  tracheo-bronchial  glands, 
capillary  bronchitis,  lobular  collapse,  emphysema,  various  hemorrhages, 
paralysis,  convulsions,  jaundice,  catarrhal  pneumonia,  tubercular  meningitis, 
and  other  diseases  of  children. 

History  and  Etiology. — We  are  told  by  Mason  Good  that  under  the 
name  of  bex  theroides  the  disease  was  known  to  the  Greeks,  and  to  the 
earlier  writers  on  medicine,  by  whom  the  convulsive  cough  was  distiu- 
gui.shed ;  Isut,  so  far  as  we  can  gather  from  the  old  writer.s,  they  appear  to 
have  included  under  the  title  many  other  forms  of  cough,  especially  those 
of  a  catarrhal  nature  accompanied  ])y  forcible  and  oft-repeated  violent 
expiratory  efforts.  We  cannot  conclude  that  the  disease  described  as  tussis 
convulsiva  by  the  old  writers  always  referred  to  whooping-cough,  though 
there  is  no  doubt  that  the  disease  existed  and  Jias  come  down  to  us  in 
unbroken  succession,  like  the  other  diseases  of  childhood,  as  mea.sles,  scar- 
let fever,  etc.  It  would  be  profitless  to  trace  its  history  further  back  than 
the  time  of  Cullen,  Avho  has  furnished  us  with  an  admirable  definition  and 
description  of  the  nature,  symptoms,  and  treatment  of  the  disease.  Ac- 
cording to  this  learned  writer,  -whooping-cough  is  morbus  contagiosus,  tussis 
convulsiva,  strangulans,  eum  inspiratione  sonora,  iterata,  ssepe  vomitus.  The 
name  in  English  phraseology  has  been  derived  from  the  sound,  and  liy 
Cnllon  it  is  called  hooping-cough  from  tlie  word  "  hoop,"  supposed  to  signify 
the  peculiar  key-note  struck  by  the  little  patient ;  other  writers  call  the 
disea.se  kin-cough,  or  chin-cough,  from  the  word  "  kink,"  or  from  kind,  the 

703 


704  PEETUSSIS. 

German  for  "child/'  as  it  is  particularly  a  malady  of  childhood.  All 
writers  acknowledge  that  it  is  a  highly  contagious  disease,  proceeding,  as 
Cullen  taught,  from  a  contagium  of  a  specific  nature  and  of  a  singular 
quality  and  having  a  peculiar  determination  to  the  lungs. 

We  must  recognize  that  we  have  to  deal  with  a  contagium  vivum,  and 
that  whooping-cough  never  arises  spontaneously.  As  surely  as  a  thistle  rises 
from  a  thistle-seed,  a  fig  from  a  fig-seed,  a  grape  from  a  grape-seed,  so  does 
whoopiug-cough  arise  from  antecedent  whooping-cough.  Primary  causa- 
tion we  must  leave  out  of  the  question ;  immediate  causation  alone  concerns 
us,  for  the  larger  question  is  out  of  the  domain  of  experience.  Practically, 
we  know  that  exposure  to  the  virus  of  pertussis  produces  the  same  disease, 
and  that  this  virus  acts  under  particular  conditions.  Thus,  for  instance, 
where  a  number  of  children  are  gathered  together  in  schools,  nurseries,  or 
ill- ventilated  buildings,  if  a  primary  case  be  introduced  it  will  spread  with 
rapidity  among  the  other  children,  being  especially  favored  by  the  indi- 
vidual states  of  health  of  the  children.  Experience  further  tells  us  that  the 
younger  the  child  the  more  liable  it  is  to  infection.  Again,  we  know  that 
it  may  be  carried  by  infective  material,  in  clothing,  that  it  may  be  spread 
from  house  to  house  in  this  way,  and  that  in  all  other  respects  it  behaves 
like  the  contagia  of  scarlet  fever,  measles,  etc. 

Holding  the  view  that  it  is  a  germ-disease,  it  follows  the  general  laws 
of  affections  having  a  similar  origin,  though  there  are  numerous  objections 
to  be  met.  Why  should  some  who  are  exposed  escape?  Why  are  the 
latency,  intensity,  and  period  of  incubation  so  various  ?  These  are  objec- 
tions applicable  to  all  the  zymotic  diseases.  We  are  able  in  a  measure  to 
explain  away  these  difficulties  by  means  of  known  laws  or  observations 
regarding  the  germ-diseases.  There  is  one  primary  law,  that  the  materies 
morhi  of  every  communicable  disease  reproduces  its  kind.  This  primary 
law  is  controlled  by  objective  and  subjective  laws :  the  diffusion  or  dis- 
persion of  germs,  their  static  existence,  the  limited  duration  of  their  active 
existence,  their  development,  maturity,  and  decay,  their  intermittent  repro- 
duction, depend  upon  climatic  influences,  physical  forces,  and  are  influenced 
by  locality,  latitude,  and  personal  environment.  Were  it  not  for  these  con- 
trolling or  regulating  influences,  the  zymotic  diseases  would  be  much  more 
fatal  and  more  widely  diffused  than  they  are.  Still  more,  what  is  true  of 
reproduction  in  the  animal  world  is  true  of  disease-production.  In  the 
animal  world  destructive  energy  is  warring  against  creative  energy ;  mil- 
lions of  ova,  at  least  of  fishes,  are  destroyed  without  fertilization ;  and  so 
in  the  vegetable  world  the  seeds  of  plants  cannot  find  favorable  root,  and 
perish.  Spores  of  disease  also  perish,  through  not  finding  favorable  soil, 
and  through  the  agency  of  oxygen  are  rendered  harmless.  All  this  is  rudi- 
mentary, but  necessary  to  a  full  appreciation  of  the  germ-theory. 

In  whooping-cough,  then,  the  chain  of  causation  proceeds  as  follows : 

1.  The  primary  case. 

2.  The  primary  case  becomes  a  centre  of  infection,  and  throws  off  in- 


PEETUSSIS. 


705 


fective  material  or  spores,  which  may  be  carried  from  place  to  place  in 
clothes,  hy  ships  or  vehicles,  or  from  one  person  to  another. 

3.  The  virus  has  a  special  predilection  for  children,  and  its  action  is 
injflueuced  by  various  agencies,  such  as  foul  air  and  overcrowding,  and  it 
especially  affects  badly-nourished  children,  and  children  who  are  recovering 
from  measles  or  who  are  teething.  It  has  its  period  of  incubation,  varying 
from  four  to  fourteen  days. 

4.  It  does  not  pay  respect  to  race,  and  climate  does  not  appear  to  control 
it,  though  seasonable  influences  apparently  modify  it. 

A  very  important  question  presents  itself  as  to  how  the  contagium  finds 
its  mode  of  entrance,  whether  it  primarily  attacks  the  bronchial  tubes  and 
air-passages,  or  whether  it  is  conveyed  thither  by  the  blood.  I  believe  that 
as  a  germ-disease  it  follows  the  laws  of  other  germ-diseases,  that  the  germs 
enter  by  some  of  the  channels  by  which  some  of  the  other  contagia  enter, 
and  that  in  the  blood  they  develop,  setting  up  primary  fever  and  other 
symptoms,  subsequently  attacking  the  pulmonary  epithelium.  From  the 
lungs  germs  are  given  off  as  well  as  from  other  parts  of  the  body,  and  we 
have  the  contagium  carried  about  and  extended.  Isolation  of  a  child  suffer- 
ing from  whooping-cough  will  prevent  its  spreading ;  and  w^hen  we  come  to 
consider  the  mortality  we  shall  see  how  important  it  is  to  recognize  the 
highly  contagious  nature  of  the  disease  and  the  importance  of  prophylaxis. 

Mortality. — Whooping-cough  is  most  fatal  among  children  who  do  not 
attend  school,  and  it  has  often  been  remarked  that  children  of  school  age 
do  not  suffer  from  it.  This  is  easily  explained.  Whooping-cough  is  most 
commonly  fatal  in  children  under  three  years  of  age.  Whooping-cough 
ranks  third  in  the  fatal  diseases  of  infancy  in  England.  The  following 
table  represents  this  in  figures  : 

ANNUAL   DEATH-KATE   PEE   MILLION   IN   ENGLAND   AND   WALES. 


Period. 

Measles. 

Scarlet 
Fever. 

Whooping- 
cough. 

1838-40  (three  vears) 

1841-42  and  1847-50  (six  years)  .    . 

1851-60  (ton  years) 

1861-70  (ten  years) 

1871-80  (ten  years) 

580 
430 
410 
440 
330 

770 
870 
990 
980 
720 

500 
490 
500 
530 
510 

In  London  the  disease  has  been  more  fatal  than  small-pox  or  measles. 
DEATHS   PER   THOUSAND   FROM   ALL   CAUSES   IN   LONDON. 


Period. 

Whooping- 
cough. 

Measles. 

Small-Pox. 

1800-53     

29 
36 
36 

23 
24 
24 

31 
16 
13 

1854-71     

1872-81     

Vol.  1.-45 


706  PERTUSSIS. 

If  we  come  to  examine  the  deaths  more  particularly,  Ave  find  that  three- 
fourths  of  all  the  deaths  occur  in  children  under  two  years  of  age,  the 
mortality  of  the  female  sex  being  in  excess  of  that  of  the  male.  The 
mortality  is  also  increased  when  whooping-cough  prevails  in  cold  weather. 
This  is  attributable  to  the  exposure  and  to  the  absence  of  proper  precautions 
on  the  part  of  parents,  who  are  inclined  to  look  upon  whooping-cough  as 
an  ailment  of  little  moment  and  requiring  but  little  treatment.  We  shall 
presently  have  to  allude  to  the  importance  of  prevention  in  view  of  the 
appalling  mortality  of  this  infantile  disease. 

Patholog-y. — In  pure  uncomplicated  whooping-cough  the  anatomist 
fails  by  rough  examination  to  detect  any  characteristic  or  pathognomonic 
lesion.  This  is  not  surprising,  and  lends  support  to  the  views  I  advocate. 
The  simple  disease  whooping-cough  is  rarely  fatal.  It  is  the  complications 
that  kill,  and  they  are  very  numerous. 

In  placing  pertussis  in  the  group  of  diseases  caused  by  protophytic 
fungi,  its  pathology  can  be  revealed  only  by  the  modern  methods  of  re- 
search, which  have  been  so  fertile  of  good  results  in  other  diseases  of  this 
class.  Linnseus  foreshadowed  modern  views  when  he  endeavored  to  prove 
that  tussis  sicca,  or  dry  cough,  was  produced  by  animalcula  or  had  an  insect 
origin.  The  insect  of  Linnseus  is  the  microbe  of  Pasteur.  Thus  two  great 
minds  arrive  at  the  same  conclusion.  Other  observers,  such  as  Poulet, 
Letzerich,  and  Binns,  suggested  the  fungoid  nature  of  pertussis.  So  far 
back  as  1867,  Poulet  found  in  the  sputa  of  pertussic  patients  little  bodies 
which  were  then  termed  infusoria  and  classed  as  bacterium  bacillus,  and 
LetzeHch  produced  whooping-cough  in  rabbits  by  inoculating  the  trachea 
with  the  sputa  of  human  subjects.  I  have  repeated  a  number  of  experi- 
ments^ to  test  the  action  of  the  blood  and  nasal  secretions,  finding  that  the 
blood  did  not  produce  any  eifects,  but  that  sputa  and  other  secretions  caused 
death.  Microscopic  examination  of  sputa  revealed  ordinary  bacteroid  forms, 
but  in  addition  I  perceived  a  microbe  somewhat  resembling  the  Spiro- 
chsste  plicatilis  Cohn.  Yet  I  was  assured  by  competent  microscopists  that 
this  microbe  was  an  illusion  and  was  accounted  for  by  the  personal  equation 
which  must  always  be  allowed  for  in  microscopic  work, — viz.,  the  desire 
of  the  observer  to  see  the  microbe  he  wishes  to  see  !  Since  the  publication 
of  this  essay,  great  strides  have  been  made  in  the  cultivation  and  staining 
of  micro-organisms,  and  other  observers  have  followed  on  the  same  lines. 

Thus,  Dr.  Burger,  of  Bonn,  has  been  working  at  the  same  subject,  and, 
according  to  the  Berliner  KlinUche  Wochenschrift,  No.  1,  1883,  has  described 
what  he  considered  as  the  special  micro-organisms  of  pertussis.  They  appear 
under  an  immersion-lens  VII.,  ocular  0,  of  Seibert  and  Ivrafft's,  as  small 
elongated  elliptical  bodies  of  unequal  lengths,  the  smallest  being  twice  as  long- 
as  broad.    Under  a  very  strong  power,  transverse  subdivision  can  be  detected 

^  Whooping-Cough,  its  Pathology  and  Treatment,  Fothergillian  Prize  Essay,  1881, 
p.  16.     By  Thomas  M.  Dolan,  M.D.     London,  Bailliere,  Tindall  &  Cox. 


PERTUSSIS.  707 

in  the  longest  specimens.  Tliey  may  form  chains  or  groups,  but  are  gen- 
erally isolated  and  scattered  singly  all  over  the  field.  They  bear  a  certain 
resemblance  to  leptoihrix  buccalis,  the  spores  of  which  are  often  found  in 
whooping-cough  sputum ;  but  the  latter  are  larger  and  stouter,  and  near 
them  the  filiform  mature  leptothrix  is  always  present.  Occasionally  some 
of  the  specific  bacilli  are  found  to  be  inside  the  mucus-cells  in  the  sputum. 
The  bacillus  is  easily  prepared ;  it  can  be  readily  recognized  if  colored  in 
the  usual  way  by  watery  solutions  of  aniline.  Fuchsin  and  methyl-violet 
were  employed  by  Dr.  Burger,  and,  as  in  the  case  of  the  bacillus  tubercu- 
losis, this  micro-organism  is  best  studied  when  mounted  dry.  Dr.  Burger 
concludes  that  this  bacillus  is  the  actual  producer  of  pertussis,  because  it  is  so 
abundantly  produced  in  whooping-cough  that  its  influence  cannot  be  doubted, 
its  numbers  increase  in  direct  proportion  to  the  severity  of  the  disease,  and 
the  course  and  symptoms  of  the  affection  are  best  explained  by  the  devel- 
opment of  this  fungus. 

Dr.  Burger's  observations  lack  the  test  of  experimental  confirmation. 
We  are,  however,  carried  a  step  further  by  M.  Afanassieff,  who  prepared 
with  all  the  precautions  for  microscopical  experimentation  a  small  portion 
of  the  expectoration  of  a  whooping-cough  patient,  which  showed  large 
numbers  of  short  rod  bacteria,  0.06  to  2.2  ij-  in  length,  part  singly,  partly 
in  two  and  of  larger  chains.  M.  Afanassieff,  availing  himself  of  modern 
methods,  made  plate-cultures  with  them,  planting  a  particle  of  the  sputum 
upon  jelly  of  beef  peptone  and  beef-peptone  agar-agar,  of  each  two  plates. 
After  two  or  three  days  there  appeared  upon  all  the  plates  numerous,  almost 
similar,  colonies  of  bacteria :  round  or  oval  light-brown  colonies  with 
smooth  borders,  which  did  not  liquefy  the  jelly ;  round,  with  slightly- 
toothed  borders  and  brown  centre,  constituting  one  round  large  coccus.  In 
the  first-named  colonies  were  to  be  seen,  through  the  microscope,  pure  cul- 
tures of  the  above-described  bacterium,  which  the  investigator,  after  a  care- 
ful comparison  with  all  bacteria  thus  far  known,  was  constrained  to  recog- 
nize as  a  bacterium  sui  generis,  and  which,  inasmuch  as  cultures  derived  from 
the  expectoration  of  still  other  whooping-cough  patients  furnished  exactly 
the  same  bacterium,  were  now  transplanted  upon  various  culture-soils.  Tliis 
rod  bacterium  grows  very  rapidly  in  D'Arsonval's  thermostat  at  the  ordi- 
nary temperature  of  the  room.  It  does  not  at  all  liquefy  the  culture-soil, 
and  flourishes  most  rapidly  and  numerously  upon  the  potato  and  upon 
beef-peptone  agar.  Upon  the  second  day  there  is  to  be  seen  a  distinct 
pellicle,  at  first  of  a  transparent  gray,  later  on  becoming  perfectly  white. 
Similar  is  the  pellicle  upon  sterilized  blood  serum,  only  that  here  it  does 
not  spread  out  far,  but  remains  stationary  at  a  certain  stage  of  its  growth. 
Upon  the  potato  the  pellicle,  too,  is  thinner,  gray,  with  a  rough  surface  and 
irregular  borders,  which  by  the  eighth  and  ninth  days  is  strongly  toothed. 
With  pure  cultures  of  these  rod  bacteria  the  investigator  has  made  eighteen 
experimental  inoculations  upon  animals.  A  solution  of  this  culture  upon 
ao;ar-a2:ar  at  least  eisrht  davs  old  and  one-half  cubic  centimetre  of  common 


708  PEETUSSIS. 

salt  was  made  and  injected  into  the  windpipe  or  lung  of  dogs  and  rabbits, 
of  course  under  antiseptic  precautions.  The  animals  all  contracted  a  dis- 
ease similar  to  whooping-cough,  often  complicated  with  broncho-pneumonia. 
Several  died,  and  section  showed  that  the  mucous  membranes  of  the  bronchi, 
of  the  trachea,  and  even  of  the  nose,  are  the  chief  seats  of  the  injected  bacteria. 
This  same  bacterium  was  found  in  the  lungs  and  respiratory  mucous  mem- 
branes of  children  who  died  of  whooping-cough,  M.  Afanassieff  considers 
it  to  be  the  true  cause  of  whooping-cough,  aud  names  it  the  bacillus  tussis 
convuldvse.  AVe  are  thus  a  step  further  on  the  way ;  and,  as  Schwenker  ^ 
and  Wenat^  have  confirmed  M.  Afanassieff 's  observations,  a  great  lacuna 
has  been  filled  up. 

Though  we  do  not  find  any  rough  pathognomonic  change  in  simple  un- 
complicated whooping-cough,  yet  it  cannot,  long  persist  without  leaving 
some  impression  on  various  parts  of  the  frame.  I  have  spoken  of  one 
important  lesion.  The  imperfect  aeration  of  the  blood,  the  disturbance  of 
the  circulation,  the  very  concussion  produced  when  in  a  severe  paroxysm 
the  child  is  shaken  from  head  to  foot,  grasping  Avith  instinctive  haste  any 
support  it  can  lay  hold  of  to  break  the  force  of  the  concussion,  the  incessant, 
teasing,  harassing  cough,  the  vomiting,  cannot  occur  without  altering  in  some 
way  either  the  texture  of  the  mucous  lining  of  the  throat,  brouchise,  or 
bowels,  or  the  structure  of  the  lung,  the  heart,  or  the  brain  and  its  meninges. 

\ie  may  briefly  mention  the  morbid  changes  found  in  the  principal 
organs. 

Brain  and  Membranes. — The  post-mortem  appearances  are  what  might 
naturally  be  expected  from  the  phenomena,  aud  are  appreciable  to  the  eye. 
The  minute  vessels  are  injected  aud  enlarged ;  there  is  cerebral  engorge- 
ment, with  effusion  of  fluid  into  the  ventricles.  There  are  no  signs  of  soft- 
ening. The  vessels  of  the  membranes  are  frequently  in  a  similar  condition, 
and  we  find  the  spinal  cord  and  its  coverings  also  congested.  In  view  of 
convulsions,  especially  occurring  in  infants  under  one  year  of  age,  the  con- 
gested state  of  the  brain  is  important. 

3Iucous  Membrane  of  Eyes,  Nose,  Bronchi,  and  Stomach. — AVe  find  the 
mucous  membranes  in  a  highly  injected  and  irritable  condition,  in  life  the 
conjunctivae  are  frequently  seen  in  a  state  of  intense  congestion,  and  we  have 
hemorrhage  from  over-distention  of  the  blood-vessels  caused  by  the  violence 
of  the  paroxysms.  The  irritable,  red,  swollen  condition  is  a  primary  occur- 
rence. Under  the  influence  of  irritation,  mucus  is  secreted,  and  after  death 
we  frequently  see  the  bronchi  filled  with  abundance  of  thick  mucus  occupy- 
ing the  cavities  of  the  air-tubes.  Owing  to  exposure,  inflammation  sets  up, 
of  which  we  have  the  usual  signs.  Vomiting  very  frequently  occurs ;  and 
hence  the  mucous  lining  of  the  stomacli  shares  in  the  general  congested 
state. 


'  Schwenker,  Lancet,  Jan.  7,  1888. 
2  Wenat,  Medical  News,  June  2,  1888. 


PERTUSSIS.  709 

Emphysema. — Emphysema,  according  to  Steffen,  is  seldom  absent  in 
the  lungs  of  children  who  have  died  of  whooping-cough.  According  to 
"West,  during  the  violent  expiratory  efforts  of  the  closed  glottis  which 
characterize  a  paroxysm  of  the  cough,  the  air  is  driven  forcibly  towards 
the  upper  parts  of  the  circumference  of  the  lungs,  and  hence  its  seat  is 
marginal.  Emphysema  is  attendant  on  expiration.  Atrophy  also  plays  a 
part  in  its  production.  The  air-cavities  are  subjected  to  pressure  and  strain, 
owing  to  the  constantly-occurring  paroxysms. 

Pulmonary  Collapse. — In  1830,  Sir  John  Alderson  described  the  ana- 
tomical characters  of  collapse ;  and  we  are  really  indebted  to  him  for  our 
knowledsre  of  this  condition.  His  observations  have  been  corroborated  bv 
subsequent  observers.  He  differentiated  between  collapse  and  pneumonia. 
The  following  short  passage  embraces  his  views.  Speaking  of  the  appear- 
ances usually  found,  he  says,  "  In  the  lower  and  posterior  portions  of  the 
kino's  the  structure  was  rendered  very  firm  and  dense ;  the  portions  which 
were  the  subjects  of  this  change  were  exactly  defined  by  the  septa,  of  a  dull- 
red  color,  devoid  of  air,  sinking  instantly  in  water,  and  thin  slices  under- 
going no  change  by  ablution.  The  individual  lobules  were  more  dense  than 
in  hepatized  lungs ;  and  the  cellular  membrane  between  them,  retaining  its 
natural  structure,  conveyed  to  the  touch  the  same  sensation  that  is  felt  on 
touching  the  pancreas.  ...  I  apprehend  that  the  appearances  detailed  differ 
from  those  found  in  peripneumony.  In  whooping-cough  the  lung  is  always 
dense  and  contracted,  as  if  the  air  had  been  expelled  and  from  the  throwing 
out  of  adhesive  matter  the  sides  of  the  air-cells  had  been  agglutinated 
together,  while  in  hepatization  the  lung  is  less  dense  than  in  whooping- 
coug-h,  and  is  rendered  more  voluminous  than  in  its  natural  state.  Pulmo- 
nary  collapse  is  the  result  very  frequently  of  bronchitis.  Thus,  if  one  or 
more  of  the  tubes  become  choked  up  with  mucus  during  expiration,  some 
air  is  forced  out  by  the  side  of  the  mucus,  but  each  respiration  draws  the 
phlegm  into  a  narrower  part  of  the  tube.  Air  is  expelled,  but  none  is  taken 
in ;  the  consequence  is,  that  the  air-sacs  collapse." 

Following  on  collapse  we  have  condensation  of  the  pulmonary  tissue,  as 
described  by  Sir  J.  Alderson.  This  lesion  is  one  of  the  most  important  in 
connection  with  the  secondary  pathological  changes  in  whooping-cough.  It 
is  characteristic. 

Capillary  Bronchitis. — As  the  result  of  exposure  to  cold  or  of  an  un- 
equal temperature,  capillary  bronchitis  is  one  of  the  most  frequent  com])li- 
cations  in  whooping-cough  :  there  is  nothing  to  distinguish  it  when  combined 
with  pertussis.  We  have  tlie  usual  inflammatory  state  of  the  large  and 
small  air-tubes ;  we  find  their  mucous  lining  soft,  turgesccnt,  injected,  with 
mucus  in  abundance,  blocking  up  tlie  air- vessels  and  interfering  with  the 
proper  aeration  of  the  blood.  With  more  intense  inflanmiation  the  bronchi- 
oles in  place  of  lacing  filk'd  with  mucus  exhibit  a  copious  secretion  of  pus. 
As  the  result  of  bronchitis,  the  bronchi  become  dilated,  with  long-continued 
cough  and  expectoration,  the  elasticity  of  the  bronchial  tubes  is  impaired  and 


710  PERTUSSIS. 

tiieir  muscular  activity  slackened,  and  hence  they  yield  to  the  distending 
influence  of  cough  in  inspiration  and  to  the  accumulated  secretions.  This 
dilatation  is  not  uufrequently  met  with.  If  uniform,  the  whole  calibre  of 
the  tube  is  affected  •  but  if  saccular,  a  number  of  bead-like  dilatations  will 
be  seen,  within  which  may  be  found  some  mucus,  which,  owing  to  the  peculiar 
form  of  dilatation,  cannot  be  got  rid  of:  we  have  bronchiectasis.  Dilata- 
tion of  the  minute  bronchi  may  be  especially  noticed  at  the  periphery  of 
the  lung: ;  and  if  we  make  a  section  of  the  smaller  tubes  we  shall  find  the 
connective  tissue  and  epithelium  destroyed. 

Enlargement  of  the  Tracheo-broncklal  Glands. —  Enlargement  of  the 
tracheal  and  bronchial  glands  is  very  frequently  met  with  in  delicate  and 
strumous  children  in  whom  there  is  enlargement  of  the  cervical,  inguinal, 
and  other  superficial  glands.  Owing  to  the  occurrence  of  this  enlargement 
in  children  who  have  died  of  whooping-cough,  Dr.  Gueneau  de  Mussy  sup- 
ported the  view  that  whooping-cough  was  essentially  an  affection  of  these 
glands,  a  bronchial  adenopathy.  We  find  these  glands  enlarged  from 
various  causes  in  other  diseases,  especially  among  children  brought  up 
amidst  unsanitary  surroundings  and  on  bad  and  impoverished  diet.  Yet 
we  do  not  find  the  usual  phenomena  of  pertussis. 

Pneumonia. — As  the  result  of  cold  and  other  causes,  we  have  pneu- 
monia, and,  associated  with  it,  inflammation  of  the  pleura ;  but  the  post- 
mortem appearances  will  be  found  to  be  exactly  identical  with  those  observed 
v/hen  the  patient  has  died  from  pneumonia  uncomplicated  with  whooping- 
cough.  According  to  the  time  at  which  the  patient  has  died,  so  shall  we 
find  the  morbid  condition  of  the  lung.  We  may  have  one  of  the  four 
stages  of  pneumonia  :  1,  the  lung  simply  congested  ;  2,  engorged ;  3,  hepa- 
tized,  with  red  coloration ;  4,  hepatized,  with  gray  coloration. 

It  is  unnecessary  to  enter  into  the  pathology  of  these  conditions  or  to 
describe  the  post-mortem  appearances  of  all  these  stages,  as  they  are  given 
in  all  our  text-books,  and  may  be  found  under  the  article  on  pneumonia  in 
this  work. 

State  of  the  Heart. — We  know  that  the  circulation  is  disturbed,  and  the 
perfect  aeration  of  the  blood  interfered  with,  in  pertussis.  We  have  but  to 
look  at  a  child  in  a  paroxysm  of  coughing  to  see  this.  As  the  result  of 
this  dfsturbance  of  the  balance  of  circulation  and  aeration,  the  heart  must 
be  thrown  out  of  gear,  and  its  action  made  irregular.  After  a  paroxysm 
the  child  pants  for  breath.  If  you  place  your  hand  over  the  cardiac  region 
in  this  state,  you  will  find  that  the  child  is  breathing  with  renewed  energy. 
You  can  feel  the  heart  palpitating,  pumping  away  with  vigorous  strokes  the 
imperfectly-aerated  blood.  Does  this  disturbance  produce  any  permanent 
alteration  in  the  heart ?  Are  tlie  valves  affected ?  Have  Me  to  dread  mis- 
chief in  the  future?  Do  we  find  whooping-cough  complicated  with  peri- 
carditis or  endocarditis? 

As  a  rule,  we  may  say  that  whooping-cough  does  not  leave  behind  it 
any  permanent  cardiac  lesion.     We  may  find  the  coronary  arteries  filled 


PERTUSSIS.  711 

with  blood,  distended,  changes  obvious  to  the  naked  eye,  but  we  do  not 
find  under  the  microscope  any  akeratiou  in  the  muscular  fibres,  such  as 
degeneration,  proliferation,  or  infiltration.  We  may  find  some  slight  signs 
of  irritation  in  the  chambers  of  the  heart,  and  the  small  vessels  in  the 
intermuscular  connective  tissue  may  be  intensely  injected.  Consequent 
u})on  the  irregular  action  of  the  heart,  we  have  a  corresponding  irregularity 
in  the  pulse ;  the  rhythm  and  force  are  altered ;  but  this  trouble  soon  passes 
away,  and  after  the  attack  of  whooping-cough  has  completely  vanished  the 
pulse  regains  its  normal  character. 

Slate  of  the  Kidneys. — Gibb  was,  I  believe,  the  first  to  point  out  that 
the  urine  is  frequently  in  a  saccharine  state  in  pertussis.  Great  stress  was 
laid  upon  this  announcement,  and  at  the  time  it  M'as  believed  that  this  con- 
dition threw  liglit  upon  the  pathology,  and  that  the  nervous  tbeoiy  was 
thereby  supported. 

Is  the  urine  always  saccharine  ? 

I  believe  it  to  be  the  exception  to  find  it  so.  I  have  examined  the  urine 
of  fifty  children  with  confirmed  whooping-cough,  and  could  find  traces  of  it 
in  only  thirteen.  It  is  possible  to  account  for  the  presence  of  sugar  in  the 
urine  of  children  without  ascribing  it  to  the  irritation  of  any  nerve,  if  we 
remember  the  kind  of  diet  upon  which  children  live. 

In  what  state  are  the  kidneys  ? 

They  share  in  the  general  congestive  state  of  the  other  organs.  Steifen 
says  that  albumen  may  be  found  in  the  urine  at  the  time  of  violent  seizures 
or  shortly  after  them,  but  that  investigations  are  wanting  as  to  whether 
admixtures  of  blood  are  always  present  in  it.  I  can  supply  this  hiatus. 
Under  the  microscope  blood-corpuscles  are  not  found.  I  have  never  seen 
hemorrhage  in  the  kidneys  during  whooping-cough,  nor  even  blood  in  the 
urine. 

Some  other  Complications. — We  may  have  general  disturbance  of  the 
nervous  system  produced  by  the  long  continuance  of  the  cough  and  the 
paroxysms.  In  infants  in  whom  the  process  of  dentition  is  still  going  on, 
this  disturbance  may  lead  to  formidable  convulsive  seizures,  especially 
in  irritable  children.  We  may  occasionally  meet  with  paralysis,  or  with 
jaundice. 

On  the  value  of  a  constant  lesion  found  in  pertussis,  viz.,  ulceration  of  the 
froenum  linguse. — This  is  a  lesion  very  frequently  found  in  whooping-cough, 
though  there  are  different  opinions  as  to  its  value  and  its  relation  to  the 
disease.  Some  consider  the  lesion  as  constant,  initial,  anterior  to  the  kink 
or  cough,  and  related  to  tlie  ditfcrent  phases  of  the  malady.  I  support  the 
view  that  this  lesion  is  produced  by  mechanical  action, — viz.,  by  contact  of 
the  tongue  during  the  seizures  with  the  lower  incisors. 

On  the  phenomena  of  the  kink  or  cough. — In  no  other  disease  do  we  meet 
with  such  a  cough.  It  has  a  character  peculiar  to  itself:  it  is  known  to 
every  mother,  and  the  diagnosis  is  soon  made  out  wlicn  once  you  hear  this 
kink.    It  is  unlike  the  cough  of  laryngismus  stridulus.     How  is  it  caused? 


712  PERTUSSIS. 

Coughing  is  a  common  effort,  consisting  in  the  first  place  of  a  deep  and 
long-drawn  inspiration,  by  means  of  which  the  lungs  are  well  filled  with 
air,  this  being  followed  by  a  complete  closure  of  the  glottis,  followed  again 
by  a  sudden  and  forcible  expiration,  in  the  midst  of  which  the  glottis  sud- 
denly opens  and  a  blast  of  air  is  driven  through  the  upper  respiratory 
passages.  Coughing  is  a  reflex  act.  But  there  is  something  more  in  the 
cough  of  pertussis.  In  what  does  the  difference  consist  ?  and  what  are  the 
pathological  conclusions,  if  any  ?     There  are  two  stages  in  the  paroxysm. 

In  the  first  stage  a  number  of  expiratory  efforts  are  made  in  quick  suc- 
cession, during  which  the  air  is  driven  out  of  the  lungs  in  jerks  of  varying 
degrees  of  violence.  During  this  stage  no  air  is  taken  in  to  make  up  for 
what  is  lost.  The  blood  is  thus  imperfectly  aerated,  and  the  patient  seems 
on  the  point  of  being  suffocated.  In  the  second  stage  there  is  exhaustion 
of  the  paroxysm  followed  by  a  long-drawn  act  of  inspiration.  At  this 
period  the  peculiar  crow,  kink,  or  whoop  so  characteristic  of  the  disease 
is  heard.  The  violent  expiratory  efforts,  followed  in  turn  by  inspiratory 
efforts,  recur  again  and  again  under  the  influence  of  reflex  irritation.  The 
paroxysm  may  go  on  until  the  irritation  is  removed,  expectoration  or  vomit- 
ing accomplishing  this. 

The  question  naturally  arises,  In  what  condition  are  the  lungs  during 
the  paroxysm?  If  the  chest  be  auscultated  between  the  short  intervals 
of  expiration  and  inspiration,  you  will  hear  some  wheezing  or  vesicular 
breathing ;  but  if  the  ear  be  applied  to  the  chest  during  the  long-drawn 
noisy  inspiration,  there  is  nothing  to  be  heard.  How  can  we  account  for 
'this  ?     Several  hypotheses  have  been  put  forward. 

1.  It  has  been  suj^posed  to  result  from  the  slow  and  imperfect  manner 
in  which  the  air  passes  to  the  lungs  through  the  chink  of  the  glottis,  which 
is  spasmodically  narrowed. 

2.  Laennec  believed  that  it  depended  in  part  upon  a  spasmodic  condi- 
tion of  the  muscular  or  contractile  fibres  of  the  bronchi  and  their  branches. 
We  have  no  post-mortem  evidence  to  confirm  Laennec's  view ;  but  if  it 
were  possible  to  examine  the  lungs  in  this  stage,  I  am  of  opinion  that  it 
would  be  found  correct,  and  I  am  strengthened  in  this  by  the  more  recent 
researches  of  Charcot  on  the  minute  anatomy  of  the  lung.  We  must  bear 
in  mind  the  minute  anatomy  of  the  lung  if  we  would  fully  appreciate  why 
all  is  silent  in  the  chest  during  the  respiratory  stage, — the  causes  at  work  in 
the  production  of  emphysema,  collapse  of  the  lung,  and  other  secondary 
conditions  in  the  pathology  of  whooping-cough.  When  the  respiratory  act 
takes  place,  the  air  at  first  does  not  penetrate  beyond  the  larger  bronchi,  and 
is  long  before  it  again  freely  permeates  the  pulmonary  vesicles.  And  why? 
Because,  though  the  larger  bronchi  are  patent,  the  muscular  fibres  of  the 
smaller  and  ultimate  bronchioles  are  closed. 

In  the  production  of  emphysema  I  accept  the  respiratory  theory  ad- 
vanced by  Sir  AVilliam  Jenner.  The  minute  anatomy  is  also  important  in 
relation  to  the  part  played  by  the  pneumogastric  nerve  in  whooping-cough. 


PERTUSSIS.  713 

Roughly  stated,  the  lungs  are  supplied  from  the  anterior  and  posterior  pul- 
monary plexuses,  formed  chiefly  by  branches  from  the  sympathetic  and  pneu- 
mogastric.  The  filaments  from  these  plexuses  accompany  the  bronchia] 
tubes,  upon  which  they  are  lost.  Small  ganglia  are  formed  upon  these 
nerves ;  irritation  of  these  nerves  is  said  to  have  the  eifect  of  producing 
contraction  of  the  bronchial  canals  sufficient  to  expel  a  certain  quantity  of 
air.  If  this  theory  be  true,  it  helps  us  in  explaining  why  the  larger, 
mediate,  and  smaller  bronchi  are  closed  during  the  expiratory  stage  of  the 
pertussoid  paroxysmal  cough.  Autenreith  suggested  that  inflammation  of 
the  vagus  was  the  primary  cause  of  whooping-cough  ;  but  this  view  is  nega- 
tived by  the  practical  outcome  of  post-mortem  examinations,  the  vagi  being 
found  perfectly  healthy  in  the  majority  of  cases. 

Summary. — A  recapitulation  of  my  data  on  the  pathogenesis  of  per- 
tussis may  help  the  reader  to  grasp  them  : 

1.  Pertussis  depends  on  a  specific  poison  or  contagium  :  this  is  universally 
admitted. 

2.  This  contagium  is  active,  highly  infective :  this  is  granted  by  all 
observers. 

3.  The  contagium  is  comparable  to  the  contagia  which  produce  splenic 
fever,  scarlet  fever,  variola,  measles,  etc. 

4.  It  has  a  particular  determination  to  the  lungs. 

5.  Like  all  the  other  contagia,  it  has  its  periods  of  activity  and  of 
decline. 

6.  The  period  of  greatest  activity  is  in  the  first  and  second  stages. 

7.  Pertussis  runs  a  regular  course,  like  measles,  scarlet  fever,  and 
variola,  and  rarely  attacks  a  person  more  than  once. 

8.  It  thus  must  be  classed  among  the  zymotic  diseases. 

9.  The  fact  that  there  is  no  primary  pathognomonic  morbid  change 
supports  this  view. 

I  hold  the  zymotic  theory  to  be  the  most  satisfactory  thus  fiir  pro- 
pounded from  a  pathological  light,  whilst  at  the  same  time  it  harmonizes 
with  the  methods  of  treatment  recommended  by  the  best  clinicians,  and 
renders  them  intelligible.  Treatment  is  even  more  valuable  than  are 
hypotheses  about  pathogenesis,  and  the  treatment  may  be  correct  even 
though  our  pathological  views  be  wrong. 

Symptomatology. — Authors  have  divided  the  disease  into  three  stao-es, 
corresponding  to  the  stadium  prodromii,  stadium  convulsivnm,  and  stadium 
decrementl;  but  this  is  an  artificial  classification,  as  the  stages  arc  not  alwavs 
sharply  defined.  This  division  is,  however,  useful.  "We  do  not  often  see 
the  disease  in  the  first  stage,  as  mothers  do  not  bring  their  children  for  treat- 
ment until  the  distinctive  paroxysms  have  apjicared,  when  we  hear  tlie 
whoop  or  kink  which  proclaims  in  crowing  accents,  as  it  were  of  jubilation, 
"  whooping-cough." 

This  first  stage  comes  on  unsuspectcdly  and  insidiously  :  the  child  may 
have  some  slight  fever,  malaise,  be  restless,  cross,  with  some  symptoms  of 


714  PERTUSSIS. 

catarrh ;  the  mother  thinks  the  child  has  a  cold,  which  will  soon  pass  away 
under  a  little  domestic  treatment.  Castor  oil  is  given,  oil  or  tallow  and  nut- 
meg are  rubbed  on  the  chest,  and  the  mother  has  the  satisfaction  of  finding  the 
child  better  in  the  morning.  It  is  so  ^vell  that  it  is  allowed  to  go  out  with- 
out any  extra  precaution,  or  without  considering  the  state  of  the  atmosphere. 
On  its  return  the  cough  is  worse  and  the  infant  exhibits  more  manifest  symp- 
toms :  there  may  be  some  discharge  from  the  nose,  the  cough  is  more  urgent 
and  teasing,  the  child  is  more  restless,  uneasy,  and  cries  as  if  in  pain.  This 
stage  progresses,  and  we  have  still  more  pronounced  symptoms  of  catarrh. 
A  little  more  care  may  then  be  taken  by  the  mother ;  the  child  may  be 
nursed,  kept  in  the  house,  and  there  may  be  again  an  improvement,  where- 
upon there  is  a  remission  of  watchfulness  on  the  part  of  the  mother  or  nurse. 
The  child  is  taken  from  a  warm  to  a  cold  room,  or  after  having  been  warmly 
wrapped  up  the  extra  clothing  is  taken  off.  Again  there  is  a  change  :  the 
cough  returns  with  intensity,  occurring  in  repeated  attacks,  during  the 
intervals  of  which  the  child  pants  for  breath.  Sometimes  the  paroxysms 
are  so  continuous  that  the  conjunctivse  become  injected.  The  second  stage 
is  now  not  far  off. 

How  long  does  the  first  stage  last  ?  Opinions  vary.  I  have  known 
the  whooping  stage  develop  in  two  days,  but  I  have  also  known  it  take 
fourteen.  In  some  cases  there  has  been  no  stadium  prodromii.  The  sta- 
tistics of  other  observers  also  vary.  Burger  has  estimated  it  as  averaging 
from  eight  to  fourteen  days ;  Lombard,  from  four  days  to  six  weeks  •  Wun- 
derlich,  from  three  to  six  days ;  West,  from  two  to  twenty-five  days.  In 
my  opinion  it  must  vary  in  accordance  Avith  the  child's  health,  the  particular 
receptivity  of  the  infant,  and  the  general  environment. 

May  the  first  stage  terminate  the  disease  ? 

I  believe  not,  though  I  have  not  the  slightest  doubt  that  the  second  and 
third  stages  may  be  materially  modified  by  the  care  and  attention  bestowed 
in  the  first  stage. 

Should  a  child  be  removed  during  the  first  stage  ? 

If  the  patient  can  be  placed  at  home  under  ordinary  favorable  sanitary 
conditions,  removal  is  not  advisable.  The  disease  cannot  be  cut  short  by 
sending  the  patient  away  to  another  atmosphere.  Where  there  is  over- 
crowding, or  where  hygienic  arrangements  are  defective,  there  can  be  no 
question  that  removal  would  be  beneficial  if  it  could  be  effected  without 
exposing  others  to  tlu^  danger. 

The  second  stage  is  but  too  familiar,  and  -when  the  characteristic  whoop 
is  heard  the  nature  of  the  disease  is  assured.  The  child  may  be  playing 
about,  wlien  suddenly  it  prei)ares,  as  it  were,  for  the  struggle,  by  grasping 
with  instinctive  haste  at  a  chair  or  anything  else  within  reach.  The  pulse 
becomes  rapid,  tlie  lu'cathing  sliort,  and  then  the  paroxysm  commences,  the 
air  being  forced  out  in  sudden  jerks,  while  a  long-drawn  whoop  is  given. 
We  have  then  a  repetition  of  the  phenomena,  of  varying  length,  until 
vomiting  ensues  or  the  attack  exhausts  itself.     During  the  paroxysm  the 


PERTUSSIS.  715 

child's  face  becomes  turgid,  and  there  are  signs  of  suffocation  :  it  has  an  air 
of  distress  most  pitiable  to  see,  and,  as  the  result  of  repeated  attacks,  the 
face  becomes  puffy  and  swollen,  the  eyes  congested,  and  in  many  cases  there 
is  bleeding  from  the  nose,  eyes,  ears,  mouth,  and  rectum.  Many  children 
are  utterly  exhausted  by  the  attack,  though  others  are  at  once  able  to 
resume  their  amusement.  The  paroxysms  may  be  so  severe  as  to  bring  on 
convulsions,  hernia,  prolapsus  ani.  The  paroxysms  are  irregular  in  their 
occurrence  and  vary  in  frequency,  but  they  are  more  numerous  at  night. 

What  do  we  learn  by  auscultation  ? 

Before  the  paroxysm  comes  on,  we  find  the  general  indications  of 
catarrh,  but  during  the  crowing  or  whoop  no  sounds  are  audible. 

How  long  does  the  stadium  convulsivum  last? 

This  will  depend  very  much  on  the  state  of  health  of  the  child,  and  on 
the  nature  of  its  surroundings.  Children  who  are  in  good  circumstances, 
and  who  can  have  careful  nursing  and  all  that  it  implies,  suffer  less  than 
those  more  unfavorably  situated.  I  have  known  the  disease  to  last  from 
five  to  sixty  days.  Gerhardt  fixes  it  at  from  two  to  ten  weeks;  Stenier, 
at  from  three  to  eight  weeks ;  Burmier,  at  from  four  to  five  weeks ;  Barthez 
and  Rilliet,  at  from  fifteen  to  sixty-five  days. 

After  a  varying  time,  the  paroxysms  become  less,  and  we  reach  the 
third  stage.  There  is  a  gradual  diminution  in  the  intensity  of  the  par- 
oxysms, the  cough  loses  its  peculiar  character,  the  whoop  is  less  frequently 
heard,  or  is  absent ;  the  bronchial  catarrh  persists,  but  after  a  time  this  also 
disappears,  and  the  course  of  the  disease  is  at  an  end.  The  duration  of  this 
period  varies,  depending  very  much  upon  the  hygienic  conditions  under 
which  the  patient  is  placed.  In  simple  cases  recovery  is  complete,  leaving 
no  after-effects,  but  in  cases  that  have  been  complicated,  through  the  com- 
plications long-lasting  mischief  may  result. 

Diagnosis  and  Prognosis. — The  diagnosis  in  the  first  stage  is  difficult, 
but  we  may  be  assisted  by  examining  the  sputa  and  detecting  the  bacillus 
tussis  convulsivse  Afanasdeff.  We  may  suspect  the  disease  if  whooping- 
cough  is  prevalent  in  the  neighborhood.  The  diagnosis  is  simple  when  the 
peculiar  cough  is  present. 

The  prognosis  must  depend  upon  the  condition  and  age  of  the  child. 
Whooping-cough  is  ])opularly  supposed  to  be  not  a  very  serious  disease : 
this  is  a  fallacy,  as  may  be  seen  by  referring  to  the  mortality  caused  by  it 
indirectly.  Experience  tells  us  that  it  causes  a  high  mortality  among  the 
poor  and  among  badly-nourished  infants.  The  prognosis  will  depend  very 
materially  upon  the  care  which  can  be  given  by  parents  to  the  children. 
We  have  also  to  be  guided  by  the  sev^erity  of  the  ])aroxvsms. 

Treatment. — I.  Frophijlaxis. — Whooping-cough,  being  a  disease  of  a 
specific  nature  and  highly  infectious,  should  be  classified  in  the  list  of 
diseases,  notification  of  which  has  to  be  sent  to  the  sanitary  authorities,  and 
penalties  should  be  cnfi)rccd  fi)r  wilful  exposure  of  children  suffering  from 
whooping-cough,  to  the  danger  of  other  children.    Children  with  whooping- 


716  PEETUSSIS. 

cough  play  in  the  streets,  travel  by  trains,  cabs,  omnibusses,  and  no  notice 
is  taken  and  no  wonder  expressed  that  such  a  thing  should  be  allowed. 
It  is  said,  "  The  child  has  only  got  the  whooping-cough."  Yes,  the  child 
has  only  a  disease  which  causes  one-fourth  of  the  annual  mortality  of  chil- 
dren in  London, — only  a  disease  from  which  thousands  of  children  die 
annually ;  and  yet  we  wonder  at  our  high  infant  mortality.  There  is  a 
great  wakening  to  the  truths  of  sanitary  science.  We  must  make  some 
systematic  attempt  to  educate  the  public  on  the  preventive  measures  which 
should  be  adopted  to  limit,  check,  or  stamp  out  whooping-cough. 

There  are  few  diseases  about  which  there  is  more  lamentable  ignorance 
and  carelessness  among  the  public ;  though  it  is  popularly  believed  to  be 
communicable,  yet  no  precautions  are  taken  against  infection. 

The  public,  unfortunately,  believe  that  every  child  must  have  whooping- 
cough,  measles,  and  scarlet  fever,  and  that,  as  it  must  have  these  diseases, 
the  sooner  it  contracts  them  the  better.  We  must  endeavor  to  enlighten 
the  public.  One  of  the  first  lessons  must  be  that  whooping-cough  is  not  a 
necessary  disease  of  childhood,  that  children  are  not  doomed  by  any  laws 
of  Providence  to  either  measles,  scarlet  fever,  or  whooping-cough  ;  and  next 
we  must  insist  that  children  suffering  from  infectious  diseases  shall  not  be 
allowed  to  play  or  in  any  way  consort  with  other  children.  Contagium  is 
what  we  have  to  contend  with  in  whooping-cough.  If  it  were  possible  on 
the  same  day  to  isolate  all  the  children  suifering  from  this  disease  and  to 
keep  them  in  quarantine  for  a  lengthened  period,  whooping-cough  might 
be  stamped  out.  This  is  impracticable.  We  may,  however,  do  much  to 
check  and  limit  it,  but  without  the  intelligent  assistance  of  the  public  we 
are  powerless. 

II.  The  preventive  measures  necessary  to  check  the  spread  of  this  special 
contagium, — modified  quarantine  or  isolation. 

Pertussis  never  arises  spontaneously.  Spreading,  then,  by  contagium, 
we  must  establish  a  form  of  quarantine  to  keep  the  unhealthy  from  the 
healthy. 

1.  In  public  institutions  where  there  are  a  large  number  of  children, 
and  where  children  are  constantly  coming  in,  quarantine  is  necessary  and 
practicable.  It  is  painful  to  witness  the  sufferings  of  a  large  number  of 
children  in  paroxysms  of  whooping-cough.  An  illustration  from  experience 
will  show  how  much  can  be  done  by  isolation,  combined  with  hygiene,  to 
limit  the  spread  of  whooping-cough  among  children. 

In  1869  I  took  charsre  for  the  first  time  of  an  institution  in  which  there 
were  a  number  of  children  and  infants.  There  was  a  nursery,  and  in  this 
nursery  there  was  a  patent  cradle,  in  which  six  infants  could  be  rocked  at 
the  same  time,  and  in  this  cradle  might  have  been  seen  six  little  human 
M-aifs,  struggling,  palpitating,  choking,  in  a  close,  polluted  atmosphere. 
The  nursery  was  badly  constituted.  Liglit  and  ventilation  were  bad.  As 
all  contagia  become  more  virulent  in  polluted  air,  I  had  ample  opportunity 
of  witnessing  whooping-cough  in  some  of  its  most  painful  forms. 


PERTUSSIS.  717 

I  need  not  detail  all  the  steps  taken  to  alter  the  conditions  of  sanitation. 
A  new  nurseiy  was  opened ;  every  article  of  clothing  that  had  been  used  in 
the  old  nursery  was  destroyed ;  and  only  fresh  admissions  to  the  institution 
were  alloAved  in  the  new  nursery.  The  infants  who  had  whooping-cough 
were  detained  in  the  old  nursery,  which  I  improved  by  ventilators,  by  the 
free  use  of  deodorants,  and  by  absolute  cleanliness,  so  that  in  a  little  time 
the  disease  among  the  little  infants  in  the  old  nursery  came  to  an  end.  As 
I  saw  all  new  patients,  I  was  able  to  ascertain  to  a  certain  extent  the  exist- 
ence of  the  disease,  and  to  isolate  the  children  in  another  series  of  rooms, 
away  from  the  nurseries,  which  were  placed  at  my  disposal  by  the  managers. 
Under  the  new  conditions,  whooping-cough  in  the  intense  and  aggravated 
form  in  which  I  first  saw  it  became  unknown. 

In  all  public  institutions,  then,  isolation  should  be  practised,  and  hos- 
pital provision  should  be  made  for  the  treatment  of  the  disease.  It  would 
be  well  if  we  could  send  the  children  of  the  very  poorest  class  to  a  hospital 
when  they  have  pertussis ;  I  mean  the  class  who  live  in  one  room,  in  which 
father,  mother,  and  children  live  and  sleep.  Such  a  course,  however,  is  im- 
practicable. This  class  is  the  puzzle  of  sanitarians,  and,  I  may  say,  of  the 
age.  How  to  reach  them  ?  How  to  help  them  ?  We  must  teach  them  the 
best  precautions  under  their  conditions ;  we  must  impress  on  them  the  evil 
caused  by  their  allowing  their  children  to  play  with  other  children  when  in 
states  of  disease.  Other  simple  truths  may  be  urged,  as  to  the  value  of 
cleanliness,  fresh  air,  light,  etc. 

Our  difficulties  become  less  when  we  have  to  deal  with  the  higher  and 
middle  classes.  It  is  possible  for  tho.se  who  have  large  houses  to  give  up  a 
room  to  the  infected  child,  to  keep  other  children  away,  and  to  carry  out  a 
form  of  quarantine. 

It  has  been  recommended,  when  whooping-cough  is  epidemic,  that 
families  in  a  position  to  remove  should  take  their  children  away  to  the 
country  or  the  sea-side.  This  I  cannot  approve  of.  The  removal  is  not 
always  efficacious :  in  too  many  cases  it  simply  means  transferring  the  dis- 
ease from  one  locality  to  another,  the  children  frequently  breaking  out  on 
their  arrival  with  the  very  disease  they  have  been  carried  away  from. 

If  we  could  establish  among  all  classes  a  belief  in  the  value  of  pre- 
ventive measures,  the  disease  would  become  rarer,  and  when  it  did  occur 
active  steps  could  be  taken  to  limit  it. 

Isolation,  then,  is  the  first  prophylactic,  and  each  family  must  be  taught 
how  to  carry  it  out  as  fully  as  their  circumstances  and  their  house  permit. 

2.  Clothing  and  articles  used  by  patients  suffering  from  pertussis  may 
carry  the  contagion  :  so  that  all  such  articles  should  be  disinfected, — if 
available,  by  heat ;  if  not,  by  some  form  of  disinfectant.  The  clothing  of 
infants  is  not  expensive,  and  the  cheapest  plan  in  the  end  is  to  burn  all 
suspected  clothing. 

3.  I  need  say  only  a  few  Avords  about  the  general  hygienic  conditions 
of  households.     We  know  that  disease  loves  dirt,  that  foul  air  and  sewer- 


718  PERTUSSIS. 

air  are  the  favorite  elements  in  which  contagion  thrives :  so  that  we  must 
insist  that  the  children  in  any  infected  house  shall  have  all  the  advantages 
of  cleanliness,  pure  water,  fresh  air,  light,  etc. 

4.  It  will  naturally  be  asked.  Do  you  propose  to  keep  the  child  in  one 
room  during  the  whole  period  of  whooping-cough  ?  I  should  not  advocate 
doing  so,  but  in  certain  cases  more  harm  is  done  by  sending  the  children  out 
into  the  air  than  by  the  measure  of  keeping  them  in.  The  children  affected 
should  have  fresh  air,  and  they  may  advantageously,  the  wind  and  weather 
being  favorable,  be  sent  out  to  breathe  pure  atmospheric  air, — to  be  dis- 
infected,— care  being  taken  not  to  bring  the  little  ones  in  contact  with  other 
children.  Oxygen  is  the  greatest  of  disinfectants.  Due  attention  must  be 
paid  to  the  underclothing  of  children  suffering  from  pertussis ;  they  must 
be  warmly  clad. 

Oxygen  is  a  destroyer  of  contagion,  and,  thanks  to  this  power,  the  viru- 
lence of  all  the  zymotic  class  of  diseases  is  lessened  :  so  that  any  objection 
which  might  arise  on  the  ground  that  by  sending  children  out  the  poison- 
germs  might  be  wafted  away,  causing  a  spread  of  the  disease,  is  mini- 
mized. 

Common-sense  principles  must  guide  the  mother  :  she" must  be  told  that 
in  pertussis  the  mucous  membrane  is  in  a  highly  irritable  condition,  that  a 
damp,  penetrating  wind  will  convert  a  simple  case  of  pertussis  into  a  com- 
plicated one,  that  the  constitution  of  the  child  must  be  studied,  whether 
strong  or  delicate,  etc.  A  few  days'  entire  confinement  to  the  house  is  a 
less  evil  than  one  hour's  exposure  in  unsuitable  weather. 

III.  Pertussis  in  Public  Institutions. — In  public  institutions  children 
must  have  exercise,  but  with  judicious  management  this  can  be  effected 
without  brinffino;  the  infected  in  contact  with  the  uninfected.  The  exer- 
cising-ground,  if  small,  can  be  used  when  other  children  are  in-doors.  In 
foundling-hospitals  and  other  similar  institutions,  the  ingenuity  of  the  offi- 
cers will  be  taxed  to  provide  for  isolation  and  exercise,  but  they  will  be  well 
repaid  for  the  trouble. 

In  those  institutions  wherein  whooping-cough  is  now  not  a  visitor  but 
one  of  the  family,  looked  upon  as  a  necessary  condition  of  babies  and  chil- 
dren, I  can  imagine  that  a  serious  amount  of  trouble  will  be  involved  in 
any  effort  at  isolation,  and  managers  may  stand  aghast  at  any  attempt  to 
stamp  out,  limit,  or  check  it.  It  is  possible  to  limit  it ;  and  it  is  a  work 
that  should  be  done,  even  though  it  may  cost  time  and  money. 

Within  my  own  recollection,  erysipelas,  hospital  gangrene,  and  bed-sores 
were  regarded  as  conditions  necessary  to  surgical  operations  and  hospitalism. 
"We  do  not  now  believe  such  false  doctrine.  Erysipelas  and  hospital  gan- 
grene followed  on  dirt,  uncleanliness,  foul  air ;  bed-sores  were  produced  by 
bad  and  careless  nursing,  by  dirt.  They  stood  almost  in  the  relation  of 
cause  and  effect.  They  are  now  unknown  in  Avell-managcd  hospitals,  and 
if  they  occur  we  may  take  it  for  granted  there  is  some  defect  in  the  hygienic 
arrangements  or  in  the  nursing.     Whooping-cough  will  flourish  and  thrive 


PERTUSSIS.  719 

in  a  colony  of  infants,  it  will  remain  there,  and  will  be  handed  down  to 
the  next  colony,  unless  some  steps  be  taken  to  destroy  it. 

It  may  be  difficult  to  provide  isolation  for  a  number  of  infants ;  in 
certain  institutions  there  is  such  a  large  annual  supply,  such  an  influx  of 
infants,  that  the  accommodation  required  might  be  thought  to  be  excessive. 

Curative  and  Palliative  Measures. — The  scientific  physician  does  not 
pretend  to  cure  scarlet  fever,  typhoid  fever,  measles,  small-pox,  etc.,  but, 
like  the  helmsman  at  the  helm  of  a  ship,  he  strives  to  guide  their  course,  to 
pilot  his  patients  safe  to  land, — to  recovery, — avoiding  the  rocks  and  reefs, 
or,  in  other  words,  the  complications  which  may  arise.  Great  skill  is 
required  in  this  process,  even  though  all  the  above  diseases  naturally  tend 
to  recovery.  Like  these  diseases,  whooping-cough,  as  a  rule,  runs  a  regular 
course ;  and  the  eiforts  of  the  physician  must  be  directed  to  steering  safely 
through  the  perils  which  surround  it.  His  aid  is  valuable,  even  though  he 
does  not  pretend  to  cure  in  the  sense  in  which  the  word  "  cure"  is  commonly 
understood. 

Many  specifics  have  been  introduced  claiming  the  power  of  arresting 
the  disease ;  most  of  them  have  proved  worthless.  Moreover,  it  would  not 
be  far  from  truth  to  say  that  nearly  all  the  drugs  in  the  Pharmacopceia 
have  been  tried :  arsenic,  alum,  acetic  acid,  antimony,  benzine,  belladonna, 
bryony,  chloral,  cannabis  indica,  cantharides,  cochineal,  croton  oil,  chloro- 
form, carbolic  acid,  drosera,  ether,  hydrocyanic  acid,  hyoscyamus,  ipecacu- 
anha, iodide  of  silver,  lobelia,  laudanum,  morphia,  nux  vomica,  nitric  acid, 
petroleum,  potassium  salts,  turpentine,  salicylic  acid,  quinine,  have  been 
recommended  and  praised  for  their  efficacy  by  various  writers.  Blistering 
and  bleeding  have  had  their  advocates. 

We  have  previously  referred  to  the  various  hypotheses  on  the  nature  of 
pertussis.  The  treatment  by  the  light  of  what  I  regard  as  the  most  ten- 
able theory  does  not  enable  us  to  abort  the  disease.  \Ye  must  treat  the 
disease  according  to  the  stao;es. 

1.  The  first  stage  {stadium  prodromii),  coming  on  insidiously  and  with 
the  ordinary  symptoms  of  catarrh,  induces  parents  to  treat  the  disease 
themselves,  so  that  we  do  not  often  have  an  opjjortunity  of  seeing  this 
stage.  The  indications  for  treatment  are  simple,  and  depend  very  much 
upon  the  constitution  of  the  child,  state  of  the  weather,  and  condition  of  the 
household.  If  possible,  and  diagnosis  be  verifiable,  precautions  must  be 
taken  to  protect  other  children  from  infection.  Tlien  next  the  child  must 
be  kept  in  an  equable  atmosphere,  and  be  warmly  clad,  proper  attention  at 
the  same  time  being  paid  to  diet,  which  should  be  plain  but  nourishing. 
A  mild  aperient  may  be  required,  and  some  simple  saline  mixture  may  be 
given  with  advantage.  We  have  found  no  advantage  in  departing  from 
the  old-fashioned  plan  of  treatment  in  tins  first  stage.  We  have  not  seen 
any  case  aborted  by  either  an  old-  or  a  new-fashioned  remedy.  If  in  the 
first  stage  there  has  been  great  irritation  and  the  couoh  is  troul)lesome,  a 
simple  mixture  of  ipecacuanha  with  syrup  of  squill  will  be  found  of  great 


720  PERTUSSIS. 

service.  "VVe  must  remember  that  the  leading  indications  are  to  allay  irrita- 
tion and  prevent  complications.  In  this  stage  it  will  be  found  useful  to 
disinfect  the  room  by  burning  a  carbon  cone  charged  with  sulphurous  acid, 
the  child  being  taken  temporarily  to  another  room ;  or,  if  a  cone  be  not 
available,  ordinary  sulphur  may  be  ignited.  Other  agents  may  be  employed, 
as  carbolic  acid,  eucalyptol,  or  thymol,  to  purify  the  atmosphere. 

2.  When  the  first  stage  is  passed,  and  the  peculiar  paroxysm  so  charac- 
teristic of  the  disease  is  established,  I  strongly  recommend  the  succus  bella- 
donnse  in  large  doses.  Here  the  chief  indications  are — first,  to  palliate  or 
cut  short  the  paroxysm ;  secondly,  to  relieve  the  irritability  of  the  lungs ; 
and,  thirdly,  to  assist  expectoration.  The  belladonna  appears  to  achieve  its 
end  by  relieving  spasm.  Chlorate  of  potassium  may  be  of  great  service, 
but  the  preference  I  should  give  to  belladonna,  and  infants,  fortunately, 
appear  to  have  a  tolerance  for  it.  To  keep  the  bronchial  tubes  free  from 
the  accumulation  of  mucus,  we  can  call  to  our  aid  the  vinum  ipecacuanhse, 
with  syrup  of  squill  and  carbonate  of  potassium. 

3.  After  a  varying  time  the  paroxysms  diminish,  and  we  reach  the 
third  stage.  Here  change  of  air — especially  sea-air — is  most  beneficial,  in 
some  cases  acting  with  an  almost  magical  influence.  If  the  cough  persist, 
an  alum  mixture  offers  us  one  of  the  simplest  and  best  forms  of  checking  it. 
Half  a  grain,  or  even  a  grain,  may  be  given  three  or  four  times  a  day, 
to  a  child  a  year  old,  associated  with  the  extract  of  belladonna  in  one- 
thirtieth-grain  dose. 

Much  advantage  will  be  derived  in  this  last  stage  from  the  use  of  phos- 
phate of  iron,  or  of  cod-liver  oil  and  malt. 

The  plan  of  treatment  I  have  sketched  will  generally  be  sufficient  to 
guide  our  little  patient  through  pertussis  when  the  case  is  simple.  But  we 
must  be  armed  in  readiness  for  the  disturbing  elements  which  may  interfere 
with  tlie  safe  conduct  to  health  of  the  little  vessel  we  are  guiding  ;  we  must 
be  prepared  to  deal  with  children  of  peculiar  constitutions,  with  neurotic 
tendencies,  with  idiosyncrasies,  and  we  shall  have  to  study  all  these  charac- 
teristics and  then  fix  upon  a  medicine  which  will  efficiently  cope  with  them. 

Thus,  we  may  have  to  resort  to  the  bromide  of  potassium,  or  the  bromide 
of  ammonium,  to  allay  nervous  irritability ;  in  another  case  we  may  have 
to  give  hydrocyanic  acid,  to  check  vomiting ;  in  still  another  we  may  have 
to  fall  back  upon  the  use  of  quinine,  not  in  the  hope  of  cutting  short  the 
disease,  but  to  sustain  the  organism  during  the  struggle  wdiicli  is  going  on. 
We  may  again  have  to  ring  the  changes,  substituting  one  medicine  for 
another,  or  mingling  them  so  as  to  make  a  compound  mixture  in  which 
shall  be  combined  belladonna,  bromide  of  potassium,  bromide  of  ammonium, 
or  maybe  using  quinine  with  hydrobromic  acid,  etc.  In  some  cases  it  may 
be  advisable  to  try  croton  chloral,  or  some  other  powerful  sedative ;  ^\hilst 
chloroform-inhalation  may  also  be  required. 

Spraying  the  fauces  has  been  praised,  and  various  substances  have  been 
recommended  for  the  purpose,  as   cocaine,  quinine,  resorcin,  benzol,  etc. 


PERTUSSIS.  721 

The  latest  favorite  as  a  specific  appears  to  be  antipyrin,  given  in  small  doses 
in  a  little  syrup.  Much  advantage  will  be  derived  from  the  nasal  douche, 
using  for  this  purpose  some  alkaline  water  with  some  mild  disinfectant,  as 
thymol,  or  permanganate  of  potassium :  the  passages  are  thus  kept  cleared 
from  irritating  matter. 

J.  Lewis  Smith  has  found  carbolic-acid  vapor  very  useful.  He  advises 
"  three  teaspoonfuls  of  the  saturated  solution  of  carbolic  acid  in  water  enough 
to  cover  the  bottom  of  the  croup-kettle  to  the  depth  of  two  inches,  and  when 
this  is  brought  nearly  to  the  boiling-point  the  vapor  is  inhaled  through  the 
tubes  every  hour  or  second  hour  for  three  to  five  minutes."  The  steam 
atomizer  can  be  used  with  a  solution  like  the  following  : 

R   Acid,  carbolic,  ^ss; 

Potass,  chlorat., 

Potass,  bromid.,  aa  ^ii; 

Glycerinse,  ^  ii ;  • 

Aquae,  ^vi.^ 
M. 

If  the  steam  atomizer  is  not  practicable,  the  room  in  which  the  child  is 
confined  can  be  saturated  with  steam  by  means  of  an  ordinary  kettle  con- 
taining the  solution  advised  by  Poulet :  ^ 

Spt.  thymol,    10  grammes. 
Alcohol,         250         " 
Water,  750        " 

The  treatment  must  be  directed  to  meeting  symptoms,  and,  by  efficient 
surveillance,  to  prevent  complications.  The  general  indications  during  con- 
valescence are  simple :  fresh  air,  tonics,  sea-bathing,  good  nourishment, 
proper  protection  of  the  body,  are  all  required,  and  these  can  be  best 
secured,  of  course,  by  the  richest  class. 

Great  attention  should  be  paid  to  the  diet  of  a  child  with  whooping- 
cough.  The  food  should  be  in  the  most  digestible  form,  in  small  amounts, 
and  given  at  short  intervals.  Milk,  eggs,  soup,  jiuddings,  are  esjtecially 
indicated,  and  if  the  child's  strength  be  much  exhausted  by  its  constant 
vomiting,  or  by  the  strain  from  the  paroxysms,  stimulants  and  tonics  should 
be  employed. 

The  complications  which  arise  in  whooping-cough  are  very  numerous. 
I  have  enumerated  Avhat  they  arc,  and  for  their  treatment  must  refer  to 
the  special  headings  under  which  they  are  described  in  this  Avork.  I  could 
have  wished  to  lay  down  a  specific  treatment  for  pertussis  and  to  write  out 
its  formula,  but,  unfortunately,  there  is  no  specific,  though  we  can  do  a  great 
deal.     We  can  alleviate,  we  can  palliate,  and  we  can  prevent. 


'  J.  Lewis  Smith. 

2  Loud.  Med.  Kecord,  Mav  15,  1884. 
Vol.  I.— 46 


VARIOLA. 

By  a.  D.  BLACKADEE,  M.D. 


Definition. — Variola  is  an  acute  febrile  and  highly  contagious  disease 
affecting  the  whole  system.  It  commences  abruptly,  after  a  definite  period 
of  incubation,  with  an  initial  fever  of  from  two  to  four  days'  duration.  This 
is  followed  by  a  cutaneous  eruption  passing,  in  determinate  sequence,  through 
the  several  stages  of  papule,  vesicle,  and  pustule,  finally  desiccating  and 
leaving  small  permanent  cicatrices  wherever  the  suppuration  has  invaded 
the  deeper  tissues  of  the  skin.  It  is  one  of  the  most  loathsome  of  diseases, 
and  is  still  much  dreaded,  not  only  because  of  the  high  rate  of  mortality 
incident  to  it,  but  also  on  account  of  the  liability  to  deformity  and  to  im- 
pairment of  function  which  frequently  result  from  an  attack.  In  the  great 
majority  of  cases  one  attack  destroys  the  susceptibility  to  subsequent  con- 
tagion. 

Synonymes. — Small-pox ;  German,  Blattern,  Pocken  ;  French,  Petite 
v^role,  Picotte. 

History. — The  earliest  records  of  the  disease  are  said  to  be  found  in 
China,  where  writings  on  the  subject  date  back  as  far  as  B.C.  1122  (Haeser). 
It  appears  to  have  been  unknown  to  the  early  Greeks  and  Romans,  although 
a  few  think  that  the  great  plague  of  Athens  (b.c.  430-425)  was  none  other 
than  small-pox.  Excluding  this,  the  first  appearance  in  Europe  of  a  plague 
that  we  can  recognize  as  resembling  small-pox  in  its  symptoms  occurred  in 
the  sixth  century  and  ravaged  the  countries  along  the  shores  of  the  INIedi- 
terranean.  During  the  times  of  the  Crusades  it  again  appeared  in  epidemic 
form  and  made  frightful  havoc  in  many  of  the  more  southern  districts  of 
Europe.  In  England  it  appeared  in  the  thirteenth  century,  and  in  Northern 
Germany  in  the  fifteenth.  It  was  conveyed  to  this  country  shortly  after  its 
discovery,  and  in  Mexico  in  one  year  its  victims  were  computed  by  millions 
(Curschmann).  It  was  universally  regarded  as  the  greatest  scourge  of 
mankind,  and  was  estimated  as  causing  one-tenth  of  all  tlie  deaths  among 
the  human  race  (La  Condamine),  "  wliile  leaving  on  those  whose  lives  it 
spared  the  hideous  traces  of  its  power."  It  was  for  a  long  time  confounded 
with  tlie  measles,  with  the  pest,  and  with  other  papular  and  pustular  skin- 
eruptions  (Curschmann).  The  first  amelioration  of  tlie  disease  came  througli 
inoculation  introduced  from  the  East  into  England  (a.d.  1717),  whence  the 
722 


YAEIOLA.  723 

practice  shortly  found  its  way  into  Northern  Europe  and  America  (1721), 
and  was  of  much  service  in  limiting  the  dire  effects  of  the  disease.  Upon 
the  discovery  of  vaccination,  in  1796,  inoculation  fell  into  desuetude,  and 
was  outlawed  in  England  in  1841,  as  tending  to  propagate  the  disease. 
Since  Jenner's  discovery  small-pox  has  lost  the  prominent  place  which  it 
held  in  medicine,  but  recurring  epidemics  from  time  to  time  warn  us  that 
the  plague  has  lost  none  of  its  power,  and  that  the  necessity  for  careful 
vaccination  is  still  imperative. 

Etiology. — Of  the  first  origin  of  small-pox  we  have  no  know^ledge. 
In  our  day  every  case  is  referred  to  a  previous  one,  from  which  the  con- 
tagion has  been  received  either  by  infection  or  by  inoculation.  It  is  very 
readily  conveyed  through  the  air.  According  to  recent  opinion,  it  may  be 
communicated  in  this  way  to  great  distances,  especially  from  small-pox 
hospitals  (Power).  The  contagium  appears  to  be  of  a  very  clinging  nature : 
clothing,  bedding-material,  and  such-like,  attainted  by  the  secretions  or  ex- 
halations of  the  body,  retain  it  in  an  active  condition  for  a  long  time,  and, 
unless  ver}'  carefully  disinfected,  may  become  the  means  of  propagating  the 
disease  months,  or  even  years,  afterwards.  It  is  liable  also  to  be  spread  by 
persons  so  slightly  affected  by  the  disease  that  its  true  nature  is  overlooked 
and  they  are  allowed  to  attend  to  their  daily  business  and  to  associate  with 
others.  In  children,  also,  cases  have  occurred  of  so  mild  a  nature  that  no 
eruption  appeared,  yet  were  they  the  means  of  communicating  the  distinct 
disease  to  others  (Collie).  Unless  extreme  care  be  taken,  it  is  also  liable, 
perhaps  more  than  any  other  disease,  to  be  carried  by  physicians  and  nurses 
from  one  patient  to  another.  The  contagium  is  most  likely  communicable 
from  the  onset  of  the  initiatoiy  fever.  Probably  all  the  secretions  and 
excretions  of  the  body  contain  it  more  or  less,  but  it  is  present  in  its 
most  active  form  in  the  contents  of  the  vesicles  just  before  they  become 
sero-purulent.  The  patient  is  infectious  so  long  as  any  particle  of  the 
original  eruption  remains  adherent  to  his  body.  Conditions  of  soil  and 
climate  have  no  effect  on  it.  Wherever  predisposed  persons  are  subject  to 
its  contagium,  there  will  it  break  out.  Tliis  predisposition  to  it,  though 
not  equally  strong  in  all,  is  very  general,  except  when  annulled  by  efficient 
vaccination  or  by  a  previous  attack.  It  is  said  that  a  very  few  can  boast 
immunity  from  it ;  but  this  may  be  considered  doubtful.  "  Susceptible  per- 
sons almost  invariably  contract  it  on  their  first  exposure,  even  if  the  expo- 
sure be  of  short  duration"  (Collie).  No  period  of  life  is  exempt,  although 
it  is  stated  that  the  predisposition  to  it  is  less  in  the  earlier  months  than 
after  the  first  year.  Even  uterine  life  does  not  exclude  the  disease.  Infants 
have  been  born  either  already  ill  with  small-pox,  or  with  traces  of  having 
gone  through  the  disease  ;  but  this  is  rare.  "  As  a  rule,  the  foetus  escapes, 
ev^en  if  the  mother  be  suffering  from  small-pox ;  and  if  the  new-born  infant 
be  vaccinated  within  a  few  hours  of  its  birth  it  usually  escapes,  even  where 
it  is  born  in  a  small-pox  ward"  (Collie).  Sex  makes  no  difference  in  sus- 
ceptibility ;  race  docs.     Colored  races  in  general  are  much  more  prone  to 


724  VARIOLA. 

the  disease  than  the  white;  the  negro  is  especially  susceptible.  It  is  less 
frequently  met  with  in  the  children  of  the  more  educated  classes,  among 
whom  vaccination  is  carefully  performed,  than  in  the  poorer  and  less  iedu- 
cated,  who  are  apt  to  be  careless.  The  presence  of  chronic  disease  exerts 
no  influence  on  susceptibility,  but  children  ill  with  another  infectious  disease 
are  tolerably  secure  for  the  time  being.  They  become  again  susceptible, 
however,  during  convalescence.  As  a  rule,  one  attack  removes  the  liability 
to  contract  the  disease,  but  it  is  asserted  that  certain  conditions,  such  as 
puberty,  and  change  of  climate,  favor  the  reawakening  of  the  predisposi- 
tion. The  contagium  of  small-pox  exhibits  much  variation  in  different  epi- 
demics as  regards  its  intensity,  its  course,  and  the  appearance  of  special 
symptoms  during  the  progress  of  the  disease. 

Patholog-y  and  Pathological  Anatomy. — The  present  state  of  our 
knowledge  does  not  warrant  any  definite  statement  as  to  the  exact  nature 
of  the  contagium,  for,  so  far,  it  has  baffled  the  researches  of  the  most  care- 
ful investigators.  Analogy  would  point  to  the  presence  of  some  micro- 
organism, and  it  is  probable  that  ere  long  some  special  micrococcus  will  be 
discovered  bearing  specific  connection  with  the  disease.  The  latest  investi- 
gations of  Guttmann  have  resulted  only  in  finding  in  the  pock-lymph  the 
well-known  staphylococcus  pyogenes  and  micrococcus  albus,  neither  of 
which  has  any  definite  connection  with  the  specific  process.  The  colonies 
of  bacteria  also  found  by  investigators  in  the  internal  organs  (lymph-glands, 
kidneys,  liver,  and  spleen)  are  due  to  septic  processes  complicating  small-pox, 
and  are  not  peculiar  to  it  (Baginsky).^  The  characteristic  anatomical  lesion 
(the  pock)  of  small-pox  is  found  in  the  skin,  where  it  first  appears  as  a 
discrete  macule  due  to  a  circumscribed  hypersemia  of  the  corium.  Asso- 
ciated with  this  congestion,  changes  take  place  in  the  adjoining  cells  of  the 
rete  Malpighii,  swelling  them,  and  raising  the  outer  layers  of  the  epiderm 
in  a  hard  papule.  In  the  cells  towards  the  centre  of  the  lesion  these  changes 
assume  a  necrobiotic  character,  transforming  the  cells  into  cloudy  flakes 
destitute  of  nuclei,  while  towards  the  periphery  active  proliferation  takes 
place.  At  the  same  time  an  exudation  of  clear  serum  occurs  from  the  upper 
layer  of  the  corium,  between  these  altered  cells  of  the  rete  Malpighii, 
separating  and  compressing  them,  and  gradually  converting  the  papule  into 
a  vesicle,  which  increases  in  size  under  the  continued  exudation,  until  a 
width  of  two  or  three  lines  is  reached.  Many  of  these  papules  are  formed 
around  the  orifices  of  a  hair-follicle  or  sweat-gland,  and  the  umbilication  in 
such  is  produced  by  the  less  yielding  nature  of  the  epiderm  at  such  points ; 

^  Kecentl}'^  Marotta,  of  Naples,  asserts  that  he  has  ohtained  a  special  micrococcus 
(micrococcus  tetragonus)  hy  making  cultures  in  a  slightly  alkaline  inedium.  The  colonies 
thus  procured  have  a  fine  orange  color,  and  produce  complete  fusion  of  the  serum  or  gelatin 
in  from  twenty  days  to  a  month.  These  solutions  have  an  intense  alkaline  reaction, — a  fact 
which  he  thinks  may  have  a  therapeutical  bearing.  Inoculations  on  calves,  even  with 
cultures  of  the  seventh  generation,  produce  pustules  identical  with  those  of  vaccinia.  (Rev. 
Mens,  des  Mai.  de  I'Enfance,  Januarj',  1887.)  These  conclusions,  however,  have  not  yet 
been  verified  by  other  observers. 


VARIOLA.  725 

but  in  others  it  is  due  to  the  coagulation-necrosis  of  the  central  cells  which 
form  unyielding  bands,  while  the  surrounding  epithelial  cells  undergo  pro- 
liferation and  become  raised  with  the  exudation-serum.  By  about  the  sixth 
day  the  pock  has  become  fully  developed,  the  central  bands  have  given  way, 
and  it  is  now  full  and  rounded,  while  its  contents  have  lost  their  opalescent 
character  and  are  jiuriform.  The  surrounding  tissues  in  the  mean  time 
have  participated  more  or  less  in  the  inflammatory  reaction,  and  a  red  and 
swollen  areola  surrounds  the  pock.  When  the  pustule  is  mature,  desic- 
cation commences.  Should  the  epiderm  break,  the  contents  escape,  and 
crusts  are  formed,  but  frequently  merely  desiccation  takes  place  and  by  the 
falling  in  of  the  epiderm  the  appearance  of  secondary  umbilication  is  pro- 
duced. Cicatrization  goes  on  underneath  these  crusts  and  scabs,  which  are 
gradually  shed,  leaving  the  new  tissue  of  a  light-brownish  or  purplish  hue. 
The  amount  of  subsequent  pitting  depends  on  the  loss  of  substance  suffered 
by  the  underlying  papillae  during  suppuration.  Similar  lesions  to  those 
found  on  the  skin,  but  not  so  typical,  are  found  on  the  mucous  membranes, 
— principally  on  those  Avhich  are  exposed  to  the  air.  Those  of  the  mouth, 
pharynx,  nares,  larynx,  and  trachea  are  the  most  frequently  affected,  but  in 
severe  cases  they  are  found  extending  into  the  bronchi  of  the  second  or 
third  order,  also  in  the  upper  part  of  the  oesophagus,  in  the  rectum  near  the 
anus,  in  the  vulva,  in  the  vagina,  and,  very  rarely,  in  the  urethra  close  to  its 
orifice.  The  blood  in  fatal  cases  is  dark  and  coagulates  imperfectly.  There 
is  congestion  of  all  the  internal  organs.  The  mucous  membrane  of  the 
mouth  and  upper  air-passages  is  hypersemic,  its  surface  covered  with  brown 
tenacious  mucus,  under  which  may  be  seen  the  characteristic  lesions  of  the 
disease  in  the  stasce  at  which  death  occurred.  In  the  more  severe  cases 
patches  of  diphtheroid  membrane  are  not  infrequently  seen  covering  exten- 
sive ulcerations.  In  the  lungs  in  children  signs  of  bronchitis  are  generally 
present,  and  catarrhal  pneumonia  is  not  infrequent  as  a  sequence.  Croupous 
pneumonia  during  the  eruptive  stage,  and  pleurisy,  are  also  met  with.  The 
exudation  in  pleurisy  is  sero-purulent  at  first,  but  it  very  rapidly  becomes 
purulent.  Pericarditis  is  sometimes  observed.  Endocarditis  is  more  rare. 
Acute  fatty  degeneration  of  the  cardiac  muscular  tissue  has  been  reported 
by  Desnos  and  Huchard.  On  the  gastro-intestinal  mucous  membrane  the 
follicles  are  found  enlarged.  Peyer's  patches  in  children  are  swollen  and 
congested,  with  the  exception  of  those  near  the  valves,  which  escape  (Collie). 
Acute  articular  inflammation,  with  sero-purulent  efl\ision  affecting  prin- 
cipally the  large  joints,  is  not  uncommon.  In  the  cutaneous  tissues  ab- 
scesses are  frequent.  Erysipelas  is  not  generally  met  with  outside  of  the 
hospitals.  Gangrene  of  the  vulva  is  occasionally  seen.  Scpticremia  and 
pyaemia,  associated  with  metastatic  abscesses,  are  frequent  causes  of  death 
in  the  later  stao;es  of  the  disease.  In  the  nervous  svstera  we  find  few 
pathological  changes  corresponding  to  the  severe  derangements  manifested. 
Westphal  has  demonstrated  numerous  disseminate  centres  of  inflammation  in 
the  spinal  cord  as  the  cause  of  the  paralysis,  or  ataxia,  which  occurs  occa- 


726  VARIOLA. 

sioually  as  a  sequence.  Collie  mentions  two  cases  where  extensive  hemor- 
rhage was  found  in  the  brain,  and  Curschmann  one  where  an  effusion  of 
blood  took  place  into  the  nerve-sheaths.  The  true  pustule  has  never  been 
known  to  occur  on  the  cornea ;  on  the  palpebral  conjunctiva  it  is  rarely 
if  ever  seen,  but  on  the  ocular  conjunctiva  it  is  not  very  infrequent.  Its 
favorite  position  here  is  about  half-way  between  the  cornea  and  the  inner 
cauthus,  and,  more  rarely,  about  midway  between  the  cornea  and  the  outer 
canthus.  There  are  seldom  more  than  two  or  three  pustules.  They  are 
small  and  surrounded  by  a  deep  injection ;  their  epithelial  covering  is  soon 
lost,  leaving  a  round  yellowish- white  ulcer,  resembling  an  ordinary  phlyc- 
tenula.  The  more-to-be-dreaded  keratitis  sets  in  about  the  fourteenth  day 
as  a  small  ulcer  on  the  margin  of  the  cornea,  leading  to  perforation  with 
total  destruction  of  the  eye.  Iritis  and  inflammation  of  the  deeper  struc- 
tures are  very  rarely  met  with  except  in  connection  with  the  above.  The 
ear  is  said  to  suffer  more  frequently  even  than  the  eye,  but,  as  a  rule,  no 
pustules  extend  beyond  the  cartilaginous  portion  of  the  auditory  canal. 
Hypersemia  and  inflammatory  swelling  extend,  however,  frequently  into 
the  deeper  parts,  and  occasionally  spread  to  the  membrana  tympani.  In- 
flammatory manifestations  have  also  been  found  on  the  mucous  membrane 
of  the  middle  ear,  but  never  any  pustules.  In  the  slighter  hemorrhagic 
forms  we  have  more  or  less  sanguineous  exudations  into  some  or  many  of 
the  pocks,  and  into  the  skin  immediately  beneath  the  papillary  layer.  In 
the  severer  forms  large  and  small  extravasations  of  blood  take  place  into 
the  skin  and  underneath  the  vesicles  or  pustules,  and  from  many  of  the 
mucous  membranes.  In  the  most  malignant  form,  purpura  variolosa,  the 
true  papules  of  the  disease  are  said  to  be  wanting ;  but  Osier  ^  says  that  fre- 
quently even  in  these  cases,  if  carefully  looked  for  upon  the  forehead  and 
wrists,  they  may  be  discovered  at  the  end  of  the  second  or  early  in  the  third 
day,  but  the  rapidly-extending  ecchymoses  soon  hide  them,  and  it  may 
afterwards  be  diflicult  even  to  feel  them.  Post-mortem  examination  reveals 
large  and  small  hemorrhages  into  many  of  the  viscera,  ecchymoses  under 
the  serous  membranes  on  the  surface  of  the  brain,  heai-t,  lungs,  liver,  and 
kidneys,  and  extravasations  into  many  of  the  mucous  membranes.  There 
is  almost  invariably  an  extensive  effusion  of  blood  behind  the  kidneys  into 
the  retro-peritoneal  tissues  and  along  the  course  of  the  ureter.  In  addition, 
Ponfick  and  Osier  call  attention  to  the  firm  dense  condition  of  the  heart 
and  abdominal  glands  in  these  forms  of  the  disease,  in  contrast  to  the  soft 
and  friable  condition  of  these  organs  found  in  variola  vera. 

Symptomatolog-y. —  The  paiod  of  incubation.  From  the  time  of  the 
reception  of  the  contagium  to  the  first  appearance  of  the  initial  fever  the 
child,  as  a  rule,  presents  no  abnormal  symptoms,  and  appears  to  be  in  its 
ordinary  health.  Occasionally  an  amount  of  irritability  and  peevishness 
unusual  to  it  may  be  noticed,  and  some  authors  have  observed  a  marked 

^  Canada  Med.  and  Surg.  Jour.,  vol.  v.  p.  297. 


VARIOLA.  727 

pallor  in  the  face ;  but  such  symptoms  are  infrequent.  The  length  of  this 
stage  is  in  general  from  ten  to  thirteen  days.  Very  rarely  is  it  shortened 
to  eight  days  or  lengthened  to  fourteen  or  fifteen.  In  severe  hemorrhagic 
types  it  is  said  to  be  from  six  to  nine.  The  stage  of  invasion  generally 
comes  on  suddenly  with  symptoms  of  severe  fever.  The  young  child 
becomes  fretful  and  restless ;  its  skin  is  hot  and  may  be  either  dry  or  per- 
spiring ;  vomiting  sets  in  early,  and  is  generally  persistent ;  there  may  be 
constipation,  but  in  young  children,  and  in  severe  cases,  diarrhoea  generally 
prevails  for  at  least  the  first  four  or  five  days.  The  respiration  is  hurried, 
drowsiness  comes  on,  and,  if  old  enough,  the  child  complains  of  severe 
headache  and  constant  pain  in  the  loins.  Frequently  there  is  abdominal 
pain  of  a  colicky  character,  which  is  increased  by  pressure  in  the  epigas- 
tric region.  The  drowsiness  may  deepen  into  stupor,  and  convulsions  or 
delirium  set  in.  The  first  onset,  in  severe  cases,  may  be  with  a  convulsion, 
from  which  the  child  passes  into  a  state  of  stupor  only  to  be  broken  by 
repeated  convulsions.  In  older  children  the  first  complaint  is  generally  of 
chilliness,  with  or  without  a  distinct  rigor ;  this  is  followed  by  pyrexia, 
great  prostration,  vomiting,  and  continuous  backache.  Sometimes  we  meet 
with  a  temporary  paraplegia  of  the  lower  limbs,  with  complaint  of  a  feel- 
ing of  numbness,  and  not  infrequently  with  an  incontinence  of  urine  and 
faeces,  which  passes  oiF  in  a  few  days.  The  tongue  is  coated,  the  tip  and 
edges  being  of  a  deep  red ;  the  pharynx  in  many  cases  is  congested,  but  not 
to  the  same  extent  that  it  is  in  scarlatina.  There  is  much  variation  in  the 
degree  of  fever.  The  temperature  in  the  axilla  may  vary  from  102°  to 
105°  Fahr.  The  pulse  is  full  and  frequent,  and  ranges  from  120  to  160. 
These  symptoms  last  until  the  appearance  of  the  rash,  which  generally 
takes  place  on  the  third  day,  though  it  is  sometimes  delayed  until  the  fourth. 
Sydenham,  quoted  by  Trousseau,  says  the  longer  the  eruption  is  delayed 
the  milder  will  the  attack  be ;  but  Curschmann  thinks  this  inference  un- 
warranted for  all  epidemics.  Certain  it  is  that  the  violence  and  intensity 
of  this  stage  are  no  reliable  indications  of  the  severity  of  the  attack,  but 
are  often  much  influenced  by  the  temperament  of  the  child.  Frequently 
the  most  violent  symptoms  at  this  stage  in  a  nervous  child  eventuate  in  a 
harmless  varioloid,  but  sometimes  the  tender  constitution  of  the  infant  may 
fail  beneath  the  severity  of  the  onset,  and  death  ensue  before  the  eruption 
can  make  the  diagnosis  certain.  In  a  very  few  the  invasion-symptoms  may 
be  so  mild  as  to  be  quite  overlooked  by  the  mother.  One  such  case  occurred 
to  myself,  where  no  cross-questioning  of  the  mother  could  elicit  any  })revious 
symptoms,  and  yet  the  papules  were  well  out,  and  ran  the  distinct  course 
of  a  discrete  variola.  Eustace  Smith  and  Day  mention  similar  cases. 
During  this  stage,  more  frequently  in  children  than  in  adults,  certain  tem- 
porary, or  initial,  rashes  occasionally  make  their  appearance.  They  are  apt 
to  be  misleading,  and  therefore  require  careful  attention.  They  generally 
occur  about  the  second  day,  but  may  be  a  little  earlier  or  later.  When 
erythematous  in  character  they  may  generally  be  classed  under  one  of  two 


728  VAEIOLA. 

varieties, — the  scarlatiniform,  resembling  an  erysipelatous  or  scarlatinal 
rash,  and  the  macular,  closely  resembling  the  eruption  of  measles.  Either 
of  these  may  more  or  less  cover  the  whole  body.  In  general  the  scarlatini- 
form is  most  marked  on  the  lower  abdominal  region,  in  the  triangle  made 
by  including  the  hypogastric  region,  the  groins,  and  the  inner  surface  of 
the  thighs  (crural  triangle  of  Simon),  and  on  the  lateral  thoracic,  including 
the  inner  side  of  the  arm,  the  axilla,  and  the  pectoral  region  (brachial 
triangle  of  Simon).  The  macular  is  most  common  on  the  chest,  on  the 
extensor  surface  of  the  extremities,  "  especially  in  the  neighborhood  of  the 
knees  and  elbows,  the  backs  of  the  hands  and  feet,  on  the  genitals,  and, 
lastly,  as  a  streak  extending  from  the  ankle  upwards  along  the  line  of  the 
extensor  proprius  pollicis."  These  rashes  may  occur  singly  or  together; 
they  generally  fade  as  the  true  eruption  comes  out,  but  sometimes  they 
more  or  less  persist.  Little  prognostic  importance  is  to  be  given  to  them. 
They  vary  much  in  frequency  in  different  epidemics,  and  are  said  to  pre- 
cede more  frequently  attacks  of  varioloid.  Curschmann  states  that  in  most 
instances  the  number  of  pustules  was  in  inverse  ratio  to  the  extent  of  the 
initial  rash.  Often  these  rashes  are  accompanied  by  petechise,  of  size  vary- 
ing from  that  of  a  pin's  head  to  that  of  a  bean.  Such  purpuric  rashes  are 
almost  invariably  limited  to  the  triangles  of  Simon,  and  are  of  much  more 
importance  than  the  simple  erythematous  rashes.  Curschmann  says  that  the 
only  pathognomonic  symptom  in  the  initial  stage  is  the  appearance  of  such 
a  hemorrhagic  exanthem  in  Simon's  crural  triangle.  The  prognosis  of  such 
cases  is  in  general  more  grave,  but  not  always,  as  the  subsequent  attack  is 
sometimes  of  the  milder  form.  In  forming  an  opinion  we  must  take  into 
account  the  general  symptoms,  and  not,  as  Sydenham  says,  "go  by  the 
external  appearance  only." 

Stage  of  eruption.  On  the  third  day,  as  a  rule,  the  true  eruption  of 
the  disease  makes  its  appearance.  Coincidently  with  it  the  temperature 
begins  to  fall,  the  pulse  becomes  quieter,  and  an  amelioration  of  all  the 
symptoms  takes  place,  except  in  the  severer  forms  of  the  disease,  when  this 
relief  is  very  partial  and  the  fall  in  temperature  is  comparatively  slight. 
The  eruption  in  most  cases  may  be  first  noticed  on  the  face,  and  its  earliest 
situations  there  are  on  the  upper  lip,  round  the  a\se  of  the  nose,  on  the  fore- 
head, and  on  the  chin.  Sometimes  in  very  young  children  it  makes  its 
first  appearance  about  the  genitals  and  in  the  fold  of  the  groin  or  about  the 
lower  part  of  the  loin  or  on  the  thighs ;  but  such  cases  are  not  frequent.  It 
is  rarely  seen  on  the  back  of  the  wrists  and  on  the  neck,  and  spreads  con- 
secutively, in  the  course  of  tlie  folIoAving  twenty-four  to  forty-eight  hours, 
over  the  chest,  back,  arms,  lower  part  of  the  trunk,  and,  lastly,  on  the  lower 
extremities ;  some  of  the  papules  may  almost  always  be  seen  on  the  palmar 
and  plantar  surfaces.  It  is  most  abimdaut  on  the  face  and  back  of  the 
hands,  next  on  the  neck  and  arms,  least  on  the  trunk.  Any  part  of  the 
cuticle  that  has  been  recently  irritated  will  probably  be  earlier  and  more 
abundantly  covered  with  the  papules  than  elsewhere.    The  eruption  appears 


VAEIOLA.  729 

as  small,  slightly  elevated  maculag,  rapidly  developing  into  conical  papules 
about  the  size  of  a  pin's  head,  or  a  little  larger,  pale  red  in  color,  and  dis- 
tinctly indurated  to  the  touch.  Sometimes,  owing  to  an  areola  which  may- 
surround  it  at  this  stage,  it  presents  an  appearance,  especially  upon  the 
trunk,  not  unlike  the  developing  stage  of  measles.  On  the  second  day 
these  papules  have  become  of  a  deeper  red,  larger,  and  more  elevated,  and 
new  ones  have  come  out  in  the  intervening  spaces,  so  that  they  appear  more 
numerous  than  on  the  first  day.  Between  the  pajDules  the  skin  may  still  be 
of  normal  color,  but  if  the  papules  be  very  close  there  may  be  a  diffused 
redness  especially  over  the  face,  and  the  skin  there  may  have  a  granular 
appearance.  An  inspection  made  at  this  time  of  the  mouth,  throat,  and 
upper  air-passages  will  reveal  spots  of  deep  congestion  on  the  mucous  mem- 
branes which,  simultaneously  with  the  eruption  on  the  skin,  develop  into 
small  elevations  and  afterwards  become  vesicular.  While  the  number  of 
the  papules  is  to  a  certain  extent  an  indication  of  the  severity  of  the  attack, 
yet  their  behavior,  as  to  whether  they  remain  separate  or  coalesce,  is  a  still 
more  important  one.  Hence  upon  this  fact  two  types  of  the  disease  have 
been  distinguished : 

1.  Discrete  small-pox,  in  which  the  pustules,  when  fully  developed, 
remain  distinct,  and  in  which  the  disease  is  generally  of  the  milder  type. 

2.  Confluent  small-pox,  in  which  the  lesions  coalesce,  sometimes  towards 
the  end  of  the  papular  stage,  but  more  frequently  when  the  vesicles  are 
changing  to  pustules.  In  this  type  the  disease  always  assumes  a  severe 
character. 

In  addition  to  these  we  distinguish, — 

3.  Hemorrhagic  small-pox,  in  which  extravasations  into  the  pock  or 
underneath  the  skin  and  hemorrhages  from  the  mucous  membranes  become 
a  prominent  feature.     Such  cases  are  almost  invariably  fatal. 

4.  Modified  small-pox,  in  which  the  symptoms  have  been  mitigated  and 
the  course  of  the  disease  more  or  less  modified  and  shortened  by  previous 
vaccination  or  inoculation,  or  by  a  previous  attack. 

Other  forms  have  been  distinguished  by  different  authors,  of  which  the 
more  important  are  coherent  or  semi-confluent  small-pox,  in  M'hich  the  pustules 
touch  but  do  not  coalesce,  and  which  generally  runs  a  favorable  course ;  and 
corymbose  small-pox,  a  somewhat  singular  and  rare  form  of  the  disease,  in 
which  the  eruption  appears  in  close-set  clusters  about  the  size  of  the  palm 
of  the  hand,  or  smaller,  while  the  skin  surrounding  these  patches  is  for 
some  distance  free  from  the  disease.  The  rate  of  mortality  in  this  type  is 
very  higli.     These  latter  forms,  however,  do  not  require  special  description. 

We  shall  first  describe  the  course  of  the  discrete  form,  as  tlie  most  typical. 
On  the  third  day  of  tlie  eruption  a  minute  drop  of  pellucid  serum  may  be 
seen  at  the  apex  of  tlie  older  papules.  This  rapidly  increases  in  amount, 
and  converts  tlie  conical  papules  into  somewhat  flattened  vesicles  Avith  clear 
opaline  contents.  "  In  the  great  majority  early  in  their  development  an 
apicial  depression  can  be  seen,  which  later  on  deepens  into  the  characteristic 


730  VARIOLA. 

umbilication.  '  This  is  more  than  a  mere  depression  of  the  summit,  and  con- 
sists in  a  fluting  or  puckering  of  the  peripheral  part  of  the  roof-wall,  giving 
the  lesion  a  crenated  appearance.  It  may  be  regarded  as  pathognomonic 
of  variola."  ^  Bv  the  fifth  day  a  slight  turbidity  may  be  noticed  in  the 
contents  of  the  vesicles,  and  on  the  following  day  (the  eighth  of  the  illness) 
they  are  distinctly  pustular  on  the  face  and  hands.  The  eruption  is  now 
said  to  be  mature,  the  pustule  is  pea-sized,  multilocular,  and  more  or  less 
spherical,  its  umbilication  having  been  removed  by  the  continued  exudation 
into  it.  The  pock  on  the  lower  limbs,  as  it  appears  later,  runs  through  all 
its  stages  one  or  two  days  behind  that  on  the  face.  On  the  mucous  surfaces 
the  eruption  during  this  stage  becomes  a  source  of  much  discomfort,  and, 
in  young  children,  of  danger.  It  always,  if  at  all  abundant,  gives  rise  to 
great  irritation.  Afl:er  the  vesicular  stage  is  reached,  the  roof-wall  of  the 
lesion  is  very  apt  to  give  way,  leaving  a  superficial  erosion  or  ulceration, 
which  may  become  covered  with  pseudo-membrane.  More  or  less  inflam- 
mation of  the  surrounding  tissues  takes  place,  causing  pain  and  dif&culty  in 
swallowing.  Should  the  larynx  be  implicated,  there  will  be  hoarseness  and 
a  metallic  or  croupy  cough.  In  the  very  young,  sudden  attacks  of  suffo- 
cation, speedily  ending  fatally,  may  ensue.  Even  when  slightly  involved, 
the  nasal  passages  in  children  become  blocked  and  increase  the  difficulty  of 
breathing.  Blepharitis  and  slight  conjunctivitis  are  frequently  present,  and 
the  oedematous  lids  are  with  difficulty  opened.  In  discrete  cases  there  may 
be  little  fever  during  this  stage,  the  appetite  may  return  to  some  extent,  the 
nervous  symptoms  abate,  and  a  certain  amount  of  quiet  sleep  be  obtained. 

When  the  contents  of  the  pock  become  puriform,  the  disease  enters  upon 
the  stage  of  maturation.  The  inflammatory  reaction  around  the  pock  now 
increases,  the  temperature  rises,  and  the  child  again  becomes  very  restless. 
This  is  the  period  of  the  secondary  fever.  It  is  liable  to  fluctuations,  and 
declines  gradually.  Its  severity  and  duration  are  much  dependent  on  the 
number  of  the  papules  and  the  type  of  the  disease.  In  the  milder  cases  it 
is  very  slight,  and  lasts  but  two  or  three  days,  but  in  the  more  severe  the 
temperature  rises  very  high  (104°-106°  F.).  "We  may  have  active  delirium 
with  a  full  and  somewhat  hard  pulse  of  120-140,  or  the  patient  may  sink 
into  a  typhoid  condition  with  a  low  delirium  or  stupor,  feeble  quick  pulse, 
and  subsultus  tendinum,  and  easily  succumb  to  one  of  fhe  many  complica- 
tions liable  at  this  time.  By  the  eleventh  or  twelfth  day  of  the  disease, 
sometimes  a  day  or  two  earlier  or  later,  the  maturation  is  completed,  and 
the  stage  of  desiccation  or  decline  commences.  The  fever  now  gradually 
abates,  the  tumefaction  of  the  skin  subsides,  and  the  contents  of  the  pus- 
tules have  a  tendency  to  dry.  In  most  of  the  pustules  the  outer  wall  is 
ruptured,  either  by  pressure  or  friction,  and  its  contents  escape  and  form 
thick  yellowish  crusts  which  afterwards  deepen  in  color.  On  the  face  when 
the  pustules  are  numerous  these  crusts  are  frequently  ver\^  large.     Cicatri- 

'  J.  Nevins  Hyde,  Pepper's  System  of  Medicine,  vol.  i.  p.  458. 


VARIOLA.  731 

zation  goes  on  beneath.  Should  the  ulceration  have  been  deep,  the  detach- 
ment of  these  crusts  is  liable  to  be  slow,  and  frequently  new  crusts  form 
with  wearisome  persistence  after  the  old  ones  have  been  removed  (Eustace 
Smith).  Brown  or  purplish-colored  cicatrices  are  left  behind,  which  in  time 
change  to  dead-white  depressed  scars  with  uneven  edges  and  an  irregular 
floor.  The  entire  course  of  the  illness  covers  a  variable  period  of  from 
three  to  five  weeks. 

In  the  conflaent  type  of  the  disease  all  the  symptoms  are  more  severe 
and  show  a  tendency  to  develop  more  quickly  than  in  the  discrete  form, 
which  we  have  just  described.  The  incubation-period  is  relatively  short, 
and  the  initial  stage  is  ushered  in  by  a  severe  chill  or  convulsion.  The 
fever  runs  high,  and  the  remission  on  the  appearance  of  the  eruption  is 
only  slight.  Even  before  the  eruption  develops,  the  skin  shows  deep  con- 
gestion. The  papules  appear  early  and  come  out  quickly  over  the  whole 
body.  They  are  dense,  deeply  set,  and  in  severe  cases  may,  even  on  the 
first  day,  be  adherent  on  the  face  and  hands.  Sometimes  large  flattened 
papules  appear  which  coalesce  during  the  vesiculo-pustular  stage  to  form 
extensive  and  irregularly-shaped  bullte.  Even  on  the  trunk,  where  there  is 
not  the  same  tendency  to  coalesce  as  elsewhere,  the  pustules  frequently  do 
not  develop  or  fill  up  well,  but  remain  flat  with  an  ill-defined  edge.  This 
is  always  a  bad  indication.  About  this  time  the  appearance  of  the  whole 
face  i^  much  altered,  owing  to  the  great  swelling  of  the  skin :  the  lips  are 
protuberant,  the  eyelids  oedematous,  and  the  nose  enlarged  and  broadened. 
Thick  crusts  of  secretion  block  the  nares.  The  mucous  membranes  suffer 
severely.  The  eruption  on  them  is  always  abundant,  with  much  surround- 
ing hypersemia.  The  fauces  are  generally  much  swollen,  and  the  tongue  is 
enlarged  and  sometimes  inflamed.  There  is  much  viscid  secretion  in  the 
throat,  and  in  many  of  these  cases  a  pseudo-membrane  forms  on  the  fauces 
which  may  extend  into  the  respiratory  passages.  Deglutition  is  extremely 
painful,  sometimes  almost  impossible,  and  respiration  is  very  seriously 
impeded.  Should  the  larynx  be  attacked,  rapid  oedema  of  the  glottis  may 
take  place,  and  should  it  escape  that,  perichondritis  with  necrosis  is  not 
uncommon.  With  the  stage  of  maturation  the  fever,  which  has  never 
subsided,  rises  still  higher,  there  is  great  thirst,  and  often  intolerable  itching 
of  the  skin.  Albuminuria  is  usually  present.  Delirium  of  a  violent  or 
low  muttering  form  may  set  in.  Sometimes  the  child  remains  in  a  half- 
comatose  condition,  with  a  feeble,  fluttering  pulse.  Complications  in  this 
type  of  the  disease  are  very  frequent.  Some  of  the  more  severe  cases 
never  properly  enter  the  pustular  stage.  The  vesicles  instead  of  swelling 
and  becoming  pustular  remain  flat.  The  face  assumes  a  dirty-white,  j)asty 
appearance,  and  profound  exhaustion  sets  in.  In  others  the  eruption  appears 
but  slightly,  the  skin  is  dusky  red,  the  circulation  is  very  feeble,  and  the 
urine  is  scanty  or  suppressed.  Such  cases  have  been  described  under  the 
term  malignant.  In  them  death  usually  takes  place  between  the  seventh 
and  the  ninth  day. 


732  VAEIOLA. 

Hemorrhagic  Small-pox. — Two  types  of  this  most  malignant  form  of 
the  disease  have  been  described.  In  the  first  and  most  severe  type  (purpura 
variolosa)  the  poison  appears  to  act  so  gravely  upon  the  blood  as  to  develop 
an  intense  purpuric  condition  with  an  overwhelming  prostration  of  the 
vital  powers.  The  characteristic  eruption  fails  to  appear.  In  such  cases, 
after  a  brief  incubation-period,  we  meet  with  a  violent  explosion  of  symp- 
toms at  the  commencement  of  the  initial  fever.  A  deep  scarlatiniform, 
sometimes  almost  purplish,  rash  appears  on  the  trunk  and  extremities,  gener- 
ally leaving  the  face  free.  In  this  rash  petechise  and  vibices  rapidly  appear ; 
on  the  extremities  these  remain  discrete,  but  on  the  trunk  they  coalesce  into 
large  irregular-shaped  figures  of  deep-black  hue.  At  the  same  time  blood 
is  effused  under  the  conjunctiva,  hemorrhages  occur  from  many  of  the 
mucous  membranes,  and  there  is  frequently  hasmaturia.  Diphtheroid  exuda- 
tions take  place  in  the  pharynx,  and  a  horrible  stench  adds  to  the  frightful- 
ness  of  the  case.  The  temperature  generally  remains  low,  rising  perhaps 
just  before  death.  The  mental  faculties  are  frequently  clear.  The  end 
may  occur  in  a  few  hours,  but  generally  two  or  three  days  elapse.  In  the 
second  form,  hemorrhagic  symptoms  set  in  during  some  stage  of  the  erup- 
tion. The  earlier  such  symptoms  occur,  the  more  intense  is  the  blood- 
poisoning  and  the  more  grave  the  general  condition.  When  they  appear 
during  the  papular  stage  the  eruption  is  genei'ally  sparse  and  the  disease 
runs  a  course  not  unlike  the  previous  form  just  described,  but  not  so  rapid. 
Death  usually  takes  place  in  five  or  six  days.  In  other  cases  the  hemor- 
rhagic condition  occurs  during  the  vesicular  stage,  and  in  others  not  until 
the  pustular  stage  is  reached.  In  such  the  effusion  takes  place  into  the 
pock,  and  more  or  less  into  the  subjacent  cellular  tissue.  In  the  more 
severe  cases  there  may  be  liEematemesis,  hsematuria,  or  melsena.  Death 
takes  place  between  the  sixth  and  ninth  days.  In  cases  less  grave,  "  if  the 
hemorrhage  be  limited  it  is  not  necessarily  a  fatal  sign,  although  the  patient 
may  die  of  small-pox,  irrespective  of  the  hemorrhage ;  but  if  it  be  exten- 
sive, in  particular  if  it  be  largely  into  the  skin,  the  case  will  be  fatal,  vacci- 
nation notwithstanding.  In  these  cases  there  is  usually  more  or  less  mental 
confusion  or  delirium.  It  is  important,  however,  not  to  confound  this  dan- 
gerous form  of  the  disease  with  an  effusion  of  sanguinolent  fluid  into  some 
of  the  pocks  only,"  the  result  probably  of  some  passive  engorgement  of  the 
tissues  (Collie). 

Varioloid  is  the  somewhat  incorrect  term  which  we  apply  to  small-pox 
modified  by  vaccination.  Inoculation  and  a  previous  attack  may  both  pro- 
duce a  similar  modification,  but  the  former  is  now  never  emploved  in  this 
country,  and  a  second  attack  in  childhood  is  unknown.  Previous  sufficient 
and  effectual  vaccination  in  infancy  is  in  the  majority  of  cases  a  complete 
protection  against  an  attack  up  to  the  age  of  eight  or  ten  years.  In  a 
very  few  before  that  age  varioloid  makes  its  appearance  even  after  efficient 
vaccination,  but  the  further  we  pass  it  the  more  frequent  do  the  cases  be- 
come.    In  varioloid  the  disease  is  always  lessened  in  its  intensity,  and  may 


VARIOLA.  733 

be  altered  both  in  its  course  and  in  its  duration.  Morrow^  says  vaccination 
denaturalizes  small-pox,  deranges  the  regular  order  of  its  evolution,  and 
effaces  its  most  distinctive  features.  The  initial  stage  is  frequently  as  severe 
as  in  the  unmodified  form,  and  sometimes  longer,  but  as  often  it  is  very 
mild.  The  temporary  rashes  are  frequently  seen.  Bartholow  says  that  the 
better  defined  they  are  the  milder  the  attack  will  be ;  but  this  is  probably 
liable  to  variation  in  different  epidemics.  Defervescence  is  rapid  and  gen- 
erally complete  with  the  commencement  of  the  eruptive  stage.  The  erup- 
tion of  varioloid  is  apt  to  be  very  irregular  in  its  appearance  and  its  course. 
Instead  of  beginning  on  the  face,  it  may  make  its  first  appearance  on  the 
back,  chest,  or  extremities.  In  general  the  number  of  the  pocks  is  much 
lessened,  frequently  under  twenty  altogether.  Their  abortion  may  take 
place  at  any  period,  convalescence  ensuing  rapidly.  Occasionally  the  course 
may  be  almost  typical,  but  the  symptoms  throughout  be  of  a  mild  form. 
In  most  cases  it  is  shortened  and  the  secondary  fever  quite  absent.  Slight 
permanent  cicatrices  may  be  left  if  the  pustule  has  fully  developed.  In  the 
milder  cases  the  danger  is  lest  the  disease  be  overlooked  till  it  spread  to 
other  members  of  the  household. 

Complications  and  Sequelae. — Speaking  generally,  we  may  say  that 
there  are  fewer  complications  and  sequelae  met  with  in  this  disease  than  in 
most  of  the  specific  fevers.  Among  those  efficiently  vaccinated,  complications 
of  all  kinds  are  generally  absent.  The  previous  health  of  the  child  seems 
to  have  a  strong  predisposing  influence,  and  weakly  and  strumous  children 
with  a  tendency  to  pharyngeal  catarrh,  bronchitis,  enteritis,  strumous 
ophthalmia,  etc.,  are  very  liable  to  suffer  in  these  parts  should  the  attack 
prove  at  all  severe.  Most  of  the  complications  met  with  are  intimately 
connected  with  the  local  affection  and  appear  towards  the  end  of  the  erup- 
tive stage.  Among  the  most  important  are  those  of  the  respiratory  tract. 
Pharyngitis,  and  oedematous  and  diphtheritic  laryngitis,  may  early  assume 
a  very  threatening  character.  As  soon  as  dyspnoea  sets  in,  relief  should 
be  given  by  tracheotomy  or  intubation.  More  or  less  bronchitis  occurs 
in  all  the  severe  cases  in  childhood;  and  not  infrequently  is  accompanied 
with  broncho-pneumonia.  Pleurisy  in  children  is  common  and  very  fatal 
(Eustace  Smith).  It  commences  suddenly,  runs  a  very  rapid  course,  and 
terminates  as  an  empyema  almost  invariably  fatally  in  three  or  four  days. 
Pneumonia  of  a  passive  form  is  liable  to  come  on  insidiously.  It  is  slower 
in  its  progress,  and  not  so  uniformly  fatal.  Trousseau  records  au  interest- 
ing case  of  a  child  of  twenty  months,  who  on  the  third  day  of  the  eruption 
was  seized  with  dyspnoea.  At  the  moment  of  performing  tracheotomy  two 
false  membranes  were  thrown  out  through  the  wound.  The  child  di(>(l  a  few 
hours  after  the  operation.  An  autopsy  showed  that  the  pseudo-membrane 
extended  to  the  larger  bronchial  tubes.  On  the  right  side  were  isolated 
masses  of  purulent  pneumonia,  and  a  small  quantity  of  purulent  effusion. 

*  Journal  of  Cutaneous  and  Venereal  Diseases,  March,  1886. 


734  VARIOLA. 

The  heart  in  children  occasionally  suffers.  Cases  of  pericarditis  and,  more 
rarely,  endocarditis  are  recorded.  Acute  fatty  degeneration  of  the  myocar- 
dium may  be  a  cause  of  sudden  death.  In  the  digestive  tract  serious  com- 
plications are  perhaps  less  frequent  in  children  than  in  adults.  Salivation 
is  rare,  and  when  it  occurs  is  not  severe  and  passes  off  in  four  or  five  days 
(Lewis  Smith).  Parotitis  and  glossitis  are  extremely  rare  in  childhood. 
Obstinate  vomiting  and  a  })8rsistent  catarrhal  diarrhoea  are  not  infrequent, 
and  add  much  to  the  exhaustion.  Peritonitis  is  very  rare.  A  mild  orchitis 
or  ovaritis  is  said  to  be  met  with  sometimes.  They  subside  coincidently  with 
the  eruption.  Although  albuminuria  is  frequent,  it  rarely  leaves  chronic 
mischief  behind.  Erysipelas  is  an  infrequent  complication.  Gangrene  of 
the  vulva  is  liable  to  occur  in  children  with  catarrhal  leucorrhoea,  and  gan- 
grene of  the  finger-tips  and  toes  is  of  rare  occurrence.  One  of  the  most 
frequent  of  the  sequelae  is  a  series  of  small  boils  or  superficial  abscesses 
in  the  subcutaneous  cellular  tissue.  More  important  are  the  deep-seated 
abscesses  which  may  occur  in  the  extremities  and  seriously  interrupt  the 
progress  towards  recovery.  They  sometimes  give  rise  to  pysemia.  Perios- 
titis may  develop  and  be  followed  by  caries  or  necrosis.  Arthritis  of  a 
suppurative  character  is  not  uncommon  in  the  larger  joints.  It  may  involve 
the  surrounding  tissues  and  lead  to  much  damage,  if  not  to  actual  loss  of 
the  joint.  Septicaemia  and  pysamia  are  not  infrequent  towards  the  later 
stages,  and  are  a  frequent  cause  of  death.  After  all  severe  attacks  the  con- 
valescent is  left  in  a  weak  and  very  anaemic  condition.  In  a  very  few, 
damage  to  the  nervous  system  may  result.  Partial  paralysis,  aphasia,  and 
tremors  are  reported,  and  sometimes  the  intellectual  powers  may  remain 
weakened  for  many  months.^  For  the  following  description  of  the  special 
complications  met  with  in  the  eye  and  the  ear,  I  am  indebted  to  Dr.  J.  J. 
Gardner,  oculist,  who  had  charge  of  a  department  of  the  Civic  Hospital, 
Montreal,  during  the  epidemic  of  1885  : 

^'Complications  met  with  in  the  eye. — Almost  every  part  of  the  eye  may 
suffer,  the  lids,  lachrymal  sac,  conjunctiva,  cornea,  choroid,  and  even  the 
retina  and  extrinsic  muscles.  These  complications  may  occur  either  during 
the  course  of  the  disease  or  afterwards.  They  are  much  more  apt  to  occur 
if  the  type  of  the  disease  be  severe,  or  if  the  patient  be  debilitated.  Con- 
junctival affections  are  common.  Some  hypersemia  is  always  seen  when  the 
eruption  occurs  on  the  lids,  but  is  of  little  moment.  Occasionally  Ave  meet 
with  a  simple  catarrhal  ophthalmia,  or  more  rarely  a  purulent  conjunctivitis 
with  great  chemosis,  sometimes  so  severe  as  to  be  mistaken  for  gonorrhoeal 
ophthalmia.  The  variolous  form,  however,  is  not  so  painful,  and  there  is 
less  swelling  of  the  palpebral  conjunctiva,  and  less  tendency  to  corneal  ulcer- 
ation. Keratitis  may  develop  from  a  purulent  conjunctivitis,  or  quite  inde- 
pendently of  this,  but  never  earlier  than  the  twelfth  day  (Adler).  It  may 
occur  either  as  a  circumscribed  superficial  infiltration,  which  heals  under 

'  H.  I^omkyns,  M.D.,  Leicester,  Eng. 


VARIOLA.  735 

atropine  and  hot  fomentations,  or  may  take  the  form  of  an  ulceration  very 
dangerous  to  the  eye.  De  Wecker  regards  this  as  in  many  cases  a  '  neuro- 
paralytic keratitis.'  It  generally  begins  near  the  margin  of  the  cornea,  is 
very  irritable,  and  seems  to  have  a  greater  tendency  to  spread  superficially 
than  to  penetrate :  so  that  we  rarely  have  perforation  till  the  greater  part 
of  the  cornea  is  destroyed.  Hypopyon,  with  iritis,  usually  accompanies  it, 
and  ultimately  panophthalmitis.  The  prognosis  depends  very  much  upon 
the  period  at  which  it  begins,  and  on  the  severity  of  the  general  symptoms. 
The  earlier  its  appearance  in  the  course  of  the  disease,  the  more  dangerous 
it  is  to  the  eye.  Complete  resolution  is  very  exceptional.  The  more  favor- 
able termination  is  a  leucoma  cornese  adherens,  which  is  frequently  total.  The 
treatment  does  not  differ  from  the  general  treatment  of  corneal  ulcer,  except 
that  it  must  be  prompt.  Early  and  frequent  examination  of  the  cornea 
should  be  made,  to  note  any  morbid  process.  Owing  to  the  great  swelling 
of  the  lids,  this  is  by  no  means  an  easy  matter,  but  with  the  aid  of  lid- 
retractors  it  can  generally  be  accomjDlished.  It  is  best  to  begin  treatment 
with  frequent  fomentations  with  a  hot  saturated  solution  of  boric  acid,  and 
instillations  of  atropine  or  eserine  three  or  four  times  daily.  The  ulcer  may 
be  dusted  with  a  little  powdered  iodoform.  If  under  this  treatment  the 
inflammation  increases,  the  edges  of  the  ulcer  should  be  thoroughly  cauter- 
ized with  the  galvano-cautery,  and,  if  necessary,  paracentesis  corneas  per- 
formed. Gentle  pressure  should  be  made  with  a  bandage.  If  there  is  much 
discharge  the  bandage  must  be  removed  very  frequently  and  the  parts 
cleansed,  and  once  or  twice  daily  the  everted  lids  should  be  brushed  with  a 
solution  of  nitrate  of  silver  (gr.  v-x  to  Sj)-  De  Wecker  claims  to  have 
had  better  success  with  eserine  than  with  atropine.  If  there  be  no  iritis  it 
may  be  freely  used.  In  lachrymal  obstruction  the  duct  must  be  opened. 
In  the  ear,  accoi'ding  to  Wendt,  complications  are  more  frequent  than  in  the 
eye.  The  milder  forms  of  hypersemia  are  generally  overlooked,  as  they 
cause  no  complaint.  Catarrh  of  the  middle  ear  is  common,  and  is  generally 
directly  due  to  swelling  of  the  naso-pharyngeal  mucous  membrane  closing 
the  Eustachian  tubes.  Sometimes  this  goes  on  to  acute  inflammation  of  the 
middle  ear,  which  may  end  in  extensive  destruction  of  the  soft  parts  and 
ossicles,  with  subsequent  permanent  deafness.  The  pain  during  the  forma- 
tion of  pus  is  very  intense,  but  subsides  as  soon  as  the  membrane  bursts  or  is 
incised.  This  complication  requires  careful  and  early  treatment.  One  or  two 
leeches  at  the  outset  may  be  applied  in  front  of  the  tragus,  and  be  followed 
by  frequent  hot  bathing.  This  is  best  accomplished  in  the  absence  of  a 
douche  by  allowing  hot  water  to  drop  from  a  sponge  held  a  few  inches  from 
the  ear,  the  water  flowing  off  into  a  basin  beneath.  If  the  pain  be  not 
quickly  subdued  and  the  membrana  tympani  be  found  bulging,  an  incision 
should  be  made  in  the  most  prominent  point.  Gentle  inflation  afterwards 
by  Politzer's  method  daily  is  of  great  service.  The  ear  must  be  cleansed 
by  syringing  with  some  antiseptic  lotion.  The  naso-phaiynx  should  at  the 
same  time  receive  treatment.    In  the  throat  the  presence  of  the  eruption  gives 


736  VARIOLA. 

rise  to  much  irritation,  and  is  the  source  of  perhaps  the  commonest  com- 
plaint of  small-pox  patients.  The  accompanying  viscid  secretion  occasions 
dysphagia,  nausea,  and  sometimes  dyspnoea  and  a  troublesome  cough^  which 
is  very  trying  to  weakly  children.  Sometimes  a  diphtheritic  membrane 
appears  in  the  soil  palate  and  tonsils,  increasing  the  gravity  of  all  the  symp- 
toms. Oedema  is  not  infreqent  in  children.  Severe  ulceration  of  the  mucous 
membrane  of  the  larynx  with  perichondritis  and  necrosis  of  the  cartilages 
may  occur,  and  be  associated  with  abscess  in  surrounding  tissues.  The 
treatment  of  all  throat  complications  is  very  unsatisfactory,  especially  in 
children.  The  pain  and  discomfort  I  found  most  relieved  by  warm  chlo- 
rate of  potash  gargles  followed  by  a  spray  of  a  ^^eak  solution  of  cocaine  of 
a  strength  of  one-half  to  two  per  cent. ;  but  this  requires  caution  in  very 
young  children.  The  parts  should  be  kept  moist  by  the  frequent  adminis- 
tration of  small  quantities  of  fluids,  or  ice.  (Edema,  if  sufficient  to  cause 
dyspnoea,  requires  scarification  or  prompt  tracheotomy,  or  intubation.  If  the 
suffocation  be  due  to  an  abscess,  it  must  be  opened." 

Mode  of  Death. — Death  during  the  first  few  days  is  generally  due  to 
variolous  toxaemia.  Later  on  in  the  course  of  the  disease  it  is  most  fre- 
quently owing  to  exhaustion.  In  young  infants  and  children,  with  their 
small  larynx  and  defective  respiratory  power,  it  not  infrequently  takes 
place  by  apnoea.  Sometimes  cerebral  symptoms  set  in,  and  death  follows 
with  coma  or  convulsions,  and  rarely  we  have  it  occurring  suddenly,  with 
signs  of  rapid  heart-failure,  when  the  previous  symptoms  had  apparently 
been  favorable.  It  is  a  notable  fact  that,  when  discrete  small-pox  proves 
fatal,  death  generally  occurs  between  the  eighth  and  ninth  days  of  the  dis- 
ease, while  in  the  confluent  form  the  most  fatal  period  is  not  till  between  the 
eleventh  and  thirteenth  days. 

Prognosis. — In  the  unvaccinated,  the  younger  the  child  the  greater  the 
danger.  Even  when  the  attack  is  discrete  in  character,  almost  all  under 
one  year  die,  and  a  large  proportion  of  those  under  two  years.  In  such, 
even  when  convalescence  seems  to  have  set  in,  a  sudden  change  may  occur 
about  the  fourteenth  or  fifleenth  day,  and  death  ensue.  Above  the  third 
year  the  discrete  variety  generally  terminates  favorably,  but  the  confluent  is 
very  fatal  in  children  of  all  ages.  The  severity  of  the  initial  symptoms 
bears  no  absolute  relation  to  the  course  afterwards,  but  the  child's  previous 
health  has  a  very  important  bearing.  Any  enfeebling  disease,  such  as 
scrofula,  phthisis,  or  syphilis,  renders  the  prognosis  bad.  The  amount  of 
eruption  governs  the  prognosis  to  a  great  degree,  as  also  the  extent  to  which 
the  mucous  membranes  are  implicated.  During  the  development  of  the 
pock,  any  cessation  or  irregularity  in  its  course  is  to  be  dreaded.  Any 
sudden  fading  of  the  eruption  or  unusual  pallor  of  the  skin,  any  failure  to 
become  full  and  swell  out  about  the  eighth  day,  or  any  sudden  shrinking 
of  the  pock,  as  if  by  absorption  of  its  contents,  is  of  the  gravest  import, 
and  is  generally  followed  by  death,  frequently  within  twenty-four  hours. 
On  the  other  hand,  a  good  defervescence  on  the  appearance  of  the  eruption, 


VARIOLA.  737 

a  bright  and  rosy  areola,  with  a  moderate  eruption  filling  out  well  about 
the  eighth  day,  a  fair  return  of  the  appetite,  and  a  moderate  secondary  fever 
with  no  complications,  are  all  of  favorable  import.  In  the  hemorrhagic 
forms  of  the  disease  the  prognosis  is  always  very  bad.  A  few  cases  in 
which  hemorrhagic  symptoms  set  in  during  the  pustular  stage  may  recover, 
but  in  general  death  is  certain.  "  Laryngitis,  if  severe  enough  to  give  rise 
to  distinct  difficulty  of  breathing,  is  mostly  fatal,  even  if  tracheotomy  be 
performed"  (Collie),  Complications  should  be  looked  for  if  the  secondary 
fever  run  high.  Different  epidemics  vary  much  in  their  mortality.  Those 
occurring  in  summer  are  generally  more  dangerous  than  those  occurring  in 
winter  (Curschmann),  and  the  mortality  is  usually  less  at  the  end  of  an 
epidemic  than  at  its  commencement.  Varioloid  is  rarely  fatal,  and  has  no 
complications. 

Diagnosis. — It  is  very  important  for  all  concerned  that  a  true  diagnosis 
should  be  made  in  every  case  of  variola  and  varioloid  as  promptly  as  possi- 
ble. An  error  either  way  exposes  the  physician  to  merited  blame,  which, 
in  general,  his  patients  will  not  be  slow  to  bestow  upon  him.  Where  there 
is  any  suspicion  that  a  case  is  this  dreaded  disease,  it  is  well  to  have  definite 
knowledge  on  the  following  points.  Are  there  other  cases  of  variola  in 
the  neighborhood?  Has  the  child  marks  of  successful  vaccination?  If 
so,  how  many  distinct  marks,  and  how  long  a  time  has  elapsed  since  they 
were  made?  If  not,  has  the  child  been  inoculated,  or  has  it  had  a  pre- 
vious attack  of  small-pox  ?  Has  there  been  any  possibility  of  exposure  ? 
Although  it  is  very  improbable  that  an  attack  of  varioloid  should  occur 
in  an  efficiently  vaccinated  child  under  ten  years  of  age,  yet  it  is  by  no 
means  impossible,  as  many  instances  during  our  Montreal  epidemic  attested. 
On  the  other  hand,  it  is  possible  for  a  child  to  have  a  very  mild  attack  of 
variola  without  previous  vaccination.  During  the  initial  stage  it  is  impos- 
sible to  make  an  absolute  diagnosis,  but  in  the  absence  of  effectual  vaccina- 
tion, and  with  the  possibility  of  previous  exposure,  we  should  regard  with 
suspicion  the  symptoms  of  this  stage  appearing  without  other  sufficient 
cause.  While  it  is  remembered  that  vomiting  \yith  pyrexia  may  usher*in 
many  of  the  ailments  of  childhood,  in  the  present  disease  the  vomiting  is 
more  apt  to  be  persistent.  Pain  in  the  back  is  a  symptom  which  it  is  diffi- 
cidt  to  elicit  or  to  estimate  the  severity  of  in  young  children,  but  should  the 
child  lose  control  of  its  sphincters  small-pox  may  be  suspected.  In  cases 
of  repeated  convulsions  with  intervening  somnolence  or  stupor,  occurring 
in  very  young  children,  the  possibility  of  small-pox  as  the  cause  should 
not  be  overlooked.  Except  in  cases  of  known  exposure,  a  physician  is, 
however,  not  justified  in  speaking  absolutely  until  the  characteristic  eruption 
fully  appears  in  the  form  of  small,  distinct,  "  shotty"  papules,  seen  first  on 
the  face  and  forehead,  and  perhaps  on  the  back  of  the  wrists,  and  succes- 
sively invading  the  neck,  trunk,  arms,  and  lower  extremities,  and  visible 
also  on  the  mucous  membrane  of  the  mouth  and  fauces.  Should  there  be 
any  irregularity  in  tlie  appearance,  or  doubt  about  the  symptoms,  the  proper 
Vol.  I.— 47 


738  VARIOLA. 

course  is  to  wait  another  twenty-four  hours,  until  the  jjapules  on  the  face 
become  vesicular.  At  this  time  a  diagnosis  ought  to  be  made  with  certainty. 
Before  this  only  one  symptom  is  said  to  be  pathognomonic,  the  hemorrhagic 
initial  exanthem  in  Simon's  crural  triangle ;  but  this  appears  only  in  the 
few. 

Morhilli  in  children  is  probably  the  disease  most  likely  to  be  confounded 
with  small-pox,  especially  when  the  former  is  of  the  papular  variety.  In 
some  cases  it  is  impossible  to  distinguish  between  the  two  rashes  for  the 
first  day.  The  points  of  difference  are  as  follows.  In  measles  during  the 
invasion-stage  we  have  catarrhal  symptoms  appearing  early  in  the  conjunc- 
tival, nasal,  and  bronchial  mucous  membranes.  These  are  absent  in  small- 
pox. The  rash  of  measles  appears  on  the  fourth  day  almost  simultaneously 
on  the  back  and  face,  and  the  papules  are  larger,  smoother,  softer,  and 
brighter  red,  as  opposed  to  the  paler  papules  of  variola,  which  communicate 
a  more  harsh  and  indurated,  or  shotty,  sensation  to  the  finger.  "  In  cases 
of  small-pox  severe  enough  to  simulate  measles,  on  passing  the  hand  over 
the  face  the  feeling  is  that  of  hardness  and  furrowed  roughness,  like  that 
produced  by  passing  the  hand  over  a  piece  of  corduroy,  whereas  in  raised 
confluent  measles  the  sensation  is  like  that  produced  by  passing  the  hand 
over  a  piece  of  velvet"  (Collie).  The  range  of  temperature  during  the 
initial  stao-e  of  measles  is  lower  than  in  variola,  but  there  is  no  defervescence 
on  the  appearance  of  the  exanthem;  on  the  contrary,  the  temperature  may 
continue  to  rise,  and  it  attains  its  maximum  during  the  height  of  the  erup- 
tion. Variola  and  varioloid  are  to  be  distinguished  from  varicella  by  the 
stage  of  invasion  lasting  two  or  three  days.  In  varicella  this  is  generally 
absent,  and  very  rarely  does  it  exceed  twenty-four  hours, — any  constitu- 
tional disturbance  met  with  usually  following,  not  preceding,  the  rash.  The 
vesicle,  in  varicella,  follows  the  papule  within  a  few  hours,  never  exceeding 
twenty-four,  and  attains  its  full  development  in  one  or  two  days.  It  is  soft, 
globular,  and  superficial,  rarely  umbilicated.  Its  contents  may  be  evacu- 
ated by  a  single  puncture.  The  eruption  is  generally  best  seen  on  the  back 
of  the  shoulders.  Small  isolated  papules,  which  do  not  form  vesicles,  are 
probably  due  to  varioloid.  In  scarlet  fever  i\iQ  rash  appears  within  the  first 
twenty-four  hours,  and  the  throat  is  invariably  implicated.  The  appear- 
ance of  a  papular  rash  on  the  third  day  would  remove  all  doubt.  Only  in 
hemorrhagic  small-pox  might  the  diagnosis  be  obscure.  Sometimes  the 
symptoms  during  the  invasion-stage  may  resemble  those  oi  pneumonia;  but 
the  ajipearance  of  the  rash  would,  of  course,  put  that  diagnosis  aside. 

Papular  eczema  may  be  mistaken  for  the  commencing  eruption  of 
small-pox,  but  it  is  very  rarely  that  there  are  any  preceding  febrile  symp- 
toms, and  if  so  they  are  of  sliort  duration.  The  red  itchy  character  of  the 
papules,  the  irregular  distribution,  the  non-implication  of  the  mucous  mera- 
l)ranes,  should  serve  to  distinguisli  it;  but  in  any  case  of  doubt  the  assist- 
ance of  time  should  be  sought.  After  forty-eight  hours  the  variolous 
papule  becomes  distinctly  vesicular.      Sudamina,  pemphigus,  herpes,  ery- 


VARIOLA.  739 

thema,  urticaria,  and  acne  have  been  mistaken  for  variola,  owing  to  hasty 
and  ill-considered  diagnoses.  If  attention  be  paid  to  the  element  of  time, 
the  anomalous  forms  of  small-pox  need  give  no  difficulty.  "  A  scarlatinoid 
rash  followed  on  the  third  day  by  an  eruption  of  papules  is  small-pox.  If 
such  rash  be  of  dark  color,  with  purpuric  and  inky  spots,  the  case  is  small- 
pox. Speaking  generally,  hemorrhagic  effusions  into  the  skin,  purpuric 
and  black  spots,  hemorrhage  into  the  conjunctiva,  and  scarlatinoid  measly 
rashes,  preceded  by  initial  symptoms,  are  small-pox"  (Collie). 

Treatment. — In  any  case  of  sickness  in  children  when  the  sudden  onset 
and  general  character  of  the  symptoms  would  indicate  specific  disease,  it  is 
of  importance  that  isolation  in  a  large  well-ventilated  room  in  the  upper 
part  of  the  house  should  take  place  at  once.  As  soon  as  the  physician  has 
determined  the  possibility  of  the  attack  being  one  of  small-pox,  arrange- 
ments should  be  made  to  insure  the  strictest  isolation,  and,  at  the  same  time, 
as  perfect  hygienic  surroundings  and  as  careful  nursing  as  can  be  obtained. 
The  room  must  be  large,  free  of  all  unnecessary  furniture,  and  possess 
means  for  thorough  ventilation  and  free  access  of  air.  Its  temperature 
should  be  kept  moderate,  about  Q6°  F.  Strong  light  should  be  excluded, 
lest  it  increase  the  tendency  to  pitting  on  the  face  and  hands.  The  diet 
should  be  light,  yet  eminently  nutritious.  In  some  instances  it  w-ould  be 
the  better  of  being  partially  pre-digestecl,  or  of  having  digestants,  such  as 
some  good  preparation  of  pepsin  or  pancreatin,  associated  with  it.  During 
the  invasion-stage  there  is  almost  always  complete  anorexia,  and  diges- 
tion and  assimilation  are  in  abeyance.  Only  the  blandest  fluids  should  be 
permitted  at  this  period ;  but  during  the  eruptive  stage  feeding  must  be 
pressed,  especially  if  the  case  be  severe.  Much  tact  and  assiduous  coaxing 
may  be  required  to  induce  the  little  one  to  attempt  to  swallow,  but  it  is 
important  that  as  much  nourishment  as  possible  should  be  taken.  In 
general  it  will  be  best  to  give  it  in  small  quantities  at  short  intervals  day 
and  night.  During  the  stage  of  suppuration,  wath  its  severe  drain  on  the 
system,  and  its  tendency  to  exhaustion,  stimulants  will  be  required  in  addi- 
tion to  the  most  nutritious  and  assimilable  food  we  can  give.  In  regard  to 
its  therapeutic  management,  it  should  be  remembered  that,  w' ith  our  present 
knowledge,  we  have  no  drug  that  will  control  or  modify  the  course  of 
variola.  It  is  a  self-limited  disease,  and,  as  Rilliet  and  Barthez  long  ago 
pointed  out,  all  treatment  tending  to  disturb  the  normal  course  of  the  ill- 
ness is  harmful.  Sydenham's  repressive  treatment,  designed  to  retard  the 
development  of  the  eruption,  by  keeping  the  skin  cool  and  using  saline 
laxatives,  and  the  course  of  treatment  adopted  before  his  time,  of  encour- 
aging derivation  to  the  skin  by  promoting  perspiration  in  every  way,  have 
both  been  found  injurious.  The  disease  runs  a  more  favorable  course  when 
the  eruption  appears  and  develops  naturally  and  regularly.  Many  anti- 
septic and  antizymotic  remedies  have  been  tried,  chief  among  which  are 
quinine,  salicylic  acid,  carbolic  acid,  and  the  sulpho-carbolates,  but  so  far 
the  results  have  not  been  in  any  way  encouraging.     It  is  well,  therefore,  to 


740  VAEIOLA. 

recognize  fully  at  the  outset  that  our  therapeutics,  at  least  for  the  present, 
should  be  confined  to  sustaining  and  palliative  measures,  and  to  the  combat- 
ing of  any  complications  that  may  arise.  Depressing  measures  of  all  kinds 
should  be  avoided  in  children,  and  especially  in  infants.  During  the  stage 
of  invasion  severe  nervous  symptoms  may  call  for  treatment.  Chloral 
hydrate,  associated  with  one  of  the  bromide  salts,  has  been  used  with  good 
results.  Antipyrin  or  antifebrin  in  cautious  doses  may  be  tried.  At  present 
they  promise  to  be  of  much  service,  both  in  reducing  the  hyperpyrexia  of 
this  period  and  in  relieving  many  of  the  nervous  symptoms.  If  the  tem- 
perature run  high  and  the  head  be  hot,  cold  applications  may  be  made  to 
the  scalp,  and  the  body  gently  sponged  with  tepid  water.  For  the  vomit- 
ing I  have  found  small  doses  of  cocaine  aiford  much  relief.  Should  it  fail, 
other  gastric  sedatives,  such  as  soda,  bismuth,  and  hydrocyanic  acid,  may 
be  tried.  In  cases  of  older  childen  one  of  the  effervescing  citrates  may 
prove  very  grateful.  Should  the  bowels  be  confined  at  this  time,  a  gentle 
laxative  may  be  given.  During  the  entire  period  of  the  eruption  one 
important  indication  seems  to  be  to  relieve  the  irritation  of  the  skin  and 
mucous  membrane.  Very  numerous  are  the  different  applications  that 
have  been  made  use  of  at  one  time  or  another  in  the  hope  of  limiting  the 
surrounding  inflammation  and  lessening  the  tendency  to  subsequent  pitting. 
It  seems  very  doubtful  if  any  of  them  are  of  great  value.  Still,  it  is  in 
most  cases  desirable  that  some  attempt  to  prevent  the  scarring  should  be 
made,  especially  on  the  faces  of  young  girls.  Perhaps  the  most  successful 
method  is  that  recommended  by  the  Germans,  of  keeping  cloths  wet  with 
water  spread  over  the  face  and  arms.  Curschmann  advises  that  the  water 
be  cool,  but  Kaposi  recommends  that  it  be  used  as  warm  as  may  be  com- . 
fortable.  If  desired,  some  antiseptic  or  deodorizer  may  be  added  to  the 
water.  Hyde  uses  a  solution  containing  one  drachm  of  boracic  acid  with 
a  drachm  or  two  of  glycerin  to  a  pint  of  water  as  warm  as  may  be  com- 
fortably borne.  Cloths  Avrung  out  of  this  should  be  constantly  applied, 
changing  them  as  they  cool.  During  the  night-time,  or  when  the  patient 
is  sleeping,  they  may  be  covered  with  oiled  silk  to  retain  the  heat  and 
moisture.  If  the  eruption  be  very  profuse  over  the  body,  and  the  irrita- 
tion very  great,  the  Vienna  plan,  of  immersion  for  two  or  three  hours 
daily,  may  be  tried  with  older  children.  The  water  should  be  maintained 
as  nearly  as  possible  at  a  temperature  of  98°  F.  Dr.  Welch  recom- 
mends a  mixture  of  olive  oil  and  lime-water  in  equal  parts,  to  be  from 
time  to  time  painted  over  the  surface  with  a  large  camel's-hair  brush.  Dr. 
Tomkyns  writes  me  that  he  has  used  Math  much  success  in  the  Fever 
Hospital,  Manchester,  England,  a  thin  solution  of  common  starch,  glycerin, 
and  tincture  of  iodine  (glyc,  Sss;  tinct.  iodini,  5ii ;  sol.  amyli,  Oss)  to 
relieve  the  dermatitis  and  prevent  pitting.  During  the  epidemic  in  Mon- 
treal in  1885,  at  the  Civic  Hospital  tincture  of  iodine  was  painted  once  or 
twice  daily  over  the  face  and  hands  while  the  eruption  was  in  the  papular 
stage.     It  was  thought  to  diminish  the  pitting.     A  solution  of  nitrate  of 


VAEIOLA.  741 

silver  has  been  used  similarly  on  the  first  appearance  of  the  papules  on  the 
face.  Schwimmer  strongly  recommends  the  use  of  the  following  paste : 
carbolic  acid,  4-10  parts ;  olive  oil,  40  parts ;  prepared  chalk,  60  parts. 
Make  a  soft  paste  to  be  spread  on  soft  linen,  and  with  this  cover  the  face 
and  arms.  The  linen  should  be  changed  every  twelve  hours.  To  diminish 
the  intolerable  itching  and  fetor  of  the  later  stages,  and  to  lessen  the  con- 
tagion, the  body  should  be  sponged  once  or  twice  daily  with  tepid  water  to 
which  a  small  quantity  of  permanganate  of  potash  has  been  added,  and 
afterwards  anointed  with  a  weak  carbolated  oil.  To  relieve  the  irritation 
of  the  mucous  membranes,  sprays  and  gargles  of  chlorate  of  potash  should 
frequently  be  used.  They  may  be  either  warm  or  cool,  as  may  be  most 
grateful.  Sometimes  a  little  biborate  of  soda  may  be  advantageously  added 
to  this  solution.  Mucilaginous  drinks  may  be  allowed  freely,  and  several 
times  a  day  the  nurse  should  gently  cleanse  the  mouth  and  fauces  with  a 
small  swab  of  absorbent  cotton  soaked  in  the  borax  solution.  The  mouth 
and  entrance  to  the  nares  should  be  kept  carefully  cleansed  from  mucus, 
and  the  nostrils  should  be  sprayed  at  least  twice  daily  with  an  alkaline 
spray  containing  a  small  amount  of  carbolic  acid.  During  the  stage  of 
decrustation  warm  baths  should  be  given  daily.  Should  the  scabs  be  exten- 
sive, it  is  important  that  pus  be  not  allowed  to  collect  in  quantity  underneath 
them.  On  the  forehead  and  face  means  should  be  taken  to  get  rid  of  them 
as  quickly  as  possible.  On  the  scalp  the  crusts  are  apt  to  persist,  and 
numerous  poultices  may  be  required  to  remove  them.  Should  suppuration 
continue,  it  may  be  checked  by  the  application  of  carbolated  zinc  ointment. 
In  children  the  itching  at  this  time  is  often  intolerable  and  may  call  for 
some  gentle  form  of  restraint  for  their  hands.  As  the  pustule  approaches 
maturation,  the  physician  must  be  on  the  watch  for  any  symptoms  indi- 
cating failure  of  development.  Such  would  require  prompt  stimulation. 
Should  laryngitis  threaten,  inhalations  of  medicated  steam  should  be  com- 
menced at  once,  and  poultices  be  applied  externally.  Should  dyspnoea  set 
in,  an  emetic,  if  the  child  be  strong  enough,  may  first  be  tried.  If  it  fail, 
resort  must  be  had  to  tracheotomy  or  intubation.  Severe  insomnia  or 
delirium  may  require  the  cautious  use  of  bromides,  opium,  or  chloral. 
Throughout  the  whole  course  of  the  illness  the  strength  of  the  patient 
must  be  conserved.  Complications  must  be  treated  on  general  principles, 
avoiding  anything  approaching  systemic  depletion,  and  interfering  surgi- 
cally when  it  is  apparent  that  such  interference  is  necessary.  During  the 
stage  of  convalescence  iron  tonics  are  generally  required,  and  one  of  the 
best  is  the  muriated  tincture  of  iron.  It  is  rendered  less  irritating  to  the 
stomach,  and  more  palatable,  by  being  combined  with  a  considerable  amount 
of  glycerin.  For  the  severe  hemorrhagic  forms  of  the  disease  no  treat- 
ment has  been  found  of  any  avail.  In  the  milder  forms,  stimulants  with 
tonics  oifer  us  the  best  hope.  My  own  predilections  are  strongly  in  favor 
of  the  use  of  iron  in  large  quantities. 

In  this  disease,  however,  our  duty  is  not  finished  with  the  mere  treat- 


742  VAEIOLA. 

ment  of  our  patient.  We  have  to  consider  other  members  of  the  household 
and  the  public  generally.  When  small-pox  enters  a  house,  vaccination  and 
re-vaccination  must  be  promptly  and  eifectually  performed.  In  such  eases, 
as  in  every  case  where  known  exposure  has  taken  place,  the  duty  of  the 
physician  is  to  give  as  prompt  protection  as  possible.  We  believe  that  this 
can  best  be  done  by  using  fresh  humanized  lymph,  which  produces  a  more 
rapid  and  certain  development  of  the  vesicle  than  does  bovine  lymph,  and 
therefore  more  quickly  secures  protection.  The  patient  may  be  considered 
free  from  infection  when  every  particle  of  scab  and  crust  is  removed  and  he 
has  received  several  thorough  subsequent  baths.  The  most  complete  disin- 
fection of  everything  that  has  come  into  contact  with  him  or  that  has  been 
in  his  room  must  be  insisted,  upon,  and  should  be  performed  under  public 
authority  and  supervision. 


VACCINATION. 

By   W.  T.  plant,  M.D. 


Definition. — The  conveyance  of  cow-pox  or  vaccinia  from  the  animal 
to  man  or  from  one  person  to  another  for  the  purpose  of  protecting  the 
system  against  small-pox. 

History. — No  chapter  of  medical  history  is  more  interesting  than  that 
of  the  discovery  of  vaccination,  the  most  beneficent  result  the  world  has 
known  of  human  thought  and  effort. 

For  several  centuries  small-pox  had  been,  more  than  any  other  pesti- 
lence, or  even  war,  the  foe  of  man.  It  had  spread  to  all  climes  and  over  all 
countries,  carrying  off,  on  an  average,  fully  one-sixth  of  all  those  attacked 
by  it,  and  inflicting  incurable  blindness  or  deafness  and  frightful  disfigure- 
ment upon  great  numbers  of  the  survivors.  Nothing  could  exceed  its  fury 
when  it  visited  a  country  for  the  first  time.  Its  introduction  into  Mexico 
in  1520  was  followed  by  the  loss  of  three  millions  and  a  half  of  people. 
In  1707  it  made  its  first  entry  into  Iceland,  and  more  than  one-fourth  of 
the  whole  population  fell  victims  to  it ;  crossing  into  Greenland  a  quarter 
of  a  century  later,  that  island  was  speedily  almost  depopulated.^  Society 
was  everj'where  largely  made  up  of  two  classes,  tliose  who  were  pock- 
marked or  otherwise  mutilated  and  those  who  were  still  liable  to  become  so. 

Small-pox  was  especially  fatal  among  the  young.  In  the  larger  cities 
of  Great  Britain  about  one-third  of  the  deaths  under  fourteen  years  were 
due  to  it,  and  the  mortality  under  five  years  was  about  fifty  per  cent. 

Such  was  the  forlorn  condition  over  the  known  world  when  in  1716 
the  Hon.  Edward  Wortley  Montagu  received  appointment  as  th'e  English 
ambassador  to  the  Ottoman  court.  The  letters  of  his  accomplished  wife, 
Lady  Mary,  who  accompanied  him  to  Constantinople,  were  so  instructive 
and  entertaining  as  to  gain  for  her  a  lasting  celebrity.  In  one  of  these, 
written  from  Belgrade  in  1717,  slic  describes  in  sprightly  terms  the  Turkish 
custom  of  "  engrafting"  small-pox,  and  declares  lier  intention  of  trying  it. 
on  her  young  son. 

Returning  to  England,  slie  seriously  undertook  the  introduction  of  the 
art  there,  and  evinced  her  faith  in  its  safety  and  virtue  by  having  her  little 


^  Chambers's  Encyclopaedia. 

743 


744  VACCINATION. 

daughter  inoculated  with  small-pox  matter.  This  was  in  April,  1721.  The 
expediency  of  the  operation  being  questioned  by  the  scientists  of  the  day, 
government  extended  remission  of  sentence  to  six  prisoners  condemned  to 
death,  on  condition  that  they  would  submit  to  inoculation.  The  experiment 
was  successful,  and  the  pardons  were  cheaply  bought.  After  this  the  opera- 
tion was  taken  into  royal  favor,  and  two  daughters  of  the  Princess  of  Wales 
in  1722  received  variolous  infection  after  the  Turkish  method. 

The  same  year  that  it  was  introduced  into  England — 1721 — it  began  to 
be  practised  in  Boston,  where  an  epidemic  of  great  virulence  was  raging. 
But  of  two  hundred  and  forty-four  persons  inoculated  by  Dr.  Boylston 
within  six  months,  six  died.  About  the  same  time  there  were  in  England 
two  conspicuous  examples  of  death  from  inoculated  small-pox.^ 

These  deaths  served,  both  here  and  in  Europe,  to  prevent  the  new  prac- 
tice from  being  received  with  that  instant  favor  which  it  otherwise  would 
have  enjoyed.  It  was  near  the  middle  of  the  century  before  it  met  with 
anything  like  general  acceptance.  In  1746  the  Small-Pox  and  Inoculation 
Hospital  was  founded  in  London,  in  order  that  the  poor  as  well  as  the  rich 
might  share  in  the  benefits  of  the  operation. 

In  Great  Britain  and  America  inoculation  or  the  "engrafting"  of  small- 
pox may  be  said  to  have  had  a  reign  of  about  fifty  years, — the  latter  half 
of  the  eighteenth  century.  People  then  made  appointments  with  the  small- 
pox physicians  as  we  now  do  with  dentists.  During  our  war  for  indepen- 
dence the  wife  of  General  Washington  improved  the  occasion  of  a  brief 
sojourn  in  Philadelphia  by  undergoing  inoculation,  and  she  had,  according 
to  history,  "  a  very  favorable  time."  ^ 

The  efficacy  of  this  operation  in  mitigating  the  severity  and  danger  of 
small-pox  was  certainly  very  great.  The  proportion  of  deaths  following  it 
was,  on  an  average,  about  three  in  a  thousand, — a  very  gratifying  contrast 
to  the  mortality  of  the  disease  communicated  in  the  usual  way.  But  there 
was  one  fatal  drawback.  However  light  the  engrafted  disease  might  be,  it 
was  still  small-pox ;  and  the  more  it  was  conveyed  in  this  way,  the  more 
were  centres  of  infection  multiplied  from  which  those  not  protected  were 
liable  to  contract  the  disease  in  its  worst  form.  To  individuals  inoculation 
was  a  great  blessing ;  to  society  at  large  it  was  a  great  curse.  In  the  early 
part  of  the  eighteenth  century,  before  inoculation,  about  one-fourteenth  of 
the  deaths  in  Great  Britain  were  from  small-pox ;  in  the  latter  part,  after 
inoculation  had  become  quite  general,  about  one-tenth  of  the  deaths  were 
from  that  disorder.^ 

But  no  sooner  had  variolous  inoculation  reached  a  position  where  it 
could  claim  for  itself  in  this  country  and  Europe  something  like  general 
recognition  and  practice,  than  one  was  born  Avho  was  to  introduce  a  new 


1  Rees's  Encyclopsedia. 

2  Irving's  Life  of  Washington. 

'  Seaton,  Hand-Book  of  Vaccination. 


VACCINATION.  745 

method,  entirely  devoid  of  danger  to  the  individual  and  free  from  the  fatal 
defect  of  spreading  small-pox. 

Edward  Jenner,  the  son  of  an  English  clergyman,  was  born  in  1749  at 
Berkeley,  in  the  county  of  Gloucester, — a  county  celebrated  then,  as  now, 
for  its  dairies.  Having  early  fixed  upon  medicine  for  a  vocation,  he  joined 
himself  to  a  surgeon  in  a  neighboring  village  for  instruction.  About  this 
time  the  confident  assertion  of  a  young  countrywoman  that,  having  had 
cow-pox,  she  was  proof  against  small-pox,  made  an  impression  on  his  mind 
that  was  lasting.  In  his  twenty-first  year  he  went  to  London  to  finish  his 
pupilage  under  the  great  John  Hunter.  After  two  years  in  the  metropolis, 
he  went  back  to  his  native  village  of  Berkeley  and  began  practice.  On 
renewing  his  acquaintance  with  the  dairy-people,  their  belief  in  an  antago- 
nism between  cow-pox  and  small-pox  was  again  brought  to  his  notice.  He 
began  to  look  into  the  matter.  By  degrees,  as  evidence  accumulated,  he 
became  convinced  that  there  was  something  in  it.  He  conceived  that  a 
disorder  that  could  be  conveyed  from  the  cow  to  the  human  system  by  rare 
chance  in  milking  might  be  more  surely  communicated  by  methodical  oj^er- 
ation,  that  it  might  also  be  carried  from  person  to  person  without  losing  its 
protective  power,  and  that  in  this  way,  the  whole  human  family  being  made 
secure  against  small-pox,  that  loathsome  disease  would  be  driven  out  of  the 
world  from  sheer  lack  of  living  accommodations.  After  this  manner  we 
find  Jenner  talking  to  his  friends  in  1780. 

From  tlie  scarcity  of  true  cow-pox,  he  was  not  yet  able  to  bring  these 
magnificent  and  inspiring  thoughts  to  the  touchstone  of  actual  experiment. 
It  was  not  until  May  14,  1796,  more  than  a  quarter  of  a  century  after  his 
thoughts  were  first  turned  that  way,  that  Jenner  made  his  first  vaccination. 
The  subject  was  a  lad  of  eight  years,  named  James  Phipps.  Several  weeks 
afterwards  the  boy  was  inoculated  with  small-pox  matter,  and,  as  Jenner 
had  predicted,  no  result  followed.  Two  years  passed  away  before  he  was 
able  to  repeat  the  experiment,  owing  to  the  disappearance  of  cow-pox  from 
the  dairies.^  Having  at  length  made  himself  certain  of  the  truth  and 
importance  of  his  discovery,  he  published  a  pamphlet  entitled  "  An  Inquiry 
into  the  Causes  and  Effects  of  the  Variolse  Vaccinae,"  and  sent  it  out  to  the 
profession.  At  first  considerable  incredulity  was  manifested,  but  it  could 
not  last,  for  the  proofs  were  at  hand  and  more  Avere  forthcoming.  Within 
a  year  from  the  first  public  announcement  of  the  discovery,  seventy  of 
the  most  distinguished  physicians  of  London  signed  a  declaration  of  their 
entire  confidence  in  it. 

With  so  much  impetus  gained,  the  sjircad  of  vaccination  was  marvel- 
lously rapid.  In  1800  it  began  to  be  practised  in  this  country,  and  a  year 
later  in  France.  In  1803  the  court  of  Spain  sent  out  an  expedition  for  the 
purpose  of  carrying  vaccination  to  all  the  Spanish  possessions  of  the  Old 
and  the  New  World.     It  returned  after  three  years,  having  made  the  cir- 

*  Encyclopaedia  Britannica. 


746  VACCINATION. 

cuit  of  the  globe.'  Within  six  years  after  it  was  first  given  to  the  public, 
the  knowledge  and  practice  of  this  beneficent  operation  had  spread  over  all 
the  world.  All  nations  hailed  it  with  demonstrations  of  joy  aiid  gladness. 
In  Russia,  the  Empress  gave  the  first  child  vaccinated  the  name  of  "  Vac- 
cinoif "  and  made  its  education  a  public  charge. 

In  the  universal  thankfulness  for  this  unparalleled  blessing,  he  through 
whom,  under  Providence,  it  had  been  secured  was  not  forgotten.  Honors 
were  conferred  on  Jenner  by  foreign  courts,  and  he  was  voted  honorary 
membership  in  many  learned  societies.  The  anniversary  of  his  birth  and 
that  of  his  first  vaccination  were  for  many  years  celebrated  in  Germany  as 
feast-days.  In  1802  Parliament  voted  him  fifty  thousand  dollars,  and  five 
years  later  a  hundred  thousand  more.^ 

With  the  modesty  that  ever  characterizes  true  greatness,  Jenner  con- 
tinued to  reside  among  his  life-long  friends  in  and  around  the  little  village 
of  Berkeley.  He  did,  it  is  true,  soon  after  he  became  famous,  try  London 
life  and  practice  for  a  time,  but  he  soon  tired  of  them  and  returned  to  his 
more  congenial  country  home.  Here  he  passed  the  evening  of  his  life  in  the 
practice  of  his  profession,  in  correspondence  relating  to  his  great  discovery, 
and  in  the  peaceful  enjoyment  of  the  society  of  his  friends.  He  died  of 
apoplexy  in  1823,  and  his  remains  were  laid  away  in  the  parish  church. 
Of  all  the  benefactors  of  mankind,  not  one  has  ever  lived  to  see  the  world 
so  abundantly  blessed  through  his  labors  as  Edward  Jenner. 

Nature  of  Vaccinia. — What  is  cow-pox,  and  whence  does  it  derive  its 
royal  power  over  small-pox?  Jenner  regarded  the  two  diseases  as  essen- 
tially the  same.  In  1801,  only  three  years  after  the  great  discovery  was 
promulgated,  Gassner,  of  Giinsberg,  inoculated  cows  with  small-pox  matter. 
Lymph  from  the  resulting  vesicles  was  conveyed  to  four  children,  and  the 
ordinary  phenomena  of  vaccination  followed.^  Later  than  that, — 1830, — 
Dr.  Sonderland,  of  Barmen,  in  Prussia,  blanketed  some  cows  with  the  bed- 
clothing  of  a  deceased  small-pox  patient.  Other  coverings  from  the  same 
bed  he  suspended  around  their  heads.  In  a  few  days  the  animals  became 
sick  and  feverish,  and  an  eruption  like  that  of  genuine  cow-pox  appeared. 
Lymph  from  these  vesicles  produced  genuine  vaccine  in  the  human  subject.* 
These  experiments  in  their  essential  features  have  been  many  times  repeated 
in  this  country  as  well  as  in  Europe,  with  like  result.  Vaccination,  then, 
is  the  conveyance  of  small-pox,  but  of  a  small-pox  wonderfully  modified 
and  stripped  of  its  terrors  by  passing  through  the  animal.  In  some  way  it 
has  parted  with  its  contagious  property,  so  that  vaccinated  small-pox  is  not 
constantly  spreading  the  disease,  as  was  the  case  with  inoculated  small-pox. 
The  horse  as  well  as  the  cow,  though  perhaps  less  readily,  may  be  made  the 
subject  of  variolous  infection.     Jenner  used  lymph  from  the  horse  quite 

^  Encyclopajdia  Britannica. 

2  Ibid. 

'  Scaton's  Hand-Book  of  Vaccination. 

*  Eberle  on  Children. 


VACCINATION.  747 

largely,  but  since  his  day  the  cow  has  been  almost  the  only  source  of  origi- 
nal supply,  so  that  the  term  vaccination,  from  vacca,  "  a  cow,"  is  entirely 
appropriate. 

Kinds  of  Lymph. — The  material  for  vaccinating  is  now  taken  from 
both  the  heifer  and  the  child  :  hence  we  speak  of  bovine  and  human  virus. 
Until  recently  the  latter  was  in  almost  exclusive  use.  Previous  to  1870 
bovine  lymph  was  seldom  procurable,  because  epidemics  of  cow-pox  were 
of  infrequent  occurrence.  But  about  that  time,  responding  to  a  clamorous 
popular  demand,  its  production  on  a  large  scale  by  vaccinating  young  cattle 
began  to  be  followed  as  a  business.  There  are  now  in  this  country  quite  a 
number  of  establishments  for  the  propagation  of  kine-pox.  Any  locality 
with  telegraph  and  railroad  communication  can  now  be  supplied  with  little 
delay  with  recent  bovine  virus.  Within  a  few  years  the  use  of  human 
lymph  has  greatly  lessened.  But,  notwithstanding  the  extended  and  still- 
spreading  popularity  of  bovine  virus,  there  are  very  many  in  the  profession 
who  believe  that  failures  with  it  are  much  more  frequent  than  with  the 
humanized,  and  that  it  is  less  regular  and  reliable  and  often  more  severe  in 
its  working, — a  view  that  my  own  observations  would  tend  to  sustain.  A 
certain  lack  of  affinity  between  lymph  from  the  cow  and  the  human  system 
is  certainly  quite  possible. 

Conveyance  of  other  Diseases. — An  asserted  advantage  of  animal 
matter  over  human  is  immunity  from  the  liability  of  conveying  other  dis- 
eases. This  is  a  moving  consideration  with  multitudes  among  the  laity, 
who  believe  that  all  sorts  of  eruptions  and  blood-disorders  are  chargeable 
to  human  lymph. 

It  is  doubtless  true  that  a  vaccination  may  be  followed  by  an  erythema- 
tous, an  erysipelatous,  or  an  eczematous  eruption  caused  by  the  local  and 
constitutional  irritation  consequent  on  the  operation ;  but  I  can  find  no 
reliable  evidence  to  warrant  the  opinion  that  chronic  enlargement  of  glands, 
or  scrofula,  or  consumption,  or  any  of  the  ordinary  skin-eruptions,  have 
ever  been  transmitted  from  person  to  person  through  vaccination. 

But  how  is  it  with  syphilis?  That  is  an  inoculable  disease:  except 
when  inherited,  it  is  had  only  through  inoculation.  May  it  be  conveyed 
with  vaccinia?  There  can  be  no  doubt  of  it.  So  many  oases  have  now 
been  recorded  in  which  cow-pox  and  syphilis  have  been  simultaneously 
imparted  by  vaccination,  that  they  cannot  be  explained  away,  and  vaccino- 
syphilis  must  be  accepted  as  a  fact.  It  was  thought  by  many  that  in  all 
such  instances  there  was  an  admixture  of  blood  with  the  lymph,  and  that 
care  to  exclude  that  would  obviate  danger.  But  one  of  the  experiments  of 
Dr.  Robert  Cory,  chief  vaccinatorHo  the  National  Vaccine  Establishment, 
England,  would  seem,  even  if  there  were  no  other  proof,  to  decide  the  ques- 
tion. To  test  this  point, — the  possibility  of  conveying  syphilis  with  clear 
lymph, — that  gentleman,  with  a  scientific  devotion  which  we  admire  but 
could  never  imitate,  carried  out  a  series  of  experiments  on  his  own  person. 
He  repeatedly  vaccinated  himself  from  children  who  were  plainly  and  some 


748  VACCINATION. 

of  tliem  actively  syijhilitic,  using  with  greatest  care  only  the  clear  lymph. 
One  of  these  trials,  made  July  6,  1881,  was  not,  as  all  the  previous  ones 
had  been,  barren  of  result.  On  this  occasion  he  vaccinated  himself  in  three 
places  from  a  three-months-old  child  that  had  an  eruption  and  sores  which 
w^ere  evidently  syphilitic.  In  three  weeks  syphilitic  papules  appeared  at 
the  seat  of  two  of  the  punctures.  These  were  followed  in  due  course  by 
sore  throat,  roseola,  and  other  indubitable  evidences  of  constitutional  syphi- 
lis.^ From  this  it  would  seem  to  be  proved  that  clear,  limpid  lymph  may 
be  a  medium  of  carrying  that  disease  from  one  person  to  another.  But, 
conceding  this,  it  is  to  be  remarked  that  this  child  was  selected  for  this 
experiment  because  it  had  syphilis  in  an  aggravated  form,  and  that  no 
medical  man  would  ever  think  of  taking  h'mph  from  such  a  source.  There 
is  no  reason  in  all  this  for  the  rejection  of  all  human  h'mph,  but  rather 
cause  for  careful  scrutiny  of  the  antecedents  and  present  condition  of  ever}^ 
proposed  vaccinifer. 

Deg-eneration  of  Lymph. — It  has  been  claimed  that  lymph  gradually 
parts  A\'ith  its  protective  virtue  by  passing  successively  through  the  human 
system,  and  that  if  we  would  make  the  protection  against  small-pox  com- 
plete we  must  use  the  bovine  product  altogether  or  return  to  it  at  short 
intervals. 

In  1816,  Jenner  wrote  that  the  vesicles  he  was  then  producing  were  in 
everj'  respect  as  perfect  as  in  the  first  year  of  vaccination,  though,  to  the 
best  of  his  knowledge,  the  matter  from  which  they  were  derived  was 
taken  from  the  cow  about  sixteen  years  before.  Prof.  Hebra  asserts  that 
in  the  principal  vaccine  establishment  at  Vienna  lymph  has  been  car- 
ried down  without  interruption  from  the  first  vaccination  at  the  beginning 
of  the  centur}'-,  and  that  it  now  " takes"  as  ^ell  and  is  as  protective  as  at 
first.^  Dr.  Charles  V.  Chapin,  Avriting  from  the  ofiice  of  the  Superin- 
tendent of  Health,  Providence,  Rhode  Island,  December,  1885,  says  that 
they  were  then  using  stock  that  had  been  maintained  by  continuous  trans- 
mission from  child  to  child  since  1856,  without  being  once  renewed  from 
the  cow  ;  that  nearly  forty-seven  thousand  persons  had  been  vaccinated  from 
it ;  and  that  it  had  shown  itself  not  inferior  to  the  bovine  product  in  pro- 
tective power,  besides  being  more  certain  to  take  and  less  liable  to  produce 
troublesome  sores.^  We  believe  that  lymph  may  degenerate,  not  because  of 
its  transmission  through  the  human  body,  however  many  times  the  trans- 
mission may  be  made,  but  through  lack  of  care  to  choose  stock  from  healthy 
and  vigorous  subjects.  Let  a  farmer  gather  seed-corn  from  stunted  ears 
growing  on  poor  soil,  and  he  will  soon  be  raising  degenerated  crops.  This 
is  a  general  fact  of  vegetable  and  animal  propagation,  to  which  vaccination 
is  no  exception. 

^  Boston  Med.  and  Surg.  Jour.,  vol.  cxi.  p.  188. 

2  Manual  of  Skin  Disease.s. 

*  Annual  Report  Supt.  of  Health,  Providence,  Rhode  Island,  1886. 


VACCIXATIOX.  749 

Forms  of  Lymph. — The  lymph  used  in  vaccinating,  whether  human 
or  bovine,  is  either  fluid  or  diy.  As  a  fluid  it  is  conveyed  by  the  lancet 
directlv  from  the  vesicle  to  another  person,  as  in  "  arm-to-arm"  vaccination. 
When  numbers  are  to  be  operated  on  at  once,  as  in  schools  and  factories, 
this  is  the  surest  and  most  convenient  way.  Fluid  lymph  may  also  be  taken 
up  from  the  vesicles  in  capillary  tubes,  which,  after  closure  of  the  ends,  are 
put  aside  for  future  use. 

The  use  of  dried  lymph  is,  in  this  country  at  least,  much  more  common. 
At  the  proper  time  the  vesicle  is  punctured  and  the  exuding  fluid  collected 
on  ivory  or  quill  points,  and  permitted  to  dry ;  or  the  vesicle  may  be  left 
to  mature.  In  the  latter  case  the  lymph  dries  down  into  a  dark-brown 
crust,  that  falls  from  the  arm  about  three  weeks  after  vaccination.  The 
bovine  crust  is  notoriously  unreliable,  and  is  not  very  much  used. 

Selection  and  Preservation. — Vaccine  lymph  is  a  perishable  sub- 
stance, soon  losing  its  virtue  if  exposed  to  light,  air,  warmth,  or  moisture. 
Under  opposite  conditions  it  may  be  kept  indefinitely.  It  is  not  injured  by 
any  degree  of  cold.  The  quills  and  ivory  points  now  supplied  l)y  various 
establishments  for  propagating  bovine  virus  are  sometimes  in  boxes,  some- 
times in  small  bundles  wrapped  around  with  rubber  cloth.  To  give  satis- 
faction they  must  be  used  without  much  delay.  The  same  is  true  of  human 
lymph  put  up  in  the  same  way.  AVhen  it  is  desired  to  preserv^e  the  stock 
for  some  time,  I  think  the  human  crust  is  preferable.  In  selecting  lymph 
our  first  thought  is  of  purity.  We  usually  take  it  from  children,  as  they 
are  not  likely  to  have  acquired  blood-disorders.  Unless  we  have  full  knowl- 
edge of  the  family,  it  is  best  not  to  vaccinate  from  a  child  of  less  than 
three  months,  because  it  might  have  latent  syphilis.  The  child  that  is  to 
serve  as  a  vaccinifer  should  have  favoring  antecedents,  should  be  in  perfect 
liealth  and  wholly  free  from  skin-eruptions,  and  should  have  a  i^erfect  vesi- 
cle. If  the  crust  is  taken,  it  should  be  freed  with  the  utmost  care  from  all 
extraneous  matters  by  paring  away  the  thin  edge  and  scraping  the  under 
surface.  A  good  way  to  preserve  the  crust  for  future  use  is  to  divide  it 
into  three  or  four  pieces  and  to  wrap  these  separately  in  a  bit  of  thin  rubber 
cloth.  Drop  these  into  a  very  small  vial,  cover  them  with  absorbent  cotton, 
and  cork  tightly.  Enclose  this  bottle  in  a  larger  one,  cover  with  cotton,  and 
cork  tightly.  Label  with  name,  age,  and  date.  Then  wrap  the  whole  in 
rubber  cloth  or  other  dark,  impervious  material,  and  put  in  a  collar  or  an 
ice-chest, — preferably  the  latter.  So  treated,  the  crust  may  be  kept  for  many 
montlis,  ready  fjr  use  at  any  time. 

Operation. — The  only  instrument  needed  is  a  lancet.  This  should  be 
perfectly  clean.  It  is  a  good  rule  to  plunge  in  hot  water  and  wipe  dry  just 
before  using.  The  outer  aspect  of  tlie  left  arm  at  or  near  the  insertion  of 
the  deltoid  muscle  is,  by  almost  universal  custom,  the  place  chosen.  The 
chief  ways  of  preparing  the  arm  now  in  vogue  are  by  abrasion  and  scarifi- 
cation or  cross-scratching.  In  the  first  the  cuticle  is  scraped  by  the  lancet 
over  a  surface  of  a  quarter  to  a  half  inch  square  until  a  little  serum  appears. 


750  VACCINATION. 

This  prolonged  scraping,  while  not  painful,  is  not  agreeable.  In  the  second, 
linear  incisions  are  made  from  half  a  line  to  a  line  apart,  and 

these  are  crossed  by  others,  after  this  manner :  -^^^^^^  This  plan  was, 
I  believe,  first  proposed  by  Dr.  D.  Francis  -^^^^^  Condie,  of  Phil- 
adelphia, not  far  from  1830.^  It  appears  to  me  to  be  the  best 
yet  devised,  not  only  because  it  presents  so  many  lines  of  absorbing  surface 
that  it  is  very  certain,  but  also  because  it  is  scarcely  at  all  painful  or  un- 
pleasant. I  have  repeatedly,  after  this  way,  vaccinated  sleeping  infants 
without  their  waking.  The  incisions  should  be  quite  superficial.  The 
little  blood  that  follows  may  be  wiped  off,  or  absorbed  by  a  blotter.  It  is 
well  to  prepare  two  or  three  of  these  places,  an  inch  or  more  apart.  This 
being  done,  the  arm  is  ready  for  the  application.  If  the  quill  or  ivory  point 
is  to  be  used,  first  moisten  the  lymph-covered  surface  with  a  drop  of  clean, 
cold  water.  If  bovine  matter  is  being  used,  remember  that  it  is  less  soluble 
than  the  other  kind,  and  it  is  well,  with  lancet  or  with  penknife,  to  rub  it 
up  with  the  water.  Now  apply  the  moistened  quill  or  ivory  to  the  abraded 
or  scratched  areas,  and  rub  and  press  well  in,  to  insure  absorption. 

In  using  the  dried  crust,  only  a  diminutive  piece  is  needed  for  one  vac- 
cination. This  is  to  be  mashed  down  with  tlie  knife-blade,  or,  better,  between 
two  small  squares  of  glass.  Add  a  drop  of.  water  and  rub  into  a  paste. 
This  is  to  be  taken  up  by  the  lancet  and  applied  in  the  same  way  as  the 
quill  or  ivory.  The  secrets  of  successful  vaccination  are  care  in  the  selec- 
tion and  preservation  of  lymph  and  cleanliness  in  every  detail. 

Phenomena. — After  the  operation,  there  is  a  period  of  latency  of  about 
three  days'  duration,  sometimes  a  little  less,  frequently  rather  more,  and  in 
rare  instances  as  much  as  a  week.  This  brief  incubative  period  of  vaccinia 
is  a  valuable  characteristic,  as  it  enables  us  to  forestall  small-pox  after 
known  exposure. 

On  or  about  the  third  day  a  small,  hard  pimple  appears  at  the  point  of 
operation.  With  two  days'  growth  it  becomes  a  vesicle.  In  another  day  it 
has  become  umbilicated  and  divided  into  eight  or  ten  cells,  like  the  small- 
pox vesicle.  By  the  eighth  day,  or  ninth  at  most,  the  vesicle  has  attained 
complete  development.  It  is  raised  prominently  above  the  surface,  and  is 
distended  with  transparent  fluid.  At  this  time,  or  earlier,  but  by  no  means 
later,  lymph  may  be  taken  for  use.  The  next  phenomenon  is  the  appear- 
ance of  a  belt  of  inflammatory  redness  around  the  vesicle, — or  pustule,  as  it 
has  now  become.  This  is  the  areola,  and  is  quite  characteristic  of  vaccinal 
activity.  With  a  day  or  two  of  growth  the  areola  attains  a  diameter  of  two 
to  three  inches.  It  is  now  of  a  bright-red  or  livid  color,  and  the  flesh 
under  it  is  commonly  hard,  itchy,  and  painful.  With  the  areola,  some  con- 
stitutional symptoms,  as  headache,  rigors,  fever,  and  general  aching,  appear. 
The  whole  arm  is  apt  to  be  lame  and  the  axillary  glands  swollen. 

After  the  tenth  day  there  is  rapid  decline.    The  constitutional  symptoms 


^  Condie  on  Diseases  of  Children,  5th  ed.,  p.  544. 


VACCINATION.  751 

abate ;  local  pain  and  itching  subside ;  the  areola  fades  away  ;  .the  fluid 
of  the  vesicle  becomes  opaque  and  concrete  and  soon  dries  down  into  a 
dark  crust.  About  the  twenty-first  day  the  crust  falls,  leaving  a  circular, 
depressed  scar  with  pits  and  radiating  lines  that  correspond  with  the  cells 
and  partitions  of  the  former  vesicle.  The  scar,  red  at  first,  gradually 
becomes  white,  and  commonly  remains  through  life. 

Deviations  from  Regular  Course. — These  are  not  very  frequent. 
The  phenomena  are  sometimes  retarded,  especially  if  bovine  lymph  is  used, 
but  the  protection  is  not  less  complete,  provided  the  symptoms  succeed  one 
another  in  due  course  with  characteristic  vesicle  and  areola.  Physicians 
have  sometimes  been  accused  of  using  impure  stock  because  the  operation 
has  been  followed  by  an  eczema  or  other  eruption  or  by  enlarged  lymphatic 
glands.  If  we  consider  how  often  the  irritation  of  coming  teeth  causes  like 
symptoms,  we  shall  not  be  surprised  that  the  "working"  of  vaccinia  should 
now  and  then  put  out  these  signals  of  systemic  perturbation. 

Doubtless  diseases  and  tendencies  that  have  been  hitherto  latent  may  be 
stirred  into  activity  by  this  operation.  If  this  is  true,  may  it  not  be  sup- 
posed that  syphilis  was  present  in  some  of  the  instances  reported  as  syphi- 
litic inoculation,  but  was  unsuspected  until  the  constitutional  commotion 
brought  about  by  vaccination  spurred  it  into  activity  ? 

Traumatic  erysipelas  may  follow  vaccination.  I  was  once  called  to 
prescribe  for  a  frugal  woman  who  had  performed  auto-vaccination,  using 
liberally  of  the  crust  that  had  been  shed  by  her  son,  without  scraping  or 
paring.  Her  whole  arm  was  erysipelatous;  large  abscesses  formed,  and 
permanent  disfigurement  resulted.  Fatal  pyaemia  has  been  known,  it  is 
said,  after  vaccination.  Doubtless  it  is  owing  to  the  care  that  physicians, 
as  a  rule,  exercise,  that  these  disorders  so  seldom  occur. 

Degree  of  Protection. — To  what  extent  does  a  single  vaccination 
insure  against  small-pox?  Certainly  with  the  majority  the  security  is  com- 
plete and  lasting.  Comparatively  few  of  those  who  can  show  a  character- 
istic scar  contract  variola  if  exposed  to  it.  But  there  are  some  for  whom 
the  operation  is  but  a  partial  safeguard, — some  in  whom  there  is  liability  to 
a  mitigated  small-pox.  It  is  probable  that  in  some  of  these  the  original 
vaccinal  impression  on  the  system  was  not  all  that  it  might  have  been,  and 
that  a  second  operation  done  soon  after  the  first  had  run  its  course  miglit 
still  have  produced  the  characteristic  "  working,"  and  so  might  have  con- 
ferred a  more  nearly  complete  security. 

It  is  certain  that  in  many  persons  the  protection  afforded  by  a  vaccina- 
tion becomes  progressively  less  with  lapse  of  time.  Especially  is  this  true 
of  some  who,  vaccinated  in  infancy,  have  reached  mature  life.  There  can 
be  no  doubt  that  the  vaccinal  influence  diminislics  with  the  constitutional 
changes  that  take  place  at  puberty. 

But  it  is  to  be  remembered  that,  while  this  operation  does  not  in  all 
cases  confer  complete  immunity,  neither  docs  small-pox  itself  do  it.  In 
numerous  instances  persons  have  had  that  disease  twice,  and  a  few  even 


752  VACCINATION. 

more  than  twice.  Abundant  observation  has  proved  the  justness  of  Jeuner's 
claim  for  vaccination  made  in  these  words  :  "  Duly  and  efficiently  performed, 
it  will  protect  the  constitution  from  subsequent  attacks  of  small-pox  as 
much  as  that  disease  itself  will.  I  never  expected  it  would  do  more ;  and 
it  will  not,  I  believe,  do  less."  ^ 

In  a  word,  then,  this  is  the  protection  aiforded  by  thorough  vaccination  : 
complete  and  lasting  to  the  vast  majority ;  to  a  small  minority  partial ;  to 
all,  with  scarcely  an  exception,  security  against  great  suffering,  extreme 
disfigurement,  and  death. 

Susceptibility  Universal. — Entire  insusceptibility  to  the  infection  of 
cow-pox  is  very  infrequent,  if  indeed  it  ever  occurs.  Often,  to  be  sure,  a 
child  is  vaccinated  two,  three,  or  more  times  without  result ;  but  I  am  of 
the  opinion  that  the  failure  is  generally  due  to  the  lymph  or  the  operator 
rather  than  to  the  subject.  Of  upwards  of  nine  thousand  operations  done 
at  the  Blackfriars  Station  of  the  National  Vaccine  Establishment  since 
1859,  there  was  but  one  case  which  on  a  second  trial  was  unsuccessful.^ 
Doubtless  there  are  times  in  the  lives  of  many,  perhaps  of  most,  when  the 
operation  succeeds  less  readily  than  at  others ;  probably  some  have  seasons 
of  complete  insusceptibility,  as  may  be  the  case  when  other  serious  diseases 
are  present  in  the  system ;  but  that  any  of  the  race  are  through  life  wholly 
insensible  to  the  influence  of  vaccinia  there  is  good  reason  to  doubt.  Skilled 
operators  with  fresh  lymph,  especially,  I  think,  with  humanized  lymph, 
have  seldom  to  report  failures  in  primary  vaccinations. 

Age  and  Season. — Evidently,  if  immunity  from  so  terrible  a  disease 
as  small-pox  can  be  conferred  by  means  so  simple  and  harmless,  the  blessing 
should  be  extended  to  early  infancy.  All  authorities  recommend,  and  the 
laws  of  many  countries  require,  the  operation  to  be  done  before  the  end  of 
the  first  year.  In  England  the  Vaccination  Act  of  1867  requires  the  oper- 
ation to  be  done  "  within  tiiree  months  of  birth,  or  as  soon  afterwards  as 
the  public  arrangements  of  the  district  in  which  the  family  lives  will 
afford  opportunity  of  obtaining  gratuitous  vaccination."^  I  believe  the  best 
time  is  between  the  first  and  fourth  months.  It  is  then  well  over  before 
dentition  begins.  If  the  child  is  sickly  or  has  any  skin-eruption,  it  should 
be  got  into  good  condition  beforehand. 

If,  however,  small-pox  is  prevailing,  there  is  no  age,  however  early,  and 
no  degree  of  poorliness,  that  should  bar  out  the  operation.  In  imminence 
of  danger,  as  when  variola  is  in  the  same  street  or  house,  I  would  vacci- 
nate an  infant  immediately  on  its  birth.  Experience  has  shown  these  early 
operations  to  bo  as  safe  and  protective  as  later  ones. 

Books  have  something  to  say  about  the  best  time  of  year  for  vaccinating, 
but  I  think  it  matters  little.     In  winter  and  in  summer  the  course  of  vac- 


'  Barron's  Life  of  .Tenner,  vol.  ii.  p.  135. 
^  Seaton,  Hand-Book  of  Vaccination. 
3  Ibid. 


VACCINATION.  753 

cinia  is  the  same :  the  important  thing  is  not  to  neglect  or  defer  it  when  it 
ought  to  be  done. 

Revaccination. — The  liability  to  loss  or  diminution  of  protection  with 
lapse  of  time  creates  a  frequent  necessity  for  revaccination.  Since  we  know 
from  statistics  that  small-pox  after  successful  revaccination  is  an  exceed- 
ingly rare  event,  public  safety  would  be  promoted  by  requiring  all  persons, 
without  regard  to  the  time  of  the  primary  operation,  to  renew  it  at  or  soon 
after  puberty.  Where  it  is  not  a  requirement  of  law,  this  duty  is  too 
much  neglected.  There  can  be  no  harm,  either, — on  the  contrary,  there  may 
be  much  good, — in  revaccinating  with  every  near  approach  of  small-pox. 

Doubtless  in  very  many  cases  of  vaccination  repeated  no  result  will  be 
manifest.  In  a  large  proportion,  however,  the  ordinary  phenomena  appear, 
but  in  an  irregular  way.  The  vesicle  is  apt  to  be  small,  acuminated,  and 
without  a  central  depression.  It  usually  takes  a  swift  course,  reaching  full 
growth  by  the  sixth  day  instead  of  the  eighth,  and  then  rapidly  declines. 
The  crust  is  likely  to  be  small  and  imperfect,  and  should  never  be  used  to 
vaccinate  from,  nor  should  lymph  for  this  purpose  ever  be  taken  from  a 
secondary  vesicle. 


Vol.  I.— 48 


VARICELLA. 

By  CHAELES   G.  JENNINGS,  M.D. 


Definition. — An  acute,  specific,  infectious  disease,  peculiar  to  infancy 
and  childhood,  characterized  by  a  short  febrile  period,  and  a  vesicular  erup- 
tion distributed  over  the  whole  surface  of  the  body.  The  vesicles  appear 
in  successive  crops  and  disappear  by  desiccation  in  from  three  to  five  days, 
occasionally  leaving  permanent  cicatrices. 

History. — The  recognition  of  varicella  as  a  distinct  disease  dates  from 
the  latter  part  of  the  seventeenth  century.  A  few  clear  descriptions  of  the 
disease  written  before  this  time  leave  no  doubt  as  to  its  existence  from  a  very- 
early  period.  Rhazes  (a.d.  910),  the  earliest  writer  on  small-pox,  imper- 
fectly described  it.  Ingrassias  (1550)  and  a  contemporary,  Yidus  Vidius, 
also  described  the  disease,  the  latter  author  under  the  term  crystalU,  a 
name  often  used  to  the  present  day.  According  to  this  writer,  the  Italians 
were  familiar  with  the  disease,  and  called  it  ravaglione,  the  name  they  still 
use.  With  these  few  exceptions,  no  mention  is  made  of  the  disease  by  the 
early  writers,  and  its  history  is  inseparably  connected  with  that  of  variola. 

To  Sydenham  (1675)  is  due  the  honor  of  finally  separating  measles  and 
variola ;  but  this  writer  makes  no  mention  of  varicella  as  a  distinct  disease. 
A  few  years  after  Sydenham's  publication,  Morton  and  another  English 
physician  (1690)  wrote  of  several  cases  of  varicella  under  the  title  of  variola 
maxime  benigna.  At  this  time  the  disease  was  popularly  distinguished  from 
variola  and  termed  chicken-pox.  Morton  introduced  this  term  into  medical 
literature  (Gregory).  Gee  and  Fagge  give  the  derivation  of  this  word  to 
be  from  cicer,  "chick-pea,"  through  the  French  ehiche.  The  name  vari- 
cella, first  given  to  the  disease  by  Vogel  (1764),  is  a  diminutive  of  varus,  a 
"pimple."  Almost  all  the  various  names  given  to  the  disease  by  different 
writers  refer  to  its  resemblance  to  variola. 

These  early  writers  observed  that  an  attack  of  chicken-pox  gave  no  pro- 
tection against  variola ;  and  it  A\as  in  all  probability  this  fact  that  led  many 
to  separate  it  from  that  disease.  With  but  an  occasional  exception,  the  physi- 
cians of  this  period  doubted  the  distinct  character  of  varicella  and  classed  it 
with  the  mild  forms  of  varioloid.  Considering  the  close  resemblance  of  the 
two  diseases,  and  the  fact  that  at  this  time  medical  kuoAvledge  was  so  cloudy 
that  measles  and  small-pox,  diseases  that  are  now  so  easily  distinguished 
754 


VARICELLA.  755 

from  each  other,  were  confounded,  it  is  not  remarkable  that  this  confusion 
should  have  existed. 

The  introduction  of  inoculation  for  the  prevention  of  small-pox  in  the 
early  part  of  the  seventeenth  century  drew  the  attention  of  observers  to  the 
mild  forms  of  varioloid  disease.  The  opposition  to  inoculation  was  strong, 
and  those  who  opposed  it  brought  forward  all  cases  of  varioloid  and  vari- 
cella to  prove  the  inefficacy  of  the  operation.  It  became  necessary  for  the 
adherents  of  the  practice  of  inoculation  to  establish  the  specific  character  of 
varicella ;  and  this  led  to  its  ver}^  careful  study. 

Although  in  1730  Fuller  made  what  appears  to  be  the  earliest  assertion 
of  the  non-identity  of  variola  and  varicella,  urging  in  the  plainest  terms 
that  chicken-pox  could  not  be  produced  by  the  contagium  of  any  other 
specific  disease,  Dr.  Heberden  ^  gave  to  the  world  the  first  full  and  accurate 
description  of  varicella.  He  fully  discussed  the  pathological  relations  of 
the  disease,  and  from  his  observations  he  came  to  the  conclusion  that  vari- 
cella was  a  disease  distinct  from  variola.  Dr.  Heberden  was  a  physician 
of  large  experience  and  a  careful  and  accurate  observer,  and  his  work  was 
looked  upon  as  a  standard  by  the  practitioners  of  his  day. 

In  Germany,  Dr.  Franck,  of  Vienna  (1805),  and  a  few  years  later  Dr. 
Heim,  of  Berlin,  made  important  contributions  to  the  literature  of  the  dis- 
ease. Writers  of  this  period  caused  much  confusion  by  the  multiplication 
of  names  and  by  the  frequent  inclusion  of  cases  of  mild  varioloid.  Heim 
affirmed  the  specific  nature  and  the  inoculability  of  varicella,  and  called 
attention  to  the  distinguishing  characteristics  of  the  cicatrices  of  variola  and 
varicella. 

In  1806,  Willan  wrote  of  varicella  and  gave  particular  attention  to  the 
minute  description  of  the  cutaneous  lesion.  According  to  their  form,  he 
termed  the  varicellous  vesicles  lenticidai^,  conoidal,  and  glohate.  These  dis- 
tinctions are  still  occasionally  to  be  found  in  medical  works,  but  such 
multiplication  of  descriptive  terms  has  become  obsolete. 

From  the  appearance  of  Heberden's  essay  until  about  the  first  part  of 
the  present  century  the  opinion  that  varicella  was  a  disease  distinct  from 
variola  was  quite  uniform.  The  defenders  of  inoculation  -for  the  mitigation 
of  variola  were  able  to  prove  by  abundant  observation  that  the  varioloid 
eruption  that  was .  so  frequently  seen  after  inoculation  was  the  distinct 
disease  varicella,  thus  removing  doubts  that  were  raised  of  the  protective 
power  of  the  operation. 

In  1798,  Jenner  communicated  to  the  world  his  great  discovery  of  vac- 
cination, and  the  practice  of  this  preventive  of  variola  quickly  supplanted 
inoculation.  AVith  the  general  introduction  of  vaccination,  and  the  result- 
ing modification  of  the  disease,  came  many  cases  of  varioloid.  The  close 
resemblance  between  mild  varioloid  and  varicella  and  the  simultaneous 
prevalence  of  epidemics  of  the  two  diseases  again  brought  doubts  to  the 

1  Transactions  of  the  Koyal  College  of  Physicians,  vol.  i.  p.  427,  1767. 


756 


VAEICELLA. 


minds  of  physicians  as  to  their  distinct  character.  The  epidemic  that  pre- 
vailed in  Scotland  in  the  years  1818  and  1819  was  carefully  observed  and 
studied  by  Dr.  Thompson,  of  Edinburgh.  In  his  work  ^  upon  the  subject 
he  reopened  the  question  of  the  specific  character  of  varicella.  His  obser- 
vations led  him  to  believe  that  varicella  was  simply  a  mild  manifestation 
of  the  variolous  poison.  Thompson's  views  of  the  pathology  of  the  disease 
found  a  number  of  supporters,  and  to  the  present  day  there  are  a  few 
eminent  writers  who  hold  to  the  same  doctrine. 

The  most  influential  supporter  of  the  theory  of  the  etiological  identity 
of  variola  and  varicella  in  recent  years  was  Hebra.  As  a  great  teacher  of 
dermatology,  his  influence  was  wide-spread,  and  his  ideas  have  had  a  con- 
trolling effect  upon  the  minds  of  many  of  the  physicians  of  Europe  and 
America.  Among  very  recent  writers  upon  varicella,  Kaposi  and  Bruyelle 
follow  the  theory  of  Hebra. 

American  literature  on  varicella  is  very  meagre,  but  American  physi- 
cians with  but  rarely  an  exception  have  given  no  credence  to  the  theory  of 
identity.  To  the  writer's  knowledge,  the  only  author  who  has  unqualifiedly 
upheld  Thompson's  views  is  Eberle.^  He  thought  the  evidence  adduced  by 
Dr.  Thompson  conclusively  proved  the  common  origin  of  the  two  diseases. 
Dr.  J.  Nevins  Hyde^  is  inclined  to  consider  the  two  diseases  identical.  His 
views  are  peculiar,  and  he  formulates  them  thus :  "  Practically  and  clini- 
cally, it  is  useful  to  regard  these  disorders  as  of  a  distinct  nature.  The 
arguments,  however,  in  favor  of  such  absolute  distinction  are  not  irrefutable. 
There  is  probably  in  both  forms  of  disease  but  a  single  virus,  that  of  variola ; 
but  this,  modified  by  evolution  among  generations  of  vaccinated  children, 
has,  in  this  process  of  natural  cultivation  or  attenuation,  produced  a  malady 
of  tender  years  whose  attacks  do  not  protect  from  variola  and  occur  irre- 
spective of  vaccination." 

Etiology. — Varicella  is  a  disease  of  infancy  and  childhood.  Infants 
under  the  age  of  six  months  enjoy  a  certain  immunity,  but  it  is  not  so 
marked  as  in  the  case  of  scarlatina  and  measles.  Congenital  varicella  has 
not  been  recorded.  Senator  observed  a  case  in  an  infant  eleven  days  old. 
In  children  over  ten  years  of  age  the  disease  is  rare,  while  in  adult  life  it 
is  so  infrequent  that  many  observers  of  large  experience  have  not  met  with 
it.  The  writer  has  observed  one  case  in  a  mulatto  aged  twenty-three  years. 
The  influence  of  age  is  well  illustrated  by  five  hundred  and  eighty-four 
cases  reported  by  Baader,*  of  Basle  : 


Cases.  Age. 

382 1  to    5  years. 

191 6  to  10      " 

7 11  to  15      " 


C.\SES.  Age. 

2 16  to  20  years. 

2  (?) 20  to  40  "    " 


^  Account  of  the  Varioloid  Epidemic  in  Scotland,  1820. 
2  A  Treatise  on  the  Diseases  of  Children,  1833,  p.  419. 
^  System  of  Medicine,  Popper,  I880,  vol.  i.  p.  481. 
*  Jahrbuch  f.  Kinderheilk.,  xvii.  104. 


VARICELLA.  757 

The  immunity  of  older  children  and  of  adults  has  been  ascribed  to 
the  heavier  C|uality  of  the  skin.  The  disease,  however,  is  so  wide-spread, 
and  such  liberty  is  allowed  to  those  aifected  by  it,  that  very  few  individuals 
pass  through  early  childhood  without  contracting  it.  These  exceptional  in- 
dividuals may  enjoy  a  peculiar  insusceptibility  which  persists  through  life. 

As  with  the  other  exanthemata,  varicella  occurs,  as  a  rule,  but  once  in 
the  lifetime  of  an  individual.     Sex  has  no  influence. 

Varicella  occurs  sporadically  and  in  epidemics.  In  large  communities 
it  is  always  present.  Thomas  has  observed  that  in  large  towns  epidemics 
are  not  separated  by  intervals  of  several  years,  as  is  the  case  with  measles 
and  small-pox,  but  occur  once  every  year  or  every  half-year.  In  Leipsic 
epidemics  occur  regularly  a  short  time  after  the  opening  of  the,  infant- 
schools.  Epidemics  of  varicella  often  precede  or  follow  epidemics  of  other 
contagious  diseases.  There  is  no  evidence  that  the  disease  is  unusually 
prevalent  during  an  epidemic  of  small-pox.  Seasons  and  meteorological 
conditions  do  not  influence  the  spread  of  the  disease. 

The  medium  of  contagion  is  in  all  probability  the  respired  air. 

Many  experiments  have  been  made  in  the  inoculation  of  varicella,  but 
the  successful  cases  have  been  very  few,  and  it  must  be  admitted  that  the 
disease  can  be  inoculated  only  with  great  difficulty.  That  it  can  be  trans- 
mitted at  all  by  inoculation  is  denied  by  many  writers.  Boyce,^  of  Edin- 
burgh, made  many  attempts  at  inoculation,  but  always  failed.  Batemau^ 
states  that  it  may  be  transmitted  by  inoculation,  but  does  not  give  experi- 
mental evidence.  Hesse  ^  collected  eighty-seven  cases  of  inoculation.  Of 
these,  nine  were  followed  by  general  disease  and  seventeen  by  local  mani- 
festation only.  The  result  in  the  other  cases  was  negative.  Thomas  ob- 
tained negative  results  in  similar  experiments,  and  states  that  Heim,  Vetter, 
Czakert,  and  Fleischmann  were  equally  unsuccessful.  In  this  country  Dr. 
J.  Lewis  Smith*  endeavored  to  communicate  the  disease  in  this  Avay,  but 
failed.  More  recent  experiments  by  Steiner  ^  tend  to  confirm  the  inocula- 
bility  of  varicella.  He  inoculated  ten  children,  in  eight  of  whom  varicella 
developed.  The  stage  of  incubation  in  the  eight  successful  cases  was  eight 
days.  Unless  these  favorable  results  fail  to  be  confirmed  by  subsequent 
observation,  or  the  experiments  are  proved  to  be  faulty  and  the  exposure  to 
have  taken  place  in  some  other  way,  it  must  be  conceded  that,  although  it 
often  fails,  the  disease  may  be  transmitted  by  inoculation. 

In  all  probability  the  disease  may  be  carried  l^y  a  third  person,  although 
so  little  attention  is  paid  to  it  that  the  origin  of  a  particular  case  is  rarely 
traced. 

The  nature  of  the  specific  virus  of  varicella  is  as  yet  unknown.     Dr. 

^  Thompson  im  Varioloid  Diseases,  p.  74. 

^  On  Cutaneous  Diseases. 

'  Ueber  Varicellen,  Leipsic,  1829. 

*  Diseases  of  Children,  5th  ed.,  p.  46. 

5  Wien.  Med.  Wochenschrift,  No.  16,  1875. 


758  VAEICELLA. 

A.  Tscliamer  ^  claims  to  have  cultivated  the  virus  and  to  have  obtained  a 
hitherto  unknown  micrococcus.  He  states  that  the  organism  is  distinct 
from  the  microbe  that  he  obtained  from  the  cultivation  of  variola  and 
vaccinia,  thus,  according  to  him,  proving  the  distinct  character  of  varicella. 
He  did  not  carry  his  experiments  with  varicella  further  than  to  isolate  the 
microbe. 

As  stated  above,  there  are  a  few  writers  at  the  present  time,  especially 
on  the  continent  of  Europe,  who  do  not  give  to  varicella  a  place  as  a  distinct 
disease.  Hebra  applied  the  term  varicella  to  cases  of  variola  in  which  the 
rash  is  very  scanty,  and  which  run  a  favorable  course  and  always  terminate 
in  recovery ;  and  this  is  about  the  opinion  of  those  who  now  hold  to  the 
doctrine  of  identity.  Manifestly,  such  a  classification  will  include  under 
the  term  varicella  not  only  all  cases  of  this  disease,  but  also  many  cases  of 
mild  or  modified  small-pox. 

Those  who  believe  in  the  non-identity  of  the  two  diseases  exclude  from 
varicella  all  cases,  regardless  of  their  clinical  features,  that  originate  from 
exposure  to  variola  or  are  capable  of  transmitting  variola  to  another  indi- 
vidual by  inoculation  or  otherwise ;  and,  unless  it  can  be  shown  that  the 
disease  which  prevails  almost  continuously  in  our  large  communities  regard- 
less of  the  presence  of  small-pox,  and  which  alone  is  entitled  to  the  name 
varicella,  can  generate  true  variola,  its  claims  to  a  distinct  position  among 
the  specific  diseases  must  be  granted. 

In  favor  of  the  non-identity  of  variola  and  varicella  are  the  following 
arguments,  modified  from  Gee  :  ^ 

1.  Varicella  and  variola  are  not  interchangeable.  There  is  not  a  single 
authentic  instance  where  either  of  the  two  diseases  was  the  result  of  expo- 
sure to  the  other.  When  the  two  diseases  prevail  together  in  a  community, 
and  there  is  free  exposure  to  both,  instances  may  arise  that  appear  to  nega- 
tive this  proposition,  but,  with  the  opportunities  for  error  that  such  cir- 
cumstances oifer,  they  are  of  little  value.  In  the  United  States  varicella  is 
one  of  the  commonest  of  diseases,  while  small-pox,  except  in  the  large  sea- 
board cities,  is  very  rare.  So  rare  is  it  that  in  many  parts  of  the  country 
practitioners  of  large  experience  pass  many  years  without  seeing  a  case. 
When  variola  appears  in  a  community  previously  free  from  it,  it  bears  no 
relation  to  the  presence  or  absence  of  varicella,  and  it  can,  with  but  few 
exceptions,  be  traced  to  outside  origin. 

Chicken-pox  often  prevails  as  an  epidemic  isolated  completely  from 
cases  of  variola.  Mohl  first  brought  forward  this  fact.  According  to  this 
writer,  between  the  years  1809  and  1823  small-pox  was  entirely  absent  from 
Copenhagen,  while  cases  of  chicken-pox  were  met  with  every  year.  This 
is  now  the  every-day  experience  of  all  American  physicians  in  general  prac- 
tice.    Now,  an  epidemic  of  varioloid  free  from  concurrent  cases  of  non- 


1  Arch.  f.  Kinderheilkunde,  B.  ii.  H.  3  (abst.  in  Amer.  Jour,  of  Obstet.,  vol.  xv.  p.  247). 
>*  Reynolds,  System  of  Medicine,  Amer.  ed.,  vol.  i.  p.  124. 


VARICELLA.  759 

modified  small-pox  has  never  yet  been  seen,  and  it  is  highly  improbable  and 
opposed  to  medical  experience  that  varicella,  if  it  were  but  modified  small- 
pox, should  never  give  rise  to  a  distinct  case  of  variola.  Furthermore, 
chicken-pox  is  inoculable  with  difiiculty,  and  the  few  successful  inoculations 
have  invariably  produced  typical  varicella.  Inoculated  small-pox,  whether 
modified  or  not,  has  never  yet  been  proved  to  have  caused  chicken-pox. 

2.  Varicella  and  variola  are  not  mutually  prophylactic. 

This  is  a  fact  acknowledged  by  all  -^Titers,  and  it  is  too  well  known  to 
require  fuller  consideration. 

3.  Varicella  and  vaccinia  are  not  mutually  prophylactic.  This,  also,  is 
every-day  experience. 

4.  Varicella  is  a  disease  only  of  very  early  life.  Variola  is  equally 
common  at  all  ages. 

In  view  of  these  great  pathological  differences,  varicella  must  be  con- 
sidered a  disease  sui  generis. 

The  theory  of  Dr.  Hyde,  cited  above,  holding  to  the  common  origin  of 
variola  and  varicella,  is  open  to  criticism.  That  the  diseases  may  have  had 
a  common  ancestor  in  remote  times  is  not  improbable,  but  Dr.  Hyde  places 
the  time  of  beginning  diiferentiation  at  too  recent  a  date.  The  existence 
of  varicella  before  the  introduction  of  vaccination  is  proved  by  the  state- 
ments of  many  writers,  and  varicella  was  as  distinctly  differentiated  from 
variola  one  hundred  years  ago  as  it  is  to-day.  No  steps  in  the  evolution 
can  be  traced.  One  of  the  most  characteristic  features  of  varicella  is  its 
almost  exclusive  appearance  in  infants  and  very  young  children.  There  is 
no  evidence  that  the  mild  and  modified  variola  that  occurs  after  vaccination 
has  any  peculiar  tendency  to  attack  young  subjects.  The  only  modification 
of  variola  that  is  produced  by  vaccination  is  in  its  severity :  every  other 
pathological  characteristic  is  retained. 

Pathological  Anatomy. — Death  from  varicella  being  almost  unknown, 
opportunity  to  study  the.  pathological  anatomy  of  the  cutaneous  lesion  rarely 
presents.  Our  knowledge  of  the  condition  is  largely  a  matter  of  inference. 
Dr.  Hyde  describes  it  thus :  "  Manifestly,  the  exanthem  is  exudative  in 
type,  the  serum  in  circumscribed  areas  lifting  the  superficial  layer  of  the 
epidermis  from  the  deeper  parts  of  the  derm.  Unquestionably,  septa  occur 
in  t}^)ically-developed  varicella  chambers,  similar  to  those  seen  in  variola, — 
a  pathological  fact  which  is  the  corner-stone  of  the  doctrine  relating  to  the 
unity  of  the  disorders.  The  serum  contained  in  these  septa  possesses  an 
alkaline  reaction.  The  formation  of  a  cicatrix  is  evidently  due  to  the  in- 
tensity of  the  process  in  certain  exceptional  lesions,  as  a  result  of  which  the 
papilla)  of  the  corium  are  superficially  destroyed.  These  sequelae  are  often 
due  to  the  picking  and  scratching  of  the  lesions." 

Symptomatolog-y. — Varicella  has  a  period  of  incubation  that  is  very 
long  and  is  more  variable  than  that  of  variola  or  of  measles.  It  is  differ- 
ently stated  by  various  observers,  but  some  of  the  most  careful  clinicians 
(Thomas,  Trousseau,  Hesse)  give  it  as  from  thirteen  to  seventeen  days.     In 


760  VARICELLA. 

the  cases  successfully  inoculated  by  Steiner  the  period  of  incubation  was 
uniformly  eight  days.  Ordinarily  there  are  no  symptoms  during  this 
period,  although  occasionally,  as  in  the  other  exanthemata,  there  may  be 
slight  deviations  from  the  perfectly  healthy  state. 

The  onset  of  the  disease  is  first  made  known,  usually,  by  the  appearance 
of  the  characteristic  rash.  Watchful  mothers  will  rarely  have  their  atten- 
tion called  to  any  symptoms  preceding  the  eruption,  and  it  is  very  seldom 
that  the  physician  is  called  until  the  formation  of  the  vesicles  is  well  under 
way.  In  numbers  of  observations  in  institutions  the  beginning  of  the 
eruption  and  the  onset  of  the  fever  have  been  simultaneous.  Hyde  ob- 
served the  evolution  of  the  disease  in  twenty  children  in  the  Chicago  Home 
of  the  Friendless,  no  one  of  whom  was  recognized  as  ailing  before  the 
eruption  appeared.  There  may  be,  however,  a  premonitory  stage  of  a  few 
hours'  duration  and  marked  by  slight  constitutional  disturbance.  More 
rarely  there  is  greater  perturbation  of  the  functions.  Inflammation  of  the 
mucous  membranes,  high  fever,  and  severe  nervous  symptoms  have  been 
noted.  The  writer  has  observed  one  case  that  was  ushered  in  by  a  convul- 
sion. A  fleeting  erythema  sometimes  precedes  the  vesicles.  It  should  be 
borne  in  mind  that  these  unusual  symptoms  often  may  have  a  cause  other 
than  the  specific  virus.  Henoch  regards  all  symptoms  during  the  invasion 
stage  as  accidental. 

The  eruption  of  varicella  generally  appears  first  upon  the  upper  half  of 
the  body  or  upon  the  chest.  As  a  rule,  according  to  the  writer's  observa- 
tion, mothers  first  note  the  rash  upon  the  upper  part  of  the  back.  Thomas, 
however,  gives  the  face  as  the  part  first  invaded.  From  the  place  where 
the  rash  begins  the  eruption  rapidly  spreads  over  the  body,  face,  hairy  scalp, 
and  extremities.  Upon  the  face  the  eruption  is  usually  most  abundant  and 
characteristic  on  the  forehead  and  near  the  temples.  The  distribution  is 
variable.  There  may  be  only  a  few  small  vesicles,  scattered  over  a  limited 
region,  or,  in  typical  and  well-developed  cases,  no  portion  of  the  cutaneous 
surface  may  escape. 

The  rash  begins  as  a  number  of  small,  red,  slightly-elevated  macules, 
which  Trousseau  very  aptly  compared  to  tjie  rose-rash  of  typhoid  fever. 
These  macules,  according  to  Dr.  Gee,  disappear  when  the  skin  is  stretched, 
— this  being  a  proof  that  there  is  no  exudation  into  the  cutis,  simply  a 
hypersemia.  In  a  few  hours  a  small  vesicle  forms  in  the  centre  of  each 
macule,  and  it  quickly  enlarges  to  its  full  size.  The  vesicles  are  round  or 
oval  in  form,  and  vary  in  size  from  a  pin-head  to  a  small  pea.  They  are 
([uite  superficial,  being  covered  only  by  the  outer  layers  of  the  epidermis, 
but  tense  and  surrounded  usually  by  a  narrow  inflammatory  zone.  Accord- 
ing to  Fagge,  they  are  sometimes  seated  upon  a  perfectly  colorless  surface, 
so  that  the  patient  looks  exactly  as  though  he  had  been  sprinkled  with 
drops  of  clear  water.  The  vesicles  are  discrete,  and  vary  in  number  from 
twenty  or  thirty  to  two  or  three  hundred.  Thomas  lias  noted  as  many  as 
Beven  or  eight  hundred.    Confluence  of  adjacent  vesicles  occurs  very  rarely. 


VARICELLA.  761 

Thomas  says  that  the  vesicles  sometimes  are  congregated  into  small  groups, 
making  the  eruption  resemble  zoster.  The  fluid  contained  in  the  vesicles  is 
at  first  clear  and  colorless  and  of  an  alkaline  reaction.  As  the  vesicles 
mature,  many  become  cloudy  and  the  contents  slightly  tinged  with  yellow 
from  the  presence  of  a  few  pus- cells,  but  they  never  become  purulent  (Fox). 

Within  a  few  hours  after  the  formation  of  the  first  vesicles,  a  fresh  crop 
of  macules  form,  which  by  the  next  morning  have  developed  into  typical 
vesicles.  This  may  be  repeated  two  or  more  times,  so  that  with  the  develop- 
ment of  the  new  and  the  fading  of  the  old  lesions  the  eruption  appears  to 
come  in  successive  crops.  As  a  rule,  only  at  the  beginning  of  the  disease 
are  the  vesicles  well  developed  and  characteristic.  Many  of  the  macules 
that  come  late  abort  before  reaching  the  vesicular  stage.  They  remain 
as  macules  for  a  few  hours  and  then  fade.  Others  may  form  small  and 
imperfect  vesicles.  Exceptional  contents  of  the  vesicles  are  rarely  seen. 
Eichhorst  mentions  blood  and  air  as  sometimes  present. 

The  eruption  begins  to  decline  on  the  second  or  third  day.  Some 
of  the  vesicles  become  flaccid  by  partial  absorption  of  their  contents  ;  others 
grow  tense  and  burst,  or  they  are  ruptured  by  the  scratching  of  the  patient. 
They  then  dry  up  and  form  thin,  yellowish  or  brownish  crusts.  Some  of 
the  vesicles  late  in  the  disease  may  enlarge  and  form  veritable  bullae,  which 
show  a  slight  umbilication  in  the  centre  when  the  lesion  begins  to  dry. 
In  very  many  cases  two  or  three  of  the  usual-sized  vesicles  also  are  slightly 
umbilicated. 

The  crusts  fall  or  are  scratched  oif  in  a  few  days,  leaving  small,  cir- 
cular, and  slightly-depressed  patches  of  reddened  skin.  When  the  skin  is 
delicate,  the  large  vesicles,  or  those  injured  by  violence,  may  leave  cicatrices 
that  persist  through  life.     The  scars  are  circular,  and  very  soft  and  white. 

The  mucous  membranes  also  are  the  seat  of  the  eruption.  Vesicles  form 
in  the  mouth  and  throat.  They  are  thickest  upon  the  hard  and  soft  palates. 
The  vesicles  quickly  lose  their  epidermal  covering  and  become  excoriated 
and  resemble  aphthous  ulcers.  Vesicles  form  upon  the  prepuce  in  boys 
and  in  the  vagina  in  girls,  and  when  present  in  these  localities  cause  diffi- 
culty in  urinating.  The  involvement  of  the  internal  organs  in  the  eruption 
has  not  been  certainly  determined.  That  it  may  occur  is  made  probable 
by  a  specimen  presented  to  the  New  York  Pathological  Society,  May  9, 
1887,  by  Dr.  Partridge.  The  patient  died  of  varicella  complicated  with 
broncho-pneumonia.  Diarrhoea  was  present  during  life.  In  the  large 
intestine  were  found  a  number  of  excoriations  that  appeared  like  varicella 
vesicles.  That  a  copious  eruption  in  the  intestine  does  not  often  occur 
is  proved  by  the  iufrequency  of  intestinal  catarrh  as  an  accompaniment 
of  the  disease,  but  it  is  also  true  that  a  few  vesicles  could  be  present — 
as  thick  as  they  appear  in  the  mouth — without  symptoms  of  intestinal 
irritation. 

The  constitutional  symptoms  of  the  stage  of  eruption  are  variable  in 
duration  and  intensity.     In  a  few  cases  the  disease  runs  its  course  without 


762  VARICELLA. 

fever.  As  a  rule;,  however,  with  the  onset  of  the  eruption,  or  preceding  it 
by  a  few  hours,  there  is  a  mild  febrile  state,  with  the  usual  symptoms  of 
that  condition.  The  fever ''may  be  ushered  in  by  a  slight  chill  or  chilly 
sensations.  The  rise  of  temperature  is  generally  not  great,  rarely  going 
above  101°  or  102°  F.  The  fever  is  remittent  in  type,  with  evening  exacer- 
bations ;  or  the  morning  temperature  may  be  normal  and  a  slight  rise  occur 
towards  evening.  Occasionally  the  fever  may  be  so  high  as  to  be  a  matter 
of  concern.  Thomas  reports  a  case  in  which  it  rose  to  106.8°  F.  but  quickly 
fell. 

The  febrile  period  continues  for  two  or  three  days,  or,  in  cases  in  which 
the  eruption  is  prolonged  by  successive  crops  of  vesicles,  it  may  extend  over 
a  longer  period.  Persistence  of  the  febrile  state  beyond  the  ordinary  time 
should  warn  the  physician  to  be  on  his  guard  for  complications. 

In  uncomplicated  varicella  no  symptoms  other  than  those  attendant 
upon  this  mild  febrile  movement  are  commonly  present.  Rarely  the  throat 
may  be  a  little  sore  and  the  cervical  glands  enlarged  and  tender.  With  the 
desiccation  of  the  vesicles  and  the  decline  of  the  fever  convalescence  is  estab- 
lished. The  duration  of  the  disease  from  the  initial  symptoms  to  the  last 
falling  off  of  the  crusts  is  eight  or  ten  days. 

In  healthy  children  the  disease  does  not  show  much  variation  in  type. 

Varicella  Gangrsenosa. — Under  this  name  physicians  of  England  have 
called  attention  to  a  peculiar  and  grave  manifestation  of  varicella.  Mr.  J. 
Hutchinson  was  the  first  to  describe  this  dangerous  form  of  the  disease.  It 
"  is  not  confined  to  weakly,  ill-nourished  children,  but  is  most  common  in 
them.  It  is  no  doubt  connected  with  the  curious  tendency  to  spontaneous 
gangrene  sometimes  met  with  in  children"  (Eustace  Smith).  According  to 
several  observers,  this  condition  often  attends  acute  miliary  tuberculosis. 

"In  gangrenous  varicella  the  vesicles,  instead  of  drying  up  in  the 
ordinary  way,  become  black  and  get  larger,  so  that  a  number  of  rounded 
black  scabs,  with  a  diameter  of  half  an  inch  to  an  inch,  are  scattered  over 
the  surface  of  the  body.  If  a  scab  be  removed  it  is  seen  to  cover  a  deep 
ulcer.  Around  it  the  skin  is  of  a  dusky-red  color.  All  the  vesicles  do 
not  take  on  the  gangrenous  action,  so  that  we  find  many  varicellous  scabs 
of  ordinary  appearance  mixed  up  with  the  blackened  crusts.  The  gan- 
grenous process  often  penetrates  deeply  through  the  skin  to  the  muscles, 
but  under  some  of  the  scabs  the  ulceration  is  more  shallow.  These  cases 
are  very  fatal.  Mr.  Warrington  Haward  has  reported  the  case  of  a  weakly 
baby  twelve  months  old,  who  weighed  only  six  pounds  and  a  half.  The 
child  was  attacked  with  gangrenous  varicella  and  died  in  a  few  days  of 
pyaemia  with  secondary  abscesses  in  the  lungs."  ^ 

According  to  Dr.  Crocker,^  the  gangrenous  eruption  does  not  always 
appear  to  come  from  the  varicellous  eruption,  but  occurs  in  parts  not  the 


'  Disease  in  Children,  Eustace  Smith,  New  York,  1884,  p.  49. 
2  Loudon  Lancet,  May  30,  1885. 


VARICELLA.  763 

seat  of  the  varicelloiis  rash.  According  to  Hutchinson,  loss  of  sight  may 
result  in  these  cases,  from  purulent  irido-choroiditis. 

Complications. — Varicella  has  no  complications  that  are  directly  de- 
pendent upon  it.  Various  diseases,  however,  have  at  times  been  seen  to 
accompany  it.  Among  those  that  have  been  noted  are  erysipelas,  otitis, 
and  peritonitis.     Measles  and  scarlatina  have  been  reported  in  this  country. 

Sequelae. — Not  infrequently  after  varicella  an  anaemic  condition  is  left 
which  may  continue,  unless  properly  treated,  for  some  time.  Pemphigus  and 
urticaria  have  been  noted  as  sequelae.  Meigs  and  Pepper  mention  severe 
bronchitis  or  broncho-pneumonia  as  liable  to  result  from  exposure  after 
varicella. 

According  to  Powell,^  it  often  leaves  behind  troublesome  sores  about 
the  head  and  body  which  are  very  likely  to  lead  to  glandular  enlargement, 
and  secondarily  to  tuberculosis ;  and  the  utmost  care  should  be  taken  to 
protect  from  the  air  by  means  of  collodion  all  vesicles  that  are  large  and 
likely  to  ulcerate. 

Henoch^  reports  four  cases  of  acute  nephritis  following  varicella,  and 
urges  the  necessity  of  examining  the  urine  for  a  few  days  following  the 
exanthem.  The  relation  of  this  grave  disease  to  varicella  is  further  confirmed 
by  two  cases  reported,  one  by  Janssen^  and  the  other  by  Oppenheim.* 
Both  of  these  writers  urge  the  necessity  of  urine-testing  following  the  dis- 
ease. So  far  as  the  writer  is  aware,  nephritis  as  a  sequel  to  varicella  has 
not  been  reported  in  the  United  States,  but  the  knowledge  of  the  relation 
may  establish  the  etiology  of  cases  attributed  to  other  causes.  According 
to  the  published  reports  of  the  above  writers,  nephritis  develops  in  from 
three  to  twelve  days  after  the  decline  of  the  rash.  With  the  exception  of 
one  case,  Avhich  terminated  in  death  and  in  which  post-mortem  examination 
revealed  parenchymatous  nephritis,  the  clinical  histories  of  the  cases  have 
been  those  of  mild  tubular  nephritis. 

Diagnosis. — Great  interest  is  attached  to  the  diagnosis  of  varicella, 
especially  to  its  clinical  separation  from  variola  and  varioloid.  The  prompt 
recognition  of  the  benign  character  of  the  disease  is  of  great  importance, 
both  to  the  patient  and  to  the  community  ;  as  failure  on  the  part  of  the  phy- 
sician to  diagnosticate  it  correctly  may  either  subject  a  patient  to  an  isolation 
made  doubly  disastrous  by  exposure  to  the  infected  air  of  a  small-pox  hos- 
pital, or  expose  a  community  to  the  danger  of  wide-spread  infection  from 
a  variolous  subject.  Either  mistake  is  a  grave  one,  and  certainly  would 
involve  the  physician  in  its  disastrous  results. 

Typically-developed  variola  diifers  so  much  from  varicella  in  its  clinical 
history  that  a  mistalce  in  diagnosis  is  liardly  possible ;  but,  as  the  result  of 
the  very  general  vaccination  that  has  taken  place  in  civilized  countries,  im- 
perfect and  vaguely-defined  cases  of  varioloid  frequently  occur  and  cause 

'  On  Diseases  of  the  Lun2;s  and  Pleurte,  New  York,  1886,  p.  278. 

2  Berlin.  Klin.  Woohenschr.,  .Jan.  14,  1884. 

s  Ibid.,  Nov.  28,  1887.  *  Il.id.,  Dec.  26,  1887. 


764  VAEICELLA. 

much  difficulty  in  recognition,  particularly  when  the  two  diseases  prevail 
together.  The  difficulty  is  so  great  that  epidemics  have  occurred  which 
for  a  time  have  baffled  the  diagnostic  skill  of  able  physicians.  A  remark- 
able example  of  such  an  epidemic  was  reported  by  Dr.  Charles  A.  Lee 
in  the  American  Journal  of  the  Medical  Sciences  for  July,  1853.  This 
epidemic  of  varioloid  prevailed  in  the  townships  of  Gorham  and  Phelps, 
Ontario  County,  New  York,  According  to  Dr.  Lee,  the  eruption  bore 
all  the  distinguishing  marks  of  varicella,  pemphigus,  purpura,  and  even 
erysipelas.  Some  of  the  physicians — one  a  practitioner  with  a  large  ex- 
perience with  small-pox — were  so  confident  that  the  disease  was  chicken- 
pox  that  they  refused  to  advise  vaccination  for  the  exposed  persons.  This 
epidemic  was  undoubtedly  one  of  variola,  but  with  unusual  manifestations. 
Cases  of  typical  small-pox  soon  occurred,  and  rigid  inquiry  traced  every 
case  directly  to  a  case  of  variola  imported  from  a  neighboring  city.  Of 
the  occasional  difficulty  in  diagnosis  Dr.  Hyde  says,  "  The  sooner  it  is 
generally  understood  that  intermediate  forms  occur  which  cannot  be  posi- 
tively assigned  to  the  one  or  to  the  other  category,  the  better  it  will  be  for 
both  the  profession  and  the  laity."  ^ 

The  clinical  characteristics  of  varicella  as  distinguished  from  variola  are — 

1.  The  age  of  the  patients  attacked  by  the  disease. 

Although  variola  attacks  persons  regardless  of  age,  varicella  is  particu- 
larly a  disease  of  infancy  and  early  childhood.  Any  varicella-like  eruption 
in  an  adult  should  be  looked  upon  with  the  gravest  suspicion,  and  the 
patient  strictly  isolated  until,  by  the  history  of  the  case,  its  source,  and  the 
course  of  the  disease,  all  doubt  as  to  the  diagnosis  is  dispelled. 

2.  The  short  period  of  invasion. 

The  eruption  of  varicella  is  not,  as  a  rule,  preceded  by  a  distinct  period 
of  invasion :  the  appearance  of  the  rash  is  the  first  indication  of  ill  health 
that  the  child  manifests.  When  an  invasion  period  is  present,  the  symp- 
toms are  of  an  ill-defined  character  and  rarely  continue  more  than  one 
day.  The  invasion  period  of  variola  is  three  days  in  duration,  and  is 
marked  by  characteristic  symptoms.  It  is  ushered  in  by  a  chill,  which  is 
quickly  followed  by  high  fever,  vomiting,  and  intense  headache  and  back- 
ache. These  symptoms  are  never  met  with  in  varicella.  Even  veiy  mild 
cases  of  varioloid  present  a  distinct  and  moderately  severe  period  of  invasion. 
Occasionally,  however,  it  is  fleeting  and  hardly  noticeable. 

3.  The  superficial  and  vesicular  character  of  the  cutaneous  lesion. 
Examination  of  the  varicellous  vesicle  shows  it  to  be  located  beneath 

the  most  superficial  layers  of  the  epidermis.  The  macular  stage  is  of  short 
duration,  and  the  macule  sofb  and  but  slightly  elevated  above  the  surface  of 
the  skin.  A  small  vesicle  quickly  forms  in  the  centre  of  the  papule,  re- 
mains a  vesicle  filled  with  clear  or  opalescent  fluid  for  twenty-four  or  forty- 
eight  hours,  and  then  dries  into  a  light,  easily-detached  crust.     The  vario- 


^  Pepper's  System  of  Medicine. 


VARICELLA.  765 

lous  eruption  passes  through  a  distinct  papular  stage  lasting  three  or  four 
days.  The  papules  are  well  developed,  raised  markedly  above  the  skin 
level,  and  by  the  hard,  shotty  character  of  the  base  are  shown  to  be  situated 
deej)  in  the  cutis  vera.  The  papules  become  vesicular  on  the  sixth  or  sev- 
enth day,  and  by  the  ninth  day  the  vesicles  are  transformed  into  umbilicated 
pustules. 

4.  -The  abundance  of  the  eruption  upon  the  body. 

In  varicella  the  eruption  is  most  abundantly  and  characteristically  de- 
veloped upon  the  back.  The  face,  hands,  and  feet  show  but  few  vesicles. 
In  variola  the  eruption  is  thickest  and  apt  to  become  confluent  upon  the 
face,  hands,  and  feet. 

5.  The  transient  febrile  stage. 

The  constitutional  symptoms  of  varicella  have  been  seen  to  be  very 
insignificant :  very  rarely  does  the  febrile  period  continue  over  three  or  four 
days.  The  temperature  is  commonly  highest  at  the  beginning  of  the  erup- 
tion and  declines  as  the  vesicles  desiccate.  There  is  no  secondary  fever. 
In  variola  the  temperature,  after  maintaining  a  high  point  during  the  in- 
vasion period,  suddenly  falls  with  the  appearance  of  the  rash,  and  when  the 
eruption  becomes  pustular  the  secondary  fever  manifests  itself. 

Although  typical  variola  and  well-developed  varioloid  diifer  thus  widely 
from  varicella,  very  mild  and  abortive  cases  of  varioloid  occur  in  which  a 
diagnosis  presents  the  greatest  difficulty.  The  invasion  stage  may  be  short 
and  so  mild  as  to  escape  observation ;  the  eruption  may  be  arrested  in  its 
evolution,  never  reaching  the  characteristic  pustular  stage  of  typical  variola ; 
and  the  febrile  stage  may  be  transient.  When  such  irregularities  occur, 
only  the  greatest  care  will  save  the  physician  from  error.  No  one  symptom 
or  manifestation  can  be  relied  upon,  but  all  the  points  in  the  history  and 
development  of  a  given  case  must  be  carefully  weighed. 

Mr.  Makuna^  states  that  the  varicella  vesicles  are  always  unilocular  and 
can  be  emptied  by  one  puncture,  and  that  the  contents  are  serous  and  watery. 
The  variolous  pustules  are  always  multilocular,  cannot  be  emptied  by  one 
puncture,  and  contain  a  plastic  and  viscous  fluid.  This  observation  is  not 
confirmed  by  other  authorities.  The  varicellous  vesicle  is  undoubtedly  oc- 
casionally umbilicated,  and  often  contains  delicate  trabeculse  which  make  it 
multilocular. 

Impetigo  and  impetigo  contagiosa  may  be  confounded  with  varicella. 
The  latter  disease  is  distinguished  by  the  accompanying  febrile  disturbance, 
the  numerous  vesicles,  the  vesicular  type  of  the  lesion,  and  the  halo  sur- 
rounding it. 

According  to  Dr.  Ashby,^  a  vesicular  syphilitic  eruption  may  simulate 
varicella.  He  cites  a  case  re])orted  by  his  colleague  Dr.  Hutton  in  which 
"  an  eruption  (apparently  syphilitic)  of  vesicles,  somewhat  hard  and  sliotty, 

1  London  Lancet,  Sept.  6,  1879. 

^  Archives  of  Pediatrics,  vol.  iii.  p.  101. 


766  VARICELLA. 

seated  on  an  inflamed  base,  made  their  appearance  in  a  child  of  three  years ; 
the  vesicles  appeared  in  crops  for  ten  days,  each  vesicle  lasting  about  six 
days,  leaving  some  staining."  The  diagnosis  between  varicella  and  syphilis 
would  be  made  by  the  history  of  the  case,  the  temperature,  which  would 
not  be  elevated  in  syphilis,  and  the  presence  and  distribution  of  other  forms 
of  the  specific  eruption,  as  bullae  or  papules. 

Prognosis. — Varicella  is  the  most  benign  of  the  exanthemata.  When 
uncomplicated, — and  complications  are  very  rare  in  the  United  States, — 
the  prognosis  is  always  favorable,  and  the  profession  and  the  laity  look 
upon  it  as  a  trifling  disorder.  Were  it  not  for  the  suspicions  that  the  erup- 
tion excites,  physicians  would  rarely  be  called  to  see  the  disease.  This  fact 
makes  the  study  of  varicella  outside  of  institutions  very  difficult. 

In  children  of  feeble  constitution  or  debilitated  by  bad  hygienic  influ- 
ences or  recent  disease,  varicella  may  leave  a  condition  of  impaired  health 
that  will  favor  the  development  of  scrofula. 

Eczematous  eruptions  after  varicella  with  concurrent  swollen  glands 
may  lead,  according  to  Powell,  to  the  development  of  phthisis. 

The  prognosis  of  varicella  gangrsenosa  is  grave,  many  of  the  cases 
terminating  rapidly  in  death. 

When  complications  occur,  the  prognosis  will  depend  rather  upon  theit 
character  than  upon  the  primary  disease.  The  cutaneous  lesion  terminates, 
with  but  few  exceptions,  in  the  complete  restoration  of  the  continuity  of 
the  skin.  Upon  the  face,  Avhen  the  skin  is  delicate,  or  because  of  violence, 
a  few  vesicles  may  leave  permanent  cicatrices. 

Treatment. — Commonly  no  prophylactic  treatment  of  varicella  by 
isolation  of  the  affected  person  is  necessary,  although  children  enfeebled 
from  any  cause,  and  to  whom  any  febrile  disease  is  a  matter  of  concern, 
should  be  protected  from  exposure. 

The  child  with  varicella  should  be  kept  quiet  in  bed  or  upon  the  sofa 
during  the  febrile  period,  and  the  indications  of  the  febrile  state  met  as 
occasion  demands.  Rarely  is  any  treatment  demanded  other  than  quiet 
and  light  food  and  the  proper  regulation  of  the  temperature  of  the  room. 

The  lesions  upon  the  face,  particularly  in  girls,  should  be  watched  and 
care  taken  to  protect  them  from  violence.  It  is  advisable  to  empty  the 
large  vesicles  upon  the  face  by  a  puncture,  and  bathe  them  with  a  mild 
antiseptic  lotion  to  favor  their  rapid  resolution. 

The  treatment  of  the  grave  form  of  the  disease  known  as  varicella 
gangrsenosa  should  be  the  supporting  treatment  of  gangrenous  conditions 
from  other  causes. 

Tlie  continued  anaemia  sometimes  following  the  disease  should  be  met 
by  iodide  of  iron  and  a  bitter  tonic ;  and  in  children  in  whom  there  is  left 
a  tendency  to  cutaneous  eruptions  attended  by  glandular  enlargements,  a 
course  of  cod-liver  oil  and  the  careful  regulation  of  the  diet  are  of  great 
importance. 


PAROTITIS. 

By  OLIVER  P.  EEX,  M.D. 


Derivation  and  Synonymes. — From  the  Greek  T:apd^  "  near,"  oZq,  wro?, 
the  "ear/'  and  the  suffix  itis,  denoting  inflammation.  Latin,  Phlegmone 
parotidEea,  Inflammatio  parotidum,  Cynanche  parotidsea ;  Italian,  Parotide ; 
Spanish,  Parotiditis ;  French,  Parotide ;  German,  Ohrspeicheldriisenent- 
ziindung, — vulg.,  Ziegenpeter,  Mumps,  Bauerwetzel,  Tolpelkrankheit, 
Kehlsucht,  Klirren ;  English,  Parotiditis,  Mumps. 

Definition, — A  contagious  epidemic  inflammation  and  enlargement  of 
the  parotid  gland,  generally  occurring  in  youth,  acute  in  its  origin  and 
course,  accompanied  by  fever  and  fever-symptoms,  followed  in  some  cases 
hj  an  abscess  of  the  gland,  but  usually  subsiding  within  a  week  or  ten  days, 
without  leaving  any  trace. 

Varieties. — A  condition  of  tumefaction  and  inflammation  may  be  set 
up  in  the  parotid  by  a  blow  or  some  external  injury,  and,  following  such  a 
tramna,  epidemic  parotitis  may  arise.  Though  this  may  occur,  a  class 
division  of  traumatic  parotitis  is  hardly  necessary  or  within  the  terms  of 
the  definition.  The  same  may  be  said  of  those  retention-cysts  which  arise 
from  occlusion  of  the  duct  by  a  foreign  body  or  as  a  result  of  local  inflam- 
mations. It  may  be  questioned  also  if  those  cases  of  so-called  mumps  that 
have  been  reported  as  caused  by  local  diseases,  stomatitis,  extensive  disease 
of  the  mouth  or  teeth,  diphtheria,  etc.,  are  not  in  reality  examples  of  duct- 
occlusion  as  a  result  of  cicatrices  or  local  injuiy.  The  epidemic  and  con- 
tagious nature  of  parotitis  must  make  us  examine  such  cases  carefully  and 
prevent  us  from  multiplying  our  varieties  of  parotitis  proper.  We  have 
remaining  two  divisions  : 

1.  Idiopathic,  or,  more  properly,  epidemic  parotitis; 

2.  Secondary,  symptomatic,  metastatic,  deuteropathic,  malignant,  or 
suppurative  parotitis,  or  that  following  typhus,  dysentery,  scarlet  fever, 
small-pox,  measles,  etc. 

The  secondary  form  of  the  disease  differs  in  no  essential  respect  from 
the  idiopathic,  except  perhaps  in  tendency  to  proceed  to  suppuration  of  the 
gland.  This  is  doubtless  due  to  the  fact  tliat,  as  a  result  of  the  previous 
or  intercurrent  disease,  not  only  is  the  system  weakened,  and  the  tissues 

767 


768  PAEOTITIS. 

rendered  less  able  to  resist  attack,  but  there  is  also  an  excess  of  the  mor- 
bific material  in  the  body,  which  acts  injuriously  upon  the  parotid  gland. 

My  own  experience,  however,  is  that  upon  opening  the  suppurating 
organ  there  is  far  less  pus  in  it  than  its  appearance  indicated. 

Besides  the  evidently  necessary  greater  attention  to  the  systemic  con- 
ditions and  disease,  the  treatment  of  secondary  parotitis  is  the  same  as  that 
for  the  idiopathic  form  that  is  given  below. 

IDIOPATHIC   OR   EPIDEMIC   PAPvOTITIS. 

Etiolog-y. — We  know  nothing  of  the  essential  nature  of  the  origin  of 
the  disease.  That  it  is  distinctly  though  not  intensely  contagious,  there  can 
be  no  doubt.  Its  epidemic  nature  is  more  evident  in  the  country  than  in 
cities.  The  law  of  its  spreading  is  not  clear.  In  some  localities  it  will 
disappear  for  twenty  or  thirty  years,  whilst  in  others  it  seems  to  be  almost 
endemic.  It  is  rarely  sporadic,  and  the  epidemics  are  usually  in  the  spring 
or  fall.  Infants  are  seldom  attacked,  and  the  affection  is  confined  to  the 
period  of  childhood  and  early  youth,  though  adults  who  have  not  previously 
had  it  are  sometimes  the  subjects.  Females  are  more  exempt  than  males. 
One  attack  gives  almost  certain  immunity  from  others.  Virchow,  Nie- 
meyer,  and  others  hold  that  it  arises  as  a  catarrhal  inflammation  of  the 
ducts  proceeding  thence  to  the  acini  of  the  gland. 

Patholog-ical  Anatomy. — From  the  fact  of  its  non-fatality,  it  is  evi- 
dent that  but  few  post-mortem  examinations  of  the  gland  during  its  disease 
have  been  made.  From  these,  however,  it  is  reasonably  clear  that  the  patho- 
logical process  consists  essentially  of  a  hypersemia  and  a  serous  infiltration 
of  the  acini.  If  not  absorbed,  this  exudation  may  lead  to  permanent  en- 
largement of  the  gland,  or,  by  compression,  to  its  atrophy.  This  hypersemia 
and  exudation  are  also  present  in  different  degrees  in  the  tissues  in  the 
neighborhood  of  the  gland,  may  extend  to  the  lymphatics  of  the  neck,  and 
occasionally  to  the  submaxillary  glands. 

Symptomatology. — The  period  of  incubation  is  variously  given  at  from 
six  days  to  two  weeks.  The  prodromic  symptoms  usually  appear  about  a 
week  after  exposure,  and  consist  in  feelings  of  languor,  malaise,  loss  of 
appetite,  irritability,  slight  feverishness,  etc.  These  signs  may  be  so  slight 
as  to  escape  notice,  or  in  the  weak  and  nervous  may  become  so  marked 
as  to  demand  great  care  or  lead  to  a  mistake  in  diagnosis.  Cases  have 
been  recorded  where  convulsions  have  occurred  during  this  initial  stage,  or 
where  vomiting,  diarrhoea,  delirium,  and  a  tendency  to  syncope  have  been 
alarming. 

The  local  exhibition  of  the  disease,  the  pain  and  swelling  of  the  parotid, 
may  appear  within  a  day  after  the  prodromes,  or  not  for  a  week  thereafter. 
Its  first  indication  is  shooting  pains  beneath  the  lobe  of  the  ear  during 
motion  of  the  jaw.  A  deep-seated  swelling  will  soon  be  found  at  this  place, 
which  gradually  increases  and  extends  till  the  side  of  the  face  and  neck  are 
implicated.     The  swelling  is  at  first  upon  one  side,  but  is  usually  followed 


PAEOTITIS.  769 

by  swelling  of  the  other  side  within  one  or  two  days.  The  head  is  at  first 
held  towards  the  affected  side,  to  avoid  tension  of  the  affected  muscles  and 
tissues,  but  when  the  affection  is  bilateral  the  head  is  held  rigidly  erect. 
The  appearance  of  the  patient  is  somewhat  ludicrous,  owing  to  the  swollen 
neck,  the  immovable  head  and  muscles  of  expression,  the  staring  eyes,  and 
the  changed,  foolish  expression  of  the  face.  This  impression  upon  the  by- 
stander has  been  so  great  as  to  stamp  itself  in  language,  numerous  derisive 
epithets  for  the  disease  existing  in  most  languages.  To  the  patient  it  is  a 
very  different  matter,  since  he  will  suffer  considerable  hunger  and  thirst 
rather  than  endure  the  pain  that  results  upon  attempting  to  chew  or 
swallow.  The  disorders  of  function  extend  to  impaired  enunciation, 
hypersecretion  of  saliva,  or  sometimes  its  reverse,  with  great  dryness  of  the 
mouth,  pains  and  ringing  in  the  ears,  imperfect  hearing,  etc.  As  a  result 
of  the  difficulty  of  eating,  loss  of  appetite,  vomiting,  constipation,  etc.,  may 
be  set  up ;  whilst  cerebral  hypersemia  may  in  rare  cases  follow  from  pressure 
upon  the  cervical  veins. 

The  constitutional  symptoms  are  those  of  the  prodromous  stage  ex- 
aggerated :  the  fever  may  rise  to  104°  F.,  but  commonly  does  not  go  above 
101°  to  102°,  with  the  increase  of  pulse  and  the  gastro-intestinal  and  cere- 
bral symptoms  that  are  concomitants  of  the  elevation  of  temperature. 

All  the  symptoms  of  mumps  may  sometimes  be  lacking  to  such  a  degree 
as  to  be  out  of  all  proportion  to  the  swelling  present. 

A  striking  peculiarity  of  this  affection  is  its  occasional  metastasis  to  the 
genital  organs.  In  boys  there  may  occur  an  orchitis,  or  swelling  of  the 
testicle  (usually  of  the  same  side,  and  this  the  left),  with  scrotal  cedema, 
whilst  in  girls  the  ovary,  vulva,  or  mammse  are  similarly  affected.  This 
inflammation  is  not  generally  severe,  and  runs  about  the  same  course,  as 
regards  time,  as  the  parotitis.  It  may  even  disappear  from  these  parts 
and  be  followed  by  an  exacerbation  of  the  parotid  symptoms  which,  at  the 
appearance  of  the  orchitis,  etc.,  had  already  notably  lessened  or  disappeared.^ 

Diag-nosis. — The  inception  of  the  malady  may  be  mistaken  for  that  of 
one  of  the  exanthematous  fevers,  but  tlie  mistake  would  be  apt  to  have  no 
very  serious  consequences,  since,  as  we  know  of  no  specific  prophylaxis,  the 
expectant  treatment  would  apply  equally  to  both.  With  the  appearance  of 
the  tumor  and  its  local  manifestations,  hardly  to  be  mistaken  for  an  enlarged 
cervical  gland,  sarcoma,  etc.,  all  doubt  is  set  at  rest,  though  a  retention-cyst 
from  occlusion  of  the  duct-orifice,  by  local  disease  or  a  foreign  body,  may 
cause  all  the  symptoms  of  epidemic  parotitis.     In  such  cases  the  lack  of  a 


1  One  of  the  interesting  curiosities  of  this  subject  is  the  case  detailed  by  Schmalle  (Inauii". 
Diss.,  Greifswald,  1886),  and  shows  that  though  the  metastasis  is  generally  from  the  parotid 
as  an  original  source,  this  reflex  neurosis  may  start  out  from  a  far-distant  point  and  end  in 
a  pronounced  parotitis.  Three  days  after  a  surgical  operation  for  hemorrhoids  with  the 
thermo-cautery,  a  severe  attack  of  acute  parotitis  with  fever  broke  forth,  and  with  such  ex- 
tensive suppuration  of  the  gland  that  three- incisions  (in  the  gland,  behind  the  ear,  and  in 
the  external  auditory  meatus)  were  required  to  give  vent  to  the  large  quantities  of  pus. 
Vol.  I.— 49 


770  PAROTITIS. 

history  of  exposure  or  of  an  existing  epidemic  will  lead  to  an  examination 
of  the  mouth,  and  more  particularly  of  the  duct.  Occlusion  by  such  almost 
imperceptible  substances  as  a  bit  of  tooth-brush  bristle  or  spicule  of  a  nut- 
bur  may  require  the  most  careful  examination  to  reveal  their  presence.  If 
there  be  local  disease  of  the  mouth,  it  is  necessary  to  keep  in  mind  the  possi- 
bility of  a  mechanical  occlusion  by  the  results  of  inflammation,  by  cicatrices, 
etc.  External  injury  may  also  set  up  a  swelling  of  the  gland  like  the  real 
parotitis  in  many  respects. 

Prognosis. — The  prognosis  is  good.  ISTo  case  of  death  has  been  reported 
due  directly  to  the  disease  itself.  The  duration  of  the  disease  is  about  ten 
days,^  though  if,  as  usual,  one  side  of  the  face  is  affected  some  time  after  the 
first,  the  whole  duration  of  the  illness  is  proportionately  lengthened.  The 
scrofulous  and  otherwise  weak  may  not  recover  so  quickly.  Atrophy  of 
the  gland  seldom  follows  a  severe  case,  and  still  more  rarely  is  there  atrophy 
of  the  testicle  in  metastatic  orchitis.  Cases  of  meningitis  due  to  parotitis 
have  been  reported. 

Treatment. — The  disease  being  self-limited,  not  dangerous,  of  short 
duration,  and  its  specific  cause  unknown,  the  indications  of  treatment  are 
of  course  manifest.  Rest,  even  some  days  of  confinement  to  bed,  or  at  least 
to  the  house,  is  advisable.  The  fever,  if  slight,  does  not  demand  active 
antipyretic  treatment.  Cooling  drinks  and  a  light  nourishing  diet  are 
recommended.  If  irregularities  of  the  digestive  system  exist,  they  should 
be  corrected  according  to  the  judgment  of  the  physician.  Saline  laxatives 
will  control  the  tendency  to  constipation.  Owing  to  the  difficulty  of  chew- 
ing and  swallowing,  liquid  food,  milk,  beaten  eggs,  broths,  etc.,  will  be  re- 
quired. If  there  be  great  restlessness  or  marked  cerebral  symptoms,  it  will 
be  well  to  apply  cold  to  the  head,  or  give  light  doses  of  aconite ;  chloral 
may  be  required,  but  morphine  only  in  rare  and  extreme  cases.  The  patient 
may  find  it  very  grateful  to  swallow  bits  of  ice,  or  to  allow  the  same  to  melt 
in  the  mouth.  The  giving  of  an  emetic  in  cases  of  bilateral  attack  or  in 
those  of  orchitis,  as  recommended  by  some  authors,  is  not,  in  my  estimation, 
advisable  for  children. 

Topically,  a  mixture  of  opium  and  sweet  oil,  one  drachm  to  the  ounce, 
should  be  rubbed  upon  the  tumor,  which  is  then  protected  by  a  light  dress- 
ing. Cold  applications,  though  perhaps  useful,  are  not  liked  by  the  patient. 
If  a  tendency  to  suppuration  is  noticed,  shown  by  a  tenseness  and  redness 
of  the  skin,  a  leech  or  two  may  be  applied  behind  the  ear.  Should  an  ab- 
scess become  inevitable,  its  formation  should  be  hastened  by  poultices,  and 
when  formed  it  should  be  opened  and  its  contents  thoroughly  evacuated,  to 
prevent  complete  disorganization  of  the  gland,  or  a  possible  perforation  of 
the  cavity  of  the  tympanum. 


ERYSIPELAS. 

By  J.  O.  HIESCHFELDEE,  M.D. 


S3monyines. — English,  St.  Anthony's  fire,  The  Rose  (Scotland)  ;  Latm, 
Febris  erysipelatosa,  Ignis  sacer ;  German,  Erysipel,  Rose,  Rothlauf ; 
French,  firysipele ;  Italian,  Risipola. 

Definition. — Erysipelas  may  be  defined  to  be  a  dermatitis  having  the 
tendency  to  spread  rapidly,  accompanied  by  comparatively  severe  constitu- 
tional symptoms,  with  rapid  resolution  and  complete  return  to  the  normal 
condition. 

The  et}^mology  of  the  term  is  obscure,  the  most  probable  derivation 
being  from  ipouj,  to  "  draw,"  and  r.ikaq,  "  near,"  the  wandering  character 
of  the  disease  being  thereby  indicated. 

History. — Knowledge  of  this  disease  dates  back  to  the  time  of  Hippoc- 
rates, who  speaks  of  it  in  his  writings.  It  is  likewise  referred  to  by  Gralen, 
who  supposed  that  a  bilious  humor  in  its  efforts  to  escape  from  the  blood 
through  the  skin  occasioned  erysipelas.  This  belief  was  long  entertained, 
and  was  succeeded  by  various  theories,  depending  upon  the  state  of  medical 
philosophy  at  different  periods.  At  one  time  looked  upon  as  the  outward 
manifestation  of  alterations  of  the  blood,  at  another  as  a  simple  inflamma- 
tion of  the  skin,  again  as  a  member  of  the  family  of  exanthematous  dis- 
eases, it  has  finally  come  to  be  regarded  by  the  best  investigators  as  the 
result  of  the  invasion  of  the  body  by  a  specific  germ. 

Etiology. — We  find  erysipelas  occurring  with  greater  or  less  frequency 
at  all  places,  at  all  seasons,  and  under  most  varying  external  conditions ; 
sometimes  showing  itself  only  here  and  there  as  sporadic  erysipelas,  at  other 
times  the  cases  becoming  so  numerous  as  to  merit  the  name  of  epidemic. 
It  may  follow  injuries  or  operations,  as  surgical  or  traumatic  erysipelas, 
which  form  we  shall  not  consider  in  this  treatise  except  in  so  far  as  the 
lessons  taught  by  it  may  lead  to  a  better  understanding  of  the  disease  in 
general.  On  the  other  liand,  erysipelas  may  arise  Avithout  any  traumatism, 
as  the  medical  or  idiopathic  form.  This  distinction  between  the  traumatic 
and  the  idiopathic  er}'sipelas  has  been  found  to  be  more  apparent  than  real ; 
for  investigation  has  shown  in  the  latter  cases  that  a  primary  lesion — a 
point  of  entrance  of  the  poison — can  be  found  in  almost  every  instance  in 
which  the  examination  is  made  with  sufficient  care.     The  erysipelas  may 

771 


772  ERYSIPELAS. 

arise  from  a  slight  abrasion  of  the  skin,  an  intertrigo,  a  small  pustule,  an 
eczema,  an  ulceration,  a  leech-bite,  or  some  such  trivial  lesion  that  under 
ordinary  circumstances  might  escape  attention. 

The  causes  that  produce  erysipelas  are  the  direct  and  the  predisposing. 
It  has  long  been  maintained  that  erysipelas  is  a  specific  disease  produced  by 
a  specific  germ ;  but  until  lately  that  germ  had  not  been  isolated  and  its 
causal  relation  to  the  disease  under  consideration  established.  The  investi- 
gations which  led  to  this  conclusive  proof  were  instituted  by  Fehleisen,  who 
discovered  micrococci  0.0004  mm.  in  length  occurring  in  chains  of  from 
six  to  twelve  in  the  erysipelatous  tissue, — micrococci  which  he  isolated  and 
cultivated.  With  the  culture-fluids  he  made  inoculations  and  produced  the 
characteristic  signs.  There  has  been  much  discussion  upon  the  subject 
of  micro-organisms  and  the  role  they  play  in  the  etiology  of  disease,  and 
much  has  been  assumed  by  the  bacteriologists  that  has  not  been  proved. 
On  the  other  hand,  however,  the  antagonists  of  the  germ-theory  have  dis- 
played a  scepticism  which  contrasts  strongly  with  the  credulity  with  which 
recommendations  of  therapeutic  measures  are  received  and  which  in  many 
instances  passes  far  beyond  the  limits  of  the  allowable.  It  certainly  be- 
hooves us  to  deal  cautiously  with  so  vital  a  question ;  but  in  the  individual 
disease  a  germ  must  be  accepted  to  be  the  etiological  factor  when  it  is  inva- 
riably found  in  every  case  and  when  inoculations  of  the  well-isolated  culture 
are  followed  by  the  characteristic  signs  of  the  disease  in  question.  Such 
conclusive  evidence  of  the  micrococcus  of  Fehleisen  being  the  cause  of 
erysipelas  has  been  brought  forth.  We  have  even  been  able  successfully  to 
inoculate  human  beings  with  such  cultures  for  the  purpose  of  curing  other 
diseases.  It  had  frequently  been  observed  that  various  tumors,  nsevi,  etc., 
upon  becoming  the  seat  of  erysipelas  disappeared.  Thus,  Busch  related  in 
1866  that  he  saw  multiple  sarcomata  disappear  after  erysipelas  following; 
extirpation  of  one  of  them.  In  a  case  of  sarcoma  of  a  lymphatic  gland  of 
the  neck  which  extended  from  the  clavicle  to  the  parotid,  erysipelas  super- 
vened upon  an  injection  of  morphine,  and  the  gland  diminished  to  one-half 
its  previous  size,  at  the  same  time  becoming  soft.  The  patient  died  of 
collapse,  and  at  the  post-mortem  examination  Rindfleisch  found  that  the 
tumor  had  become  changed  to  an  emulsified  fluid  filling  a  reticulum. 

These  therapeutical  experiments  were  repeated  by  Fehleisen  upon  a 
larger  scale.  He  successfully  inoculated  six  individuals  affected  with  sar- 
coma, carcinoma,  and  lupus  with  cultures  of  the  fourth,  ninth,  fourteenth, 
fifteenth,  sixteenth,  and  seventeenth  generations,  producing  erysipelas.  The 
shortest  period  of  incubation  was  fifteen  hours,  the  longest  sixty-one 
hours. 

Janicke  inoculated  a  case  of  cancer  of  the  breast  with  Fehleisen's  cocci. 
In  seven  or  eight  hours  a  chill  occurred,  with  a  temperature  of  104.5°  F. 
Twelve  hours  later  erysipelas  set  in,  extending  over  the  entire  body,  pro- 
ducing death  on  the  fourth  day.  At  the  post-mortem  examination  the 
cancer  was  found  to  be  softened  and  infiltrated  with  the  cocci. 


ERYSIPELAS.  773 

Whatever  may  be  the  therapeutic  value  of  these  experiments,  they  cer- 
tainly prove  that  erysipelas  is  caused  by  the  micrococcus. 

Sex. — It  is  frequently  stated  that  females  are  more  disposed  to  erysipelas 
than  males.     This  statement  is,  however,  erroneous. 

Age. — It  is  more  frequent  in  the  first  year,  and  after  that  age  occurs  as 
often  in  adults  as  in  children. 

Season. — Erysipelas  is  supposed  to  occur  more  frequently  during  the 
cold  than  during  the  warmer  months.  This  is  not  invariably  the  case,  as 
one  of  the  severest  epidemics,  that  of  Paris  in  1861,  took  place  during  the 
summer.  Hirsch  found  erysipelas  most  frequent  during  sudden  changes  of 
the  weather. 

Contagion. — There  cannot  be  the  slightest  doubt  that  under  certain 
circumstances  erysipelas  is  directly  contagious  from  person  to  person.  It 
does  not  act  at  a  distance,  as  do  other  infectious  diseases,  for  a  number  of 
cases  are  not  affected  at  once.  This  contagion  is  not  always  evident,  but  in 
many  instances  it  has  been  firmly  established.  In  all  the  works  upon  the 
subject, conclusive  cases  have  been  cited  in  great  numbers.  One  of  the  most 
classic  instances  is  that  communicated  by  Dr.  Blin  to  the  Paris  Academy 
in  April,  1864.  Dr.  Paintevin,  assistant  of  Voillemier  in  the  Lariboisiere, 
contracted  erysipelas  from  two  cases  under  his  charge  in  the  ward.  Dr. 
Testart,  from  Guise,  a  place  in  which  up  to  the  time  there  had  been  no 
erysipelas,  visited  him  during  the  acme  of  the  attack.  Dr.  Testart  returned 
to  Guise,  and  three  days  after  leaving  Paris  became  affected  with  erysipelas. 
Dr.  Testart  infected  a  servant  who  waited  upon  him,  and  a  relative  who 
visited  him  from  a  distance  of  about  twenty-four  miles  and  who  manifested 
the  disease  two  days  later.  The  wife  of  the  latter  patient  then  became  in- 
fected, and  also  three  members  of  a  family  named  Lefranc  who  had  called 
upon  the  invalids.  A  relative  of  Lefranc,  aged  seventy,  living  in  a  neigh- 
boring village,  became  infected  after  a  visit,  and  likewise  two  Sisters  of 
Mercy  who  waited  upon  the  Lefrancs.  Upon  returning  to  their  convent 
they  infected  others.  The  physician  who  attended  them  died  of  erysipelas, 
and  his  daughter  became  infected  eight  days  after  his  return  home,  the  in- 
fection in  the  latter  case  having  its  orig-in  in  leech-bites  that  had  been  made 
over  enlarged  submaxillary  glands. 

Epidemics  of  erysipelas  have  been  recorded  in  various  hospitals,  and 
have  been  most  frequent  in  the  obstetric  wards  in  which  puerperal  fever 
existed.  These  epidemics  differ  from  those  of  the  exanthemata  which  spread 
ov^er  a  large  area,  inasmuch  as  tliey  are  limited  to  one  hospital  or,  it  may  be, 
to  one  bed.  The  rise  and  disappearance  of  tliese  hospital  o])idemics  are 
somewhat  mysterious.  They  are  most  frequently  observed  in  crowded, 
filthy,  and  ill-ventilated  wards,  l)ut  have  also  occurred  wlierc  the  hygienic 
conditions  were  the  most  favorable  imaginable.  On  the  other  hand,  the 
most  unfavorable  states  have  not  always  been  productive  of  erysipelas,  as, 
for  example,  during  tlio  Ch'imcan  War,  in  which  the  sanitary  measures  were 
almost  entirely  neglected,  hardly  any  cases  of  the  disease  were  observed. 


774  EEYSIPELAS. 

In  some  instances  a  direct  relation  to  sewer-gas  poisoning  could  be 
traced,  as  in  the  notorious  case  of  the  Middlesex  Hospital.  Here  during 
a  long  period  a  number  of  cases  of  erysipelas  occurred  in  two  beds,  whereas 
no  other  cases  were  observed  in  the  ward.  No  reason  for  this  peculiarity 
was  discovered  until  a  defective  drain-pipe  from  a  privy  was  found  to  run 
behind  the  plaster  between  these  beds.  The  defect  was  remedied,  and  no 
more  cases  occurred  until  ten  years  later,  when  the  same  faulty  condition  of 
the  drainage  again  led  to  erysipelas  in  the  same  beds,  and  again  ceased  upon 
repair  of  the  pipes. 

Vaccination  is  a  frequent  etiological  factor.  Thus,  Dr.  Doepp,  of  St. 
Petersburg,  vaccinated  nine  children  from  one  who  developed  erysipelas  on 
the  following  day.  All  of  the  nine  individuals  became  affected  with  erysip- 
elas. In  1850  vaccination  in  and  around  Boston  was  so  frequently  followed 
by  erysipelas  that  the  vaccination  was  discontinued.  A  cachectic  condition 
of  the  individual  seems  to  predispose  to  the  disease. 

Erysipelas  not  infrequently  returns  in  the  same  patient  every  year  or 
oftener.  This  is  especially  the  case  when  the  face  is  the  seat  of  the  disease. 
In  such  instances  chronic  rhinitis,  eczema,  or  some  other  form  of  chronic 
inflammation  exists,  from  which  the  infection  occurs. 

Symptoms. — Erysipelas  in  children  over  six  months  of  age  very  much 
resembles  that  of  adults,  differing  from  it  only  in  slight  respects.  That  of 
the  new-born,  however,  is  quite  distinct.  We  shall  first  describe  the  form 
occurring  in  older  children,  and  then  consider  the  affection  of  the  new-born. 

Erysipelas  may  be  introduced  by  a  prodromal  stage,  which  is,  however, 
often  absent.  When  present  the  prodromes  are  not  characteristic,  being 
those  common  to  many  other  diseases.  We  find  the  child  drowsy  or  rest- 
less. There  is  a  general  feeling  of  malaise  and  aching  of  the  limbs.  There 
may  be  more  or  less  fever,  and  in  some  instances  oppressed  breathing  may 
exist  for  a  few  days  previous  to  the  manifest  signs  of  the  disease. 

The  disease  proper  frequently  begins  with  a  chill,  which  may  be  more 
or  less  severe,  and  which  in  younger  children  is  often  replaced  by  convul- 
sions and  vomiting.  Following  these  there  is  a  rise  of  temperature,  which 
may  reach  as  high  as  105°  F.  Usually  the  local  manifestations  begin  to 
develop  immediately ;  there  is  a  feeling  of  warmth,  tension,  and  pain  in  the 
affected  part,  which  becomes  mottled  pink  and  somewhat  oedematous.  The 
patches  gradually  become  more  intensely  red,  and  coalesce  to  form  a  single 
fiery  patch,  whose  color  disappears  upon  pressure,  to  reappear  when  the 
pressure  is  removed.  At  the  same  time  the  swelling  of  the  affected  skin 
increases,  especially  if  the  part  be  one  in  which  the  subcutaneous  tissue  is 
loose.  The  edge  of  the  patch  is  elevated  on  one  side  and  terminates  sharply 
towards  the  healthy  skin.  From  this  elevated  edge  the  erysipelatous  infil- 
tration rapidly  extends  to  the  neighboring  skin.  The  extension  usually 
first  begins  by  the  formation  of  small  branches  followed  by  the  line  of  infil- 
tration ;  as  the  disease  progresses,  the  parts  behind  gradually  become  paler, 
and  within  two  or  three  days  have  all  the  appearances  of  healthy  skin.    The 


ERYSIPELAS.  .775 

extension  may  be  more  or  less  rapid  and  may  involve  a  smaller  or  a  larger 
territory.  The  fever  during  the  progress  of  the  disease  remains  high,  and 
is  accompanied  by  more  or  less  severe  constitutional  symptoms.  The  appe- 
tite is  lost.  Nausea,  vomiting,  intense  headache,  and  thirst  are  present. 
The  tongue  is  covered  with  a  thick,  dry  coat.  The  urine  is  passed  in  small 
quantities,  and  not  infrequently  contains  albumen.  Sleep  is  much  disturbed, 
or  may  even  be  entirely  absent.  In  some  cases  delirium  or  a  soporous  con- 
dition may  be  present.  The  mucous  membranes  adjoining  the  skin  are 
oftentimes  likewise  involved  in  the  process.  In  the  cases  terminating  in 
recovery  the  progress  of  the  skin-aifection  ceases,  the  redness  gradually 
pales,  the  swelling  subsides,  and  the  fever  disappears.  Where  death  ensues, 
it  usually  occurs  with  a  high  temperature. 

Seat  of  Commencement — Erysipelas  begins  most  frequently  in  the  face. 
Some  local  affection  of  the  skin  determines  its  point  of  origin.  This  is 
most  frequently  situated  where  the  skin  passes  into  the  mucous  membrane 
at  the  nose,  mouth,  eyelid,  or  ear.  It  may  arise  at  the  genitals  or  the 
rectum,  and  not  infrequently  proceeds  from  intertrigo,  eczema,  a  pustule  or 
acne  eruption,  or  some  other  affection  of  the  skin  which  occasions  a  solution 
of  continuity.  Erysipelas  may  arise  in  the  mucous  membrane,  as,  for 
example,  in  the  pharynx,  and  may  then  extend  outwards  to  the  skin  and 
from  there  run  its  usual  course.  In  fact,  many  of  the  cases  of  facial  ery- 
sipelas in  which  no  point  of  origin  can  be  found,  and  which  were  formerly 
thought  to  be  idiopathic,  proceed  from  the  interior  of  the  nose.  These 
internal  forms  may  pass  outward  upon  one  or  more  of  the  following  routes : 
1,  to  the  lip;  2,  through  the  choanse  and  nostrils;  3,  through  the  nasal 
cavity  and  lachrymal  ducts ;  4,  through  the  Eustachian  tube,  passing 
through  the  middle  ear  to  the  external  ear :  the  tympanum  offers  no  ob- 
struction. Many  of  the  cases  of  erysipelas  which  appear  at  the  root  of 
the  nose  pass  through  the  lachrymal  duct  from  the  interior  of  the  nose. 
Under  such  circumstances  the  lachrymal  sac  appears  distended,  as  when 
obstruction  of  the  passage  occurs.  This  sign  may  precede  the  external  ery- 
sipelas by  some  days,  and  through  it  we  may  prognosticate  the  approaching 
affection.  Erysipelas  occurs  with  greatest  frequency  on  the  head,  next  on 
the  trunk,  and  least  often  on  the  extremities. 

Integument. — Upon  the  surface  of  the  skin  erysipelas  usually  begins  as 
a  mottled  pink  patch,  which  rapidly  becomes  darker  and  confluent.  From 
this  initial  focus  the  redness  rapidly  extends,  running  in  the  direction  of 
those  lines  of  least  tension  of  the  tissue  to  which  attention  has  been  called 
by  Langer.  At  parts  where  the  subcutaneous  tissue  is  firm  and  adherent 
the  progress  of  the  erysipelas  is  arrested,  as,  for  example,  at  the  base  of  the 
skull,  over  Poupart's  ligament,  etc.  The  surface  of  the  skin  may  be  smooth 
and  glistening,  but  is  often  covered  witli  vesicles  that  vary  in  size  from  the 
very  smallest,  which  require  a  lens  to  observe  them,  to  large  bullae.  The 
skin  often  feels  rough  like  shagreen  leather.  The  blebs  are  sometimes  tinged 
with  blood,  and  gradually  become  turbid  from  admixture  of  pus  and  epi- 


776  ERYSIPELAS. 

thelial  cells  with  the  serum.  There  is  always  more  or  less  swelling  present, 
depending  in  degree  upon  the  severity  of  the  affection  and  the  looseness 
of  the  areolar  tissue.  In  certain  parts,  as  the  face  and  the  genitals,  the 
intumescence  may  reach  enormous  dimensions.  On  the  third  to  the  fifth 
day  the  redness  and  swelling  in  the  part  affected  gradually  fade ;  vesicles 
that  are  present  are  either  absorbed,  or  burst,  or  dry  to  yellowish  crusts. 
In  the  subsequent  desquamation  the  cuticle  either  is  shed  in  a  fine  scurf  or 
peels  off  in  layers.  The  skin  rapidly  returns  to  its  normal  appearance.  At 
times  in  parts  abscesses  develop,  or  gangrene  may  ensue.  The  latter  lesion 
is  preceded  by  the  development  of  bloody  blebs.  It  has  been  stated  that 
the  gangrenous  process  may  be  prevented  by  the  early  pricking  of  these 
sanguineous  vesicles. 

Mucous  Membranes. — The  membranes  most  frequently  the  seat  of  ery- 
sipelas are  those  of  the  respiratory  tract.  The  erysipelas  may  be  pri- 
mary, or  may  extend  from  the  skin.  In  either  case  we  find  the  surface 
intensely  red,  and  glistening  as  if  varnished.  There  is  but  little  swelling. 
According  to  Todd,  the  muscles  of  the  pharynx  do  not  react  to  irritation,, 
so  that  when  the  patient  swallows  solids  do  not  pass  into  the  oesophagus, 
but  remain  in  the  larynx.  The  paralysis  is  both  motor  and  sensory.  The 
process  may  extend  to  the  glottis  and  produce  death  by  suffocation  through 
oedema  glottidis,  or  may  pass  onward  to  the  lungs,  giving  rise  to  a  peculiar 
form  of  pneumonia.  We  find  slight  dulness,  with  subcrepitant  rather  than 
crepitant  rales,  changing  their  seat  from  day  to  day,  differing  from  the  ordi- 
nary form  of  pneumonia  in  the  rapid  extension  of  the  lesion  from  one  part 
to  the  other.  In  such  cases  both  Strauss  and  Denuce  found  no  fibrinous 
exudation  in  the  alveoli,  but  instead  leucocytes  and  granular  cells.  The 
lymph-glands  supplied  by  the  affected  region  rapidly  swell,  and  are  very 
painful.  In  erysipelas  of  the  face  swelling  of  the  submaxillary  glands  may 
precede  the  external  appearance  upon  the  skin  by  several  days.  In  such 
cases  we  have  some  hidden  origin  of  erysipelas,  as  in  the  nose. 

Digestive  Tract — We  find  a  thick,  dry  coat  upon  the  tongue,  which 
niay  even  be  crusty.  The  ordinary  symptoms  accompanying  fever  are 
present. 

Kidneys. — The  urine  is  similar  to  that  of  other  febrile  affections.  It  is 
claimed  by  some  that  albumen  is  usually  present.  According  to  Blechmaun, 
albuminuria  reaches  its  greatest  height  from  the  second  to  the  sixth  day,  and 
may  last  from  nine  to  twenty-two  days,  or  may  be  chronic.  Da  Costa  finds 
it  In  every  severe  case  of  erysipelas,  and  often  transitorily  even  in  slight 
cases.  The  quantity  of  albumen,  according  to  this  author,  is  usually  small. 
He  not  unfrequently  finds  red  and  white  blood-cells,  but  rarely  blood-casts. 
The  albuminuria  may  be  due  to  parenchymatous  changes  of  the  kidney, 
such  as  accompany  all  high  fevers,  or  to  specific  nephritis. 

Cerebral  Symptoms. — Tlicse  may  be  the  ordinary  febrile  disturbances 
of  the  brain,  headache,  hebetude,  etc.,  or  we  may  liave  wild  delirium  or  a 
comatose  condition.     The  cerebral  sis-ns  are  more  intense  in  affection  of  the 


ERYSIPELAS.  777 

scalp,  and  were  formerly  incorrectly  ascribed  to  meningitis.  Trousseau  and 
others  following  him  have  found  nothing  pathological  within  the  cranial 
cavity.  The  disturbances  are  to  be  ascribed  in  part  to  the  fever,  in  part  to 
a  specific  alteration  of  the  blood,  and  in  part  to  impeded  return  of  venous 
blood  from  the  brain  through  the  pressure  of  the  oedematous  scalp. 

Fever  is  usually  introduced  by  a  chill,  or  at  least  by  a  sensation  of  chilli- 
ness. The  temperature  rapidly  rises  to  a  high  degree,  and  falls  somewhat 
with  the  appearance  of  the  eruption.  Following  this  is  a  further  rise,  the 
temperature  remaining  high  during  the  progress  of  the  erysipelas.  Fall 
usually  occurs  by  crisis  in  from  twenty-four  to  forty-eight  hours,  but  may  be 
more  gradual, — by  lysis,  as  it  is  termed.  The  critical  fall  may  be  preceded 
by  a  precritical  rise. 

The  pulse  goes  hand  in  hand  with  the  temperature,  except  in  very  feeble 
individuals,  in  whom  it  is  proportionately  more  rapid. 

Erysipelas  in  the  new-born  presents  a  very  different  picture  from  that 
witnessed  in  older  children.  We  do  not  usually  find  the  same  violent  onset. 
It  arises  insidiously,  and  the  fatal  disease  has  generally  developed  before 
the  attendants  are  aware  of  the  fact. 

In  the  new-born,  erysipelas  usually  begins  about  the  navel  or  in  the 
region  of  the  genitals.  On  the  first  day  all  that  is  seen  is  a  slight  blush  of 
the  affected  parts.  The  infant  suckles  well,  and  may  have  no  fever.  If 
it  be  robust,  this  condition  may  continue  for  as  long  as  three  or  four  days. 
Soon,  however,  a  change  in  the  scene  occurs.  High  fever  develops ;  the 
child  no  longer  takes  the  breast  willingly  ;  it  nurses  irregularly,  and  vomits 
that  which  it  had  taken.  It  becomes  agitated,  restless,  sleepless,  cries  con- 
tinuously. The  pulse  is  irregular,  small,  and  frequent.  Diarrhoea  with 
stools  that  are  yellow  occurs  in  the  beginning,  but  later  the  dejecta  become 
green  and  liquid.  At  the  same  time  the  affected  skin  becomes  enormously 
distended  and  glistening.  The  tension  of  the  part  is  so  great  that  it  is  dif- 
ficult to  make  an  impression,  and  this  when  made  rapidly  disappears.  The 
appearance  has  been  well  compared  to  that  of  a  urinary  infiltration.  Phleg- 
monous inflammation  with  the  development  of  subcutaneous  abscesses  is 
very  frequent.  In  many  cases  gangrene  of  the  affected  parts  occurs.  Death 
almost  invariably  results.  The  child  either  becomes  more  and  more  soporous 
and  finally  passes  away  in  a  condition  of  coma,  or  death  may  be  ushered  in 
by  convulsions.  The  course  of  erysipelas  in  the  new-born  is  more  erratic 
than  in  adults,  but  the  progress  of  the  disease  is  not  attended  with  the 
same  exacerbations  of  fever.  The  fever  does  not  usually  reach  the  height 
which  it  attains  in  older  children.  The  disease  generally  lasts  from  five 
to  fifteen  days ;  but  the  progress  of  convalescence  is  often  retarded  by 
abscesses  or  gangrene.  Death  may  be  hastened  by  complications,  which 
readily  ensue,  especially  peritonitis,  which  is  apt  to  be  produced  by  exten- 
sion of  the  inflammatory  process  through  the  umbilical  vein.  Meningitis, 
pleuritis,  and  pulmonary  complications  are  by  no  means  rare. 

Course. — Erysipelas  is  an  acute  disease,  and  runs  its  course,  as  a  rule. 


778  EEYSIPELAS. 

in  from  ten  to  fourteen  days.  The  duration  is  longest  where  the  trunk  is 
involved,  and  shortest  where  it  is  localized  in  the  lower  extremity.  Re- 
lapses of  erysipelas  are  comparatively  frequent.  The  second  attack  usually 
has  the  same  seat  and  runs  the  same  course  as  the  first,  but  is  apt  to  be 
lighter.  Certain  individuals  are  predisposed  to  the  disease,  and  are  the 
victims  of  an  habitual  erysipelas  which  occurs  yearly  or  even  more  fre- 
quently. Such  habitual  erysipelas  is  usually  facial,  and  has  its  origin  in 
persistent  affections  of  the  mucous  membranes  of  the  head.  It  is,  therefore, 
more  frequent  in  scrofulous  subjects. 

Complications  and  Sequelae. — In  cases  of  long  duration,  especially 
such  as  are  attended  with  enfeeblement  of  the  patient,  hypostatic  pneumonia 
is  very  apt  to  ensue.     Croupous  pneumonia  likewise  occurs. 

Pleuritis  is  a  very  frequent  complication.  It  is  maintained  by  some 
observers  that  it  is  due  to  a  direct  continuation  of  erysipelas  of  the  skin 
which  covers  the  thorax ;  but  it  has  also  been  found  in  some  cases  in  which 
the  chest  is  not  otherwise  involved,  as,  for  example,  in  erysipelas  of  the  face. 

Peritonitis  is  a  complication  which  occurs  with  moderate  frequency.  It 
is  especially  apt  to  occur  in  the  erysipelas  of  the  new-born,  in  whom  puru- 
lent inflammation  of  the  umbilical  vein  is  the  connecting  link  between  the 
external  and  the  internal  affection. 

Affection  of  the  endocardium  has  lately  been  frequently  assumed  by 
French  authors  as  a  concomitant  of  erysipelas.  It  is  certainly  not  so  fre- 
quent as  they  suppose,  the  murmurs  leading  to  the  diagnosis  probably  being 
more  frequently  due  to  ansemia  than  to  affection  of  the  valves. 

Pyaemia  is  most  apt  to  occur  in  traumatic  cases  and  in  such  as  are 
accompanied  by  gangrene. 

Various  affections  of  the  eyes  have  been  observed  in  erysipelas,  from 
simple  conjunctivitis  to  perforation  by  corneal  ulcers.  Amaurosis  has  been 
produced  by  retrobulbar  abscess. 

Pathological  Anatomy. — The  histological  changes  that  occur  in  the 
skin  in  erysipelas  are  similar  to  those  observed  in  a  burn  or  those  occasioned 
by  an  application  of  iodine.  There  is  excessive  congestion  of  the  blood- 
vessels where  the  erysipelatous  process  is  at  its  height,  together  with  transu- 
dation of  a  large  quantity  of  plasma,  so  that  the  affected  tissue  is  more  or 
less  cedematous.  At  the  same  time  we  find  numerous  leucocytes  surround- 
ing these  blood-vessels  like  a  sheath.  This  infiltration  of  small  cells  is  most 
evident  in  the  deeper  layers  of  the  corium  and  in  the  subcutaneous  cellular 
tissue  enveloping  the  fat-cells.  The  tissue-elements  themselves  are  not 
affected  :  there  is  no  increase  in  the  connective-tissue  cells.  The  epidermis 
is  loosened  from  its  connection  with  the  corium,  so  that  the  dried  cuticle 
can  be  readily  removed,  leaving  the  swollen  papillae  exposed. 

In  the  skin  immediately  in  advance  of  the  red  margin,  and  extending 
for  a  distance  of  about  one  centimetre  corresponding  to  the  line  of  advance, 
Fchleisen  found  tlie  tissue  infiltrated  with  the  specific  micrococcus.  These 
little  bodies,  0.0004  mm.  in  size,  are  of  high  refraction  and  occur  in  chains 


ERYSIPELAS.  779 

of  from  six  to  twelve.  They  fill  the  lymph-j)assages  of  the  corium, 
especially  in  its  superficial  layers,  and  are  but  few  in  number  in  the  sub- 
cutaneous tissue.  None  are  found  in  the  blood-vessels.  They  rapidly 
increase  in  numbers  by  fission. 

In  the  red  zone  Fehleisen  finds  signs  of  inflammatory  reaction.  Here, 
as  described  above,  a  large  number  of  wandering  white  blood-corpuscles 
are  found  among  the  micrococci,  repelling  them  and  in  part  enclosing  them. 

In  the  part  immediately  behind  the  red  zone  only  the  leucocytes  are 
found,  but  no  micrococci. 

When  the  erysipelatous  redness  begins  to  fade,  the  leucocytes  rapidly 
degenerate,  changing  to  a  finely  granular  mass,  so  that  in  a  few  hours  all 
that  remains  is  a  fine  detritus.  Within  a  day  or  two  this  also  disappears, 
and  the  skin  resumes  its  normal  condition.  This  rapid  restitutio  ad  integrum 
is  characteristic  of  erysipelas,  and  is  due  to  the  fact  that  the  tissue-elements 
are  not  themselves  the  seat  of  any  lesion.  In  some  cases,  however,  they  do 
not  entirely  escape.  The  white  blood-corpuscles  wander  out  in  such  num- 
bers that  the  nutrition  of  the  tissue-elements  suffers,  and  a  breaking  down 
occurs,  leading  to  the  formation  of  abscesses.  Such  minute  abscesses 
develop  most  frequently  at  the  apices  of  the  papillae. 

Respiratoi^y  Tract. — Inflammation  of  all  parts  of  the  respiratoiy  tract 
is  found  in  erysipelas,  from  congestion  of  the  mucous  membrane  of  the  nose 
to  an  erysipelatous  infiltration  of  the  tissue  of  the  lungs  differing  from 
croupous  pneumonia  by  the  absence  of  fibrinous  exudation  into  the  alveoli. 
Hypostatic  congestion  of  the  lungs  is  frequently  found  post  mortem ;  also, 
at  times,  pleuritis,  with  serous  or  even  purulent  fluid.  In  the  intestinal 
tract  inflammatory  changes  have  been  observed,  especially  in  the  duodenum^ 
in  which  small  ulcers  sometimes  occur.  These  are  similar  in  character  to 
those  occurring  in  extensive  burns  of  the  skin,  and  are  probably  similarly 
produced  by  reflex  hypereemia  of  the  mucous  membrane. 

The  spleen  is  usually  found  to  be  enlarged  and  soft.  The  kidneys,  the 
heart,  and  the  liver  have  been  described  by  Poufick  to  be  in  a  state  of 
parenchymatous  degeneration,  as  in  all  cases  of  continued  high  temperature. 
Nothing  characteristic  of  erysipelas  has  been  found  in  these  organs. 

Diagnosis. — Where  the  disease  has  developed  upon  the  skin,  as  a 
general  thing  the  diagnosis  presents  no  difficulty.  The  sharply-defined 
redness  with  intumescence  gradually  extending  forward,  with  rapid  retro- 
gression in  the  older  portions,  and  the  severe  constitutional  signs,  render  its 
recognition  easy.  Before  the  eruption  has  manifested  itself,  however,  the 
diagnosis  may  be  more  difficult.  Cliill,  fever,  and  depression  are  signs  of 
many  diseases;  but  the  painful  swelling  of  the  lympliatic  glands  of  the 
region  about  to  be  involved  offers  a  sign  of  some  value.  In  erysipelas  of 
the  face  the  glands  of  the  neck  are  swollen,  in  that  of  the  upjjer  ex- 
tremity, those  of  the  axilla ;  and  in  erysipelas  of  tlie  lower  extremity  the 
lymphatics  of  the  groin  will  be  found  tumefied  and  sensitive.  Swelling  of 
the  lachrymal  sac  is  an  important  diagnostic  aid  in  approaching  cases  of 


780  ERYSIPELAS. 

facial  erysipelas.  Primary  erysipelas  of  the  mucous  membrane  is  sometimes 
very  difficult  to  diagnosticate  before  it  has  jjrogressed  to  the  skin.  The  glis- 
tening, varnished-like  appearance  of  the  membrane  is  characteristic,  together 
with  the  painful  enlargement  of  the  glands  and  the  severe  constitutional 
affection.     These  are  especially  indicative  during  an  epidemic  of  erysipelas. 

Eczema  ruhrum  may  be  recognized  by  the  red  color,  with  oedema  and 
small  vesicles,  but  without  fever. 

In  simple  erythema  we  have  a  brighter  red  color  of  the  skin,  without 
tumefaction  or  sensibility  on  pressure,  and  Avithout  fever. 

In  urticaria  we  have  a  whealy  eruption,  with  simultaneous  affection  of 
various  parts  of  the  body.  There  is  likewise  manifest  absence  of  general 
symptoms. 

With  the  new-born  the  commencement  of  sclerema  is  sometimes  taken 
for  erysipelas.  In  the  latter  the  induration  is  confined  to  the  skin  and 
the  subcutaneous  tissue,  whereas  in  sclerema  it  occupies  the  entire  thick- 
ness of  the  member,  involving  the  muscles  likewise.  The  tumefaction  is 
firm  and  hard,  without  redness,  and  with  a  depression  rather  than  a  rise  of 
temperature. 

In  superficial  lymphangitis  the  redness  is  streaked  and  follows  the 
lymphatics,  which  may  be  felt  as  hard  cords,  or  disseminated  nodules  may 
be  found  along  the  course  of  the  lymphatics. 

In  phlegmonous  inflammation,  or  pseudo-erysipelas,  the  swelling  of  the 
skin  is  more  board-like,  and  usually  terminates  in  abscesses.  The  redness 
of  the  skin  is  darker  than  in  erysipelas,  and  is  not  so  sharply  defined. 

Prognosis. — Erysipelas  occurring  in  older  children,  as  a  rule,  runs  a 
favorable  course.  While  this  is  true  in  ordinary  cases,  there  are  certain  epi- 
demics of  erysipelas  in  which  the  prognosis  is  far  more  unfavorable.  Age  is 
a  very  important  prognostic  element.  Erysipelas  of  the  new-born  is  a  most 
malignant  disease.  All  observers  unite  in  the  statement  that  almost  every 
child  under  three  weeks  that  becomes  affected  with  erysipelas  dies.  This 
excessive  mortality  is  thought  to  be  due  not  so  much  to  any  specific  character 
of  the  disease  as  to  the  feebleness  and  vulnerability  of  the  infantile  organ- 
ism, although  it  has  been  maintained  by  Trousseau,  among  others,  that  the 
erysipelas  of  the  new-born  is  not  ordinary  erysipelas,  but  a  puerperal  form. 

With  increasing  age  of  the  child  the  prognosis  becomes  more  favorable. 
After  the  second  year  a  child  is  in  but  little  more  danger  than  an  adult. 
The  feebler  the  organism,  other  things  being  equal,  the  greater  the  danger. 

High  temperature  of  itself  is  not  a  specially  unfavorable  sign,  unless  it 
be  of  long  duration. 

Ambulatory  erysipelas  is  dangerous  on  account  of  its  lengthened  course 
and  the  consequent  effects  upon  the  patient.  Severe  delirium  is  likewise  an 
unfavorable  symptom. 

Affection  of  the  mucous  membranes  increases  the  danger,  as  was  known 
as  far  back  as  the  time  of  Hippocrates,  a\'1io  stated  that  it  was  an  unfavor- 
able sign  when  erysipelas  extended  inward. 


ERYSIPELAS.  781 

Comjilications,  of  whatever  kinds,  render  the  prognosis  of  erysipelas 
more  unfavorable. 

Treatment. — Prophylaxis.  For  the  prevention  of  the  spread  of  erysip- 
elas, isolation  of  cases  is  absolutely  necessary,  as  the  contagious  character 
of  the  disease  has  been  established  beyond  a  possibility  of  doubt.  The 
experience  of  all  hospitals  in  which  erysipelas  has  been  prevalent  proves 
the  necessity  of  strict  quarantine  of  affected  cases.  In  some  institutions 
through  this  measure  the  disease  has  become  practically  eradicated.  In  the 
new-born,  scrupulous  cleanliness,  with  antiseptic  treatment  of  the  umbilical 
cord,  especially  where  the  mother  is  the  victim  of  puerperal  disease,  may  in 
many  cases  save  the  life  of  the  infant.  In  the  treatment  of  erysipelas  the 
remedies  that  have  been  advised  are  innumerable.  Each  observer  has 
seemed  to  be  justified  in  extolling  his  favorite  drug  or  remedial  procedure 
by  the  favorable  results  obtained,  forgetting  that  the  natural  uninfluenced 
course  of  the  disease  is  towards  recovery. 

It  will  be  readily  understood  that  at  different  periods  of  the  history  of 
medicine  the  treatment  of  erysipelas  has  been  influenced  by  the  prevailing 
medical  theories.  The  earliest  treatment — that  of  Hippocrates — consisted 
merely  in  the  continuous  application  of  cold  water.  Afterwards  venesection 
was  applied,  as  in  almost  all  other  diseases.  A  reaction,  however,  set  in 
later  against  blood-letting  in  erysipelas,  and  the  method  was  abandoned. 

During  the  time  when  erysipelas  was  looked  upon  as  caused  by  a  bilious 
condition,  emetics,  cathartics,  and  cholagogues  were  the  prevalent  remedial 
agents.  And  indeed  it  would  be  a  lengthy  task  to  enumerate  all  the  various 
remedies  that  have  been  used  in  erysipelas.  Every  possible  method  of  in- 
ternal medication  has  been  resorted  to, — depurative,  depleting,  stimulating, 
sedative,  tonic,  and  specific.  Every  possible  external  application  has  been 
utilized,  from  oil  to  caustics. 

The  local  treatment  has  undergone  various  changes.  At  one  time  it 
was  feared  that  the  disease  might  be  driven  in  by  too  energetic  treatment, 
and  simple  applications  only  were  employed,  such  as  non-irritant  powders 
and  enveloping  the  part  in  cotton. 

The  external  remedies  that  have  been  and  are  still  used  more  or  less 
extensively  may  be  grouped  into  the  following  classes : 

1.  Such  as  protect  from  the  air  : 

a.  Powders. 
h.  Emollients. 

c.  White  of  egg. 

d.  Collodium. 

2.  Anodynes. 

3.  Antiphlogistics. 

4.  Astringents. 

5.  Stimulants. 

6.  Antiseptics. 

1.  Many  different  non-irritant  powders  have  been  utilized,  such  as  rice 


782  EEYSIPELAS. 

flour,  lycopodium,  potter's  clay,  oxide  of  zinc,  etc.  In  ancient  times  emol- 
lient poultices  derived  from  mucilaginous  plants  were  frequently  applied. 
Fats  of  various  kinds  have  likewise  been  used,  lard  being  employed  either 
alone  or  as  an  excipient  for  various  drugs.  Lately  Sir  Dyce  Duckworth  has 
highly  extolled  a  well-prepared  mixture  of  lard  and  chalk.  Glycerin  has 
been  looked  upon  with  favor  by  many  ;  and  Frere  praises  a  combination  of 
linseed  oil  and  white  lead  with  which  the  erysipelatous  skin  is  to  be  freely 
painted.  White  of  egg  is  employed  for  a  similar  purpose,  as  is  also  water- 
glass,  which  was  introduced  by  Piazza.  Collodium  is  used  for  the  pur- 
pose of  excluding  the  air,  and  at  the  same  time  exerting  a  pressure  by  its 
contraction  upon  the  erysipelatous  tissue.  It  has  long  been  looked  upon 
with  favor,  and  is  still  employed  by  many.  One  decided  objection  to  the 
collodium  is  that  it  is  hable  to  crack,  and  at  the  rough  edges  irritation  is 
apt  to  occur.  Lately  a  solution  of  iodoform  in  collodium  has  been  painted 
over  the  aifected  part. 

2.  Anodynes  have  been  used  externally.  The  various  narcotics  have 
either  been  added  to  the  poultices  or  applied  independently.  The  ethereal 
solution  of  camphor  and  tannin,  which  was  the  favorite  remedy  of  Trous- 
seau, may  be  classed  under  this  head.  Trousseau  recommends  it  especially 
in  the  case  of  the  new-born. 

3.  Of  antiphlogistics  the  only  one  that  has  been  retained  in  favor  is 
cold  water,  which  was  employed  by  Hippocrates.  Ice  bladders  or  cold 
compresses  are  placed  upon  the  affected  parts  to  allay  the  inflammatory 
process.  Griscom  advised  glycerin  for  the  purpose  of  withdrawing  water 
from  the  inflamed  tissues  and  thereby  depleting  them.  As  glycerin  does 
not  act  through  the  epidermis,  the  method  is  as  faulty  as  the  theory.  Dob- 
son,  Bright,  Hutchinson,  Lawrence,  and  others  scarified  the  erysipelatous 
skin  in  many  places  for  the  purpose  of  depletion,  and  Lisfranc  advised  the 
use  of  as  many  as  fifty  leeches  in  order  that  the  part  might  be  thoroughly 
depleted.     The  method  has  been  abandoned  as  useless. 

4.  As  in  other  inflammations,  so  in  erysipelas  the  employment  of  astrin- 
gents readily  suggested  itself;  but  clinical  observation  has  shown  the  results 
to  be  worthless.  The  astringents  which  have  most  frequently  been  used 
are  sugar  of  lead,  tannin,  sulphate  of  zinc,  alum,  sulphate  of  iron,  and 
vinegar,  either  alone  or  associated  with  anodynes  and  emollients. 

5.  Acting  upon  the  idea  that  by  setting  up  a  counter-irritation  either 
upon  or  near  the  erysipelatous  portion  a  cessation  of  the  peculiar  inflamma- 
tion might  be  brought  about,  various  stimulant  applications  have  been 
employed.  Blisters  have  been  applied  to  the  erysipelatous  skin ;  but  their 
use  has  simply  increased  the  distress  without  favorably  influencing  the  con- 
dition of  the  patient.  In  1829,  Higginbottom  advised  the  use  of  nitrate  of 
silver.  He  thoroughly  washed  the  part  with  a  solution  of  potash,  and  then 
painted  it  and  a  portion  of  the  healthy  skin  adjoining  with  a  strong  solution 
of  lunar  caustic,  one  to  ten.  This  method,  <:allcd  the  ectrotic,  has  been 
looked  upon  with  great  lavor,  and  ■  is  still  employed  by  many.     Another 


EEYSIPELAS.  783 

favorite  mode  of  using  the  nitrate  of  silver  was  to  paint  a  heavy  line  some 
distance  from  the  margin,  completely  encircling  the  erysipelatous  skin,  in 
the  hope  that  an  insurmountable  wall  would  thereby  be  erected  that  would 
stay  the  progress  of  the  disease.  However,  the  erysipelas  passed  over  the 
black  line  as  well  as  over  the  unpainted  skin.  For  a  similar  purpose  the 
hot  iron  was  used  by  Larrey,  and  with  the  same  negative  results.  It  was 
found  that  immediately  after  a  thorough  application  of  the  nitrate  of  silver 
the  temperature  fell,  but  only  for  a  short  time. 

In  like  manner  the  tincture  of  iodine  has  been  employed,  with  some 
good  results.  In  order  that  the  iodine  should  accomplish  its  best  results  it 
is  necessary  that  its  application  be  thorough.  The  parts  should  be  painted 
until  they  are  black-brown. 

6.  The  employment  of  antiseptics  is  most  in  accord  with  our  knowledge 
of  the  etiology  of  erysipelas.  However,  the  results  obtained  have  not  yet 
been  as  striking  as  might  have  been  expected.  The  reason  thereof,  proba- 
bly, lies  in  the  fact  that  the  epidermis  oifers  an  impervious  barrier  to  all 
non-volatile  substances  that  do  not  cause  a  loosening  of  the  cells,  and  that 
therefore  most  of  these  antiseptic  solutions  and  unguents  are  practically 
useless. 

Of  all  the  antiseptics  carbolic  acid  is  the  most  frequently  used,  being 
applied  either  in  solution  or  as  a  spray,  as  recommended  by  Verneuil,  or 
hypodermically,  as  advised  by  Hueter.  There  is  no  doubt  that  the  carbolic- 
acid  solution  is  readily  absorbed,  as  is  proved  by  the  olive-colored  urine 
which  is  frequently  secreted  within  a  few  hours  after  the  commencement  of 
the  applications.  The  results  obtained  in  many  cases  are  excellent,  although 
where  the  erysipelas  has  extended  over  large  areas  in  young  infants  the  pos- 
sibility of  carbolic-acid  poisoning  should  be  borne  in  mind.  Verneuil  uses 
a  spray  of  a  two-per-cent.  solution  of  carbolic  acid  directed  upon  the  ery- 
sipelatous skin  during  five  minutes  every  hour.  The  method  of  Hueter 
has  found  great  favor.  He  made  hypodermic  injections  of  three-per-cent. 
solutions  of  carbolic  acid,  and  found  that  injections  of  a  syringeful  thereof 
sufficed  for  an  area  two  inches  square,  one  injection  being  made  for  each 
such  portion  of  the  aifected  part  until  all  had  been  acted  upon.  He  made 
as  many  as  twelve  injections  at  one  time  without  producing  any  unfavorable 
symptoms.  The  carbolic-acid  treatment  is  certainly  rational,  and  has  the 
support  of  experiment,  for  both  Tillmann  and  Fehleisen  find  that  cultures 
of  the  micrococci  mixed  with  two  per  cent,  to  four  per  cent,  of  carbolic  acid 
fail  to  produce  the  disease.  Similarly  to  carbolic  acid,  corrosive  sublimate 
has  been  lately  employed,  the  solution  used  varying  from  one  part  in  two 
hundred  and  fifty  to  one  part  in  five  thousand. 

Formerly  turpentine  was  highly  esteemed  as  an  external  application. 
It  has  lately  been  recommended  by  Luecke,  Avho  finds  a  fall  of  tempera- 
ture and  a  diminution  of  burning  after  each  application  and  believes  that 
the  erysipelas  passes  off  more  rapidly.  Kaczorowski  advises  a  mixture 
of  carbolic  acid  one  part  with  turpentine  ten  parts.     After  this  application 


784  ERYSIPELAS. 

lead-water  compresses  are  used^  and  in  severe  cases  ice.  In  this  treatment 
the  skin  rapidly  becomes  intensely  red,  but  the  erysipelas  is  said  to  be 
aborted  in  from  twenty-four  to  forty-eight  hours.  Nussbaum  has  lately 
advised  the  external  application  of  one  part  of  ichthyol  with  ten  parts  of 
vaseline,  basing  his  favorable  report  upon  five  cases.  Lorenz  employs  a 
still  stronger  preparation, — viz.,  two  parts  of  ichthyol  with  one  part  each 
of  glycerin  and  ether.  Wilde  advises  hypodermic  injections  of  an  eight- 
per-cent.  solution  of  sulphocarbolate  of  soda.  Of  this  solution  one  or  two 
syringefuls  are  injected.  The  temperature  is  said  to  fall  immediately,  the 
borders  of  the  erysipelas  to  become  diffused,  and  the  process  to  disappear 
in  three  or  four  days.     It  is  not  followed  by  any  unpleasant  symptoms. 

Alcoholic  stimulants  are  of  great  service;  and  experience  has  taught 
us  not  to  be  sparing  in  their  use.  Of  all  internal  medication,  that  with 
the  tincture  of  iron,  introduced  by  Hamilton  Bell  in  1851,  has  been  re- 
ceived with  the  greatest  favor.  Those  who  are  loudest  in  its  praise  advise 
large  doses,  employing  with  adults  as  much  as  one  drachm  every  four  hours 
and  with  children  proportionately  less.  J.  Lewis  Smith  gives  four  drops 
every  three  hours  to  a  child  of  from  one  to  two  years.  According  to  Bal- 
four Campbell  and  others,  it  materially  shortens  the  disease  and  mitigates 
the  severity  of  the  symptoms.  Large  doses  of  quinine  have  been  used 
both  as  a  specific  and  for  the  purpose  of  reducing  the  fever.  For  a  similar 
purpose  salicylic  acid  and  its  preparations  have  been  used.  Lately  Haber- 
korn  advises  large  doses  of  benzoate  of  soda,  claiming  that  it  reduces  the 
temperature  to  the  normal  in  forty-eight  hours  and  that  the  redness  rapidly 
disappears. 

Bartholow  uses  small  doses  of  atropine  every  hour,  and  Mavrikos 
recommends  that  five  to  six  drops  of  tincture  of  aconite  be  given  to  infants 
in  twenty-four  hours.  PirogofP  administers  camphor  followed  by  hot  tea, 
and  claims  good  results. 

In  the  treatment  of  erysipelas  nourishment  is  of  the  utmost  importance, 
and  this  is  especially  the  case  with  feeble  children  and  small  infants.  The 
disease  belongs  to  the  asthenic  form,  and  requires  a  supporting  treatment. 
Large  quantities  of  milk,  with  or  without  alcohol,  should  be  insisted  upon, 
and  where  much  cannot  be  taken  at  a  time  frequent  administration  should 
be  resorted  to.  The  various  forms  of  peptonized  foods  are  to  be  highly 
recommended.  Where  the  nourishment  by  the  mouth  is  insufficient,  or 
where  it  is  impossible  on  account  of  obstinate  vomiting,  rectal  alimentation 
is  absolutely  necessary.  Strict  attention  should  be  paid  to  the  dietary,  as 
so  much  depends  upon  proper  and  systematic  nourishment  in  this  disease ; 
and  the  importance  of  hygiene  and  careful  nursing  cannot  be  overestimated. 


RHEUMATISM. 

By  W.  B.  CHEADLE,  M.D.,  F.E.C.P. 


Definition. — The  term  rheumatism  has  been  used  very  loosely  to  indi- 
cate almost  any  affection  accompanied  by  pain  and  tenderness  of  joints  and 
muscles,  and  to  include  morbid  conditions  of  widely  different  nature. 

This  is  no  doubt  a  partial  survival  from  the  Hippocratic  age,  when  every 
disorder  of  the  body  was  attributed  to  the  flow  of  a  subtle  morbid  essence 
or  virus  to  the  part  aifected.  Rheum  and  catarrh  both  have  origin  in 
the  same  word  picu,  and  its  stronger  form  y.a-appiuj.  Eventually  the  two 
terms  became  differentiated,  catarrh  becoming  restricted  to  affections  of  the 
mucous  membranes,  associated  with  actual  flux  therefrom,  and  rheum  being 
applied  to  painful  conditions  of  parts,  also  connected  in  the  minds  of  the 
pathologists  of  the  time  with  the  shifting  flow  of  acrid  humor.  Latterly 
there  has  been  further  narrowing  of  the  scope  of  the  term,  and  a  tendency 
to  restrict  its  use  to  the  acute  and  genuine  form  of  the  disease  in  its  dif- 
ferent degrees  of  severity. 

It  is  in  this  limited  sense  that  the  designation  will  be  used  here, — viz.,  as 
signifying  acute  rheumatism,  with  its  subacute  and  chronic  forms.  Rheu- 
matoid arthritis  will  be  considered  separately,  as  a  thing  apart,  differing  in 
essential  characters  from  the  genuine  disease. 

While,  however,  the  term  rheumatism  must  in  this  relation  be  taken 
strictly  as  indicating  a  special  pathological  state  of  which  what  is  known  as 
acute  rheumatism  or  rheumatic  fever  is,  in  the  case  of  adults  at  least,  the 
sharpest  and  most  distinctive  expression,  it  must,  on  the  other  hand,  be 
enlarged  so  as  to  include  much  more  than  inflammation  of  the  joints  and 
fibrous  tissues. 

A  study  of  the  disease  as  it  is  seen  in  children  forces  upon  us  a  far  Avider 
conception.  The  delicate  tissues  and  organization  of  a  child  exhibit  a  more 
extensive  area  of  disturbance  under  the  influence  of  the  rheumatic  state  than 
the  more  stable  structures  of  an  adult.  Some  phenomena,  unquestionably 
associated  in  childhood  with  the  rheumatic  state,  such  as  chorea  and  the 
development  of  tendinous  nodules,  for  example,  are  rare  or  altogether  want- 
ing in  later  life.  Moreover,  in  the  rheumatism  of  childhood  the  chief  and 
most  characteristic  symptom  of  the  disease  as  seen  in  adults — the  articular 

affection — is  often  extremely  slight,  sometimes  absent  altogether.    It  is  over- 
VoL.  I.— 50  785 


786  RHEUMATISM. 

shadowed  or  replaced  by  other  manifestations  set  up  by  the  same  morbid 
influence  which  gives  rise  to  the  inflammation  of  the  joints. 

We  are  so  accustomed  to  look  upon  rheumatism  in  the  one  aspect  in 
which  it  has  been  most  familiar  to  us,  that  it  is  diflicult  to  conceive  it  in  its 
larger  connection.  The  old  definition  of  rheumatism  w^as  founded  upon 
observation  of  the  disease  as  modified  in  adults.  But  it  is  quite  inade- 
quate as  applied  to  the  phenomena  developed  in  the  simpler  conditions 
of  early  life. 

In  children  more  clearly  than  in  grown  j>ersons  clinical  observ^ation 
reveals  a  series  of  phenomena  connected  wholly  or  partially  with  the  rheu- 
matic state  which  are  not  limited  to  the  joints  or  to  fibrous  tissues  or  serous 
membranes,  but  involve  occasionally  also  mucous  membrane  and  skin,  and 
even  the  central  nervous  system  itself.  Erythema,  tonsillitis,  chorea,  pleurisy, 
tendinous  nodules,  may  be  results  of  the  rheumatic  disturbance  as  certainly 
as  articular  inflammation  or  pericarditis.  They  are  found  associated  wdth 
articular  rheumatism,"  and  when  they  occur  alone  are  met  with  especially  in 
rheumatic  subjects.  We  must  regard  all  these  affections  in  certain  instances 
as  manifestations  of  the  rheumatic  state,  although  they  may  be  set  up  in 
other  instances  by  other  causes,  just  as  arthritis  or  pericarditis,  while 
usually  rheumatic,  may  be  due  to  scarlatina  or  septic  poisoning  or  pyaemia. 
They  are  not  invariably  rheumatic,  but  most  commonly  rheumatic.  This 
series  of  rheumatic  phenomena  may  occur  in  any  order  of  sequence,  in  any 
combination.  Any  one  of  the  phases  may  be  absent,  one  only  may  be 
preseiit,  or  two  or  three,  or  the  whole  series  may  be  complete  in  the  same 
patient.  There  may  be  articular  aifection  alone,  for  example,  or  there  may 
be  in  addition  pericarditis  or  endocarditis,  or  these  may  occur  without  any 
affection  of  the  joints,  or  with  chorea  and  tendinous  nodules,  or  there  may 
be  erythema  or  tonsillitis  instead  of  any  of  these,  or  in  addition  to  them. 
This  is  seen  constantly  in  clinical  experience.  The  different  manifestations, 
again,  may  occur  not  only  in  any  order  and  combination,  but  separated  by 
varying  inters^als  of  time,  following  one  another  in  quick  succession,  or  some 
appearing  months  or  years  after  the  rest.  Thus,  an  endocarditis  or  a  peri- 
carditis or  a  chorea  may  occur  first  and  alone,  the  joint-affection  long  after. 
The  various  manifestations  of  rheumatism  massed  together  in  the  case  of 
adults  tend  to  become  isolated  in  the  case  of  children,  so  that  the  whole 
phenomena  are  distributed  over  years  instead  of  weeks  or  months,  and  the 
history  of  a  rheumatism  may  be  the  history  of  a  whf)le  childhood.  It  has 
been  said  that  affection  of  the  joints  is  frequently  not  a  marked  symp- 
tom in  the  rheumatism  of  childhood,  and  that  it  is  sometimes  altogether 
wanting.  It  cannot,  therefore,  be  regarded  as  essentially  typical  or  charac- 
teristic in  earlv  life.  If  anv  one  of  the  rheumatic  series  is  to  be  regarded 
as  fairly  constant  and  representative,  it  is  perhaps  endocarditis.  In  child- 
hood arthritis  is  at  its  minimum,  endocarditis  at  its  maximum. 

It  has  been  hitherto  customary  to  speak  of  all  manifestations  of  rheu- 
matism outside  and  beyond  the  joint-aiFcction  as  complications :  in  child- 


EHEUMATISM.  787 

hood  they  do  not  centre  round  the  articular  affection,  and  when  the  joint- 
affection  is  slight  or  wanting  or  has  occurred  apart,  before  or  after,  the 
endocarditis,  or  pericarditis,  or  pleurisy,  cannot  well  be  looked  upon  as 
secondary  and  dependent  upon  it.  These  inflammations  are  in  truth  just 
as  much  direct  results  of  the  rheumatic  virus  or  disturbance,  whatever  its 
nature,  as  the  articular  inflammation,  and  any  satisfactory  definition  of  the 
disease  must  be  broad  enough  to  cover  them.  Rheumatism  may  be  defined, 
then,  as  a  general  or  constitutional  morbid  state,  characterized  by  shifting 
inflammation  of  the  fibrous  structures,  especially  those  of  joints  and  serous 
membranes ;  this  involves  sometimes  other  tissues,  such  as  the  subcutaneous 
connective  tissue,  the  skin,  and  the  mucous  membrane,  and  oftentimes  causes 
also  in  children  disorder  of  the  central  nervous  system,  as  evidenced  by  the 
emotional  and  motor  phenomena  of  chorea. 

Etiology. — The  common  and  immediate  cause  of  rheumatism  is  chilling 
of  the  surface  of  the  body.  Exposure  to  cold  is  most  effective  when  the 
body  has  previously  been  heated  by  exercise  or  by  sitting  in  a  hot  room  and 
the  skin  is  perspiring  and  its  vessels  relaxed.  The  surface  thus  cools 
more  rapidly  through  the  evaporation  of  perspiration  and  the  exposure  of 
a  larger  proportion  of  blood  in  the  dilated  cutaneous  vessels  to  the  cooling 
process.  Under  these  circumstances  a  draught  of  cold  air,  or  remaining  in 
damp  clothes,  is  a  frequent  exciting  cause  of  rheumatism ;  but  it  may  also 
be  induced  without  previous  overheating,  by  prolonged  exposure  to  any 
cooling  influence,  as  a  damp  bed,  or  wet  clothes,  or  an  east  wind.  In  the 
case  of  children  these  sources  of  chill  are  especially  frequent :  a  child  grows 
hot  and  perspiring  with  romping  and  games  of  play,  and  stands  about  in- 
different to  the  dangers  of  wet  feet  and  currents  of  cold  air. 

Muscular  exercise  has  indeed  been  credited  with  the  power  of  exciting 
an  attack  of  rheumatism ;  and  Dr.  Sibson  suggested  that  those  joints  were 
most  liable  to  be  affected  which  are  most  employed  in  habitual  work.  Rheu- 
matism has  been  observed  to  be  common  among  artisans  who  follow  heavy 
labor,  and  to  be  liable  to  come  on  after  long  marches.  Yet  this  probably 
means  nothing  more  than  that  these  conditions  naturally  favor  heating  and 
chilling  of  the  body,  and  also  by  producing  fatigue  or  exhaustion  so  lower 
the  circulation  as  to  aid  the  production  of  congestions.  The  formation  of 
lactic  acid  in  muscular  action  may  be  another  factor.  Although  children 
do  not  commonly  follow  occupations  which  are  physically  laborious,  their 
naturally  active  habits  would  tend  to  produce  conditions  of  excited  and 
then  enfeebled  circulation  similar  to  those  which  result  from  the  more 
severe  muscular  exertion  of  adults.  The  view  that  chill  is  the  chief  ex- 
citing cause  of  acute  rheumatism  is  supported  by  evidence  which  goes  to 
show  that  the  disease  is  most  prevalent  in  cold  and  temperate  climates  and 
in  the  spring  and  winter  seasons,  although  by  no  means  uncommon  in 
warm  weather  or  hot  climates,  where  overheating  is  readily  produced  and 
subsequent  chill  liable  to  follow. 

There  appears  to  be  one  other  direct  exciting  cause  of  the  rheumatic 


788 


EHEUMATISM. 


state  in  the  case  of  children, — viz.,  the  poison  of  scarlatina.  It  is  well 
known  that  affection  of  the  joints  not  to  be  distinguished  from  that  of 
ordinary  rheumatism  occurs  occasionally  in  the  course  of  scarlet  fever,  and 
that  this  scarlatinal  rheumatism  is  liable  to  be  comj)licated  by  endocarditis 
and  pericarditis.  Dr.  Ashby  ^  met  with  twelve  instances  of  this  rheumatism 
out  of  five  hundred  cases  of  scarlatina.  Its  occurrence  may  mean  merely 
that  the  scarlatinal  virus  has  a  similar  eifect  upon  fibrous  tissues  and  serous 
membranes  to  that  of  rheumatism,  and  the  connection  of  tonsillitis  with  the 
two  affections  would  favor  this  view ;  or  it  may  be  that  the  development  of 
the  true  rheumatic  virus  is  favored  by  scarlet  fever ;  or,  again,  the  inflam- 
mation may  be  due  to  septic  poisoning  from  foul  discharges  of  ears  or  throat. 
In  some  instances  the  endocarditis  or  pericarditis  set  up  in  the  course  of 
scarlet  fever  may  be  caused  by  the  ursemic  poison  from  nephritis.  Dr. 
West  ^  states  that  in  fifteen  cases  in  which  he  noted  the  supervention  of 
cardiac  inflammation  in  connection  with  scarlet  fever, — viz.,  ten  of  endo- 
carditis, three  of  pericarditis,  and  two  of  both  combined, — the  symptoms 
did  not  manifest  themselves  until  the  stage  of  desquamation,  and  were  ac- 
companied by  anasarca.  No  mention,  however,  is  made  of  the  condition  of 
the  urine,  or  of  the  throat  or  ears.  Yet  endocarditis  and  pericarditis  occur 
also  in  the  early  stages  of  scarlatina  concurrently  with  joint-affection  undis- 
tiuguishable  from  that  of  acute  articular  rheumatism.  Several  such  cases 
have  come  under  my  own  observation.  Henoch^  records  one  in  which 
acute  arthritis  appeared  in  the  first  week  of  scarlet  fever,  accomj)anied  by 
chorea  and  mitral  murmur.  Dr.  Barlow^  states  that  he  has  seen  well-marked 
arthritic  symptoms  on  the  third  day.  In  Dr.  Ashby's  cases,  previously 
alluded  to,^  the  joint-symptoms  came  on  with  great  regularity  at  the  end  of 
the  first  week.  He  holds  that  the  arthritis  is  of  septic  or  pyagmic  origin, 
due  to  foul  throat,  or  otitis,  or  empyema.  The  septic  poison  does  un- 
doubtedly produce  arthritis  on  occasion,  and  septic  poisoning  not  unfre- 
quently  arises  from  the  causes  mentioned  in  the  course  of  scarlatina.  But 
such  septic  condition  does  not  arise  until  later  in  the  course  of  the  disease. 
Moreover,  articular  or  cardiac  inflammation  is  not  found  to  be  specially 
associated  with  foul  ulceration  of  the  throat  or  with  otitis,  and  other  signs 
of  septicaemia  are  wanting.  Those  cases  of  rheumatism  coming  early  in 
scarlet  fever,  then,  are  probably  not  septic,  a  condition  Avhich  does  not  usually 
arise  till  much  later.  When  arthritis  occurs  late,  it  may  be  in  some  cases 
of  septic  origin.  The  ursemic  poison  does  not  cause  arthritis,  but  it  may  in 
certain  cases  cause  an  endocarditis  or  pericarditis  coming  late  in  the  course 
of  the  specific  fever.  On  the  whole,  it  seems  clear  that  either  genuine  acute 
rheumatism  does  arise  in  the  course  of  scarlet  fever,  or  else  that  the  scarla- 

1  Brit.  Med.  Jour.,  Sept.  15,  1883,  p.  514. 

^  Diseases  of  Infancy  and  Childhood,  7th  ed.,  p.  554. 

2  Diseases  of  Children,  Eng.  trans.,  p.  80. 
*  Brit.  Med.  Jour.,  Sept.  15,  1883,  p.  509. 

6  Bi-it,  Med.  Jour.,  Sept.  15,  1883,  pp.  514,  515. 


RHEUMATISM.  789 

tinal  virus  occasionally  produces  an  inflammation  of  fibrous  tissues  and 
serous  membranes  closely  corresponding  with  that  set  up  by  the  rheumatic 
poison. 

Rheumatism  has  been  attributed  to  the  entrance  of  micrococci  into  the 
blood,  to  that  of  a  specific  vegetable  organism,  the  Zymotosis  translucens 
of  Salisbury,  and  to  a  miasm  analogous  to  that  of  malarial  fevers.  But 
these  are  theories  which  have  not  so  far  been  confirmed  and  established. 
Two  conditions  which  undoubtedly  favor  the  occurrence  of  rheumatism 
in  the  adult — viz.,  childbirth  and  the  existence  of  gonorrhoea — are  not,  of 
course,  concerned  in  its  causation  during  the  period  of  childhood ;  and  the 
only  three  active  influences  which  can  be  accepted  as  directly  determining 
the  development  of  acute  rheumatism  are  chill,  perhaps  excessive  muscular 
exercise,  and  scarlet  fever. 

One  of  the  most  certain  predisposing  causes  appears  to  be  hereditary 
tendency.  Rheumatism  runs  remarkably  in  families.  It  is  passed  on  from 
parents  to  oifspring  as  strongly  as  the  tendency  to  gout  or  to  tuberculosis. 
Statistics  show  that  in  a  large  proportion  of  cases  of  rheumatism  there  is  a 
history  of  similar  affection  in  near  blood-relations.  The  percentage  varies 
from  twenty-five  to  sixty,  according  to  the  minuteness  of  the  inquiry  and 
the  degree  of  joint-affection  which  is  regarded  as  sufficiently  distinctive  of 
an  attack  of  acute  rheumatism.  My  own  statistics  yield  forty  per  cent.. 
Dr.  Goodhart's  about  sixty  per  cent.,  in  the  case  of  children.  Whatever 
may  be  the  exact  proportion,  the  fact  that  children  who  have  a  family 
history  of  acute  rheumatism  in  immediate  blood-relations  are  especially 
liable  to  acute  rheumatism  is  indisputable. 

Out  of  492  cases  of  all  kinds,  both  medical  and  surgical,  among  the  in- 
patients in  the  Children's  Hospital  at  Great  Ormond  Street,  in  which  the 
history  with  regard  to  the  occurrence  of  acute  rheumatism  in  the  family 
was  carefully  inquired  into,  it  was  found  that  there  was  a  clear  history  of 
its  previous  occurrence  in  near  blood-relations  in  173.  Of  these  173  with 
rheumatic  family  taint,  38,  or  20.2  per  cent.,  developed  unquestionable 
rheumatism.  If  chorea  and  the  minor  rheumatic  manifestations  were  ad- 
mitted as  evidence,  the  proportion  would  be  considerably  higher.  Taking 
next  the  remaining  319  of  the  gross  number  of  cases,  medical  and  surgi- 
cal, where  there  is  no  history  of  rheumatism  in  the  family,  15  only  have 
developed  rheumatism, — i.e.,  4.7  per  cent. 

It  would  appear,  therefore,  that  with  a  family  history  of  acute  rheuma- 
tism in  immediate  blood-relations,  especially  in  father  and  mother,  the 
chance  of  any  child  with  such  hereditary  predisposition  contracting  acute 
rheumatism  is  very  nearly  five  times  as  great  as  that  of  a  child  whose 
family  history  is  clear  of  such  taint, — strong  evidence  of  the  influence  of 
inherited  predisposition.  Sometimes  several  members  of  a  family  which 
inherits  the  rheumatic  diathesis  develop  acute  rheumatism. 

Any  number  of  examples  might  be  quoted  in  illustration  of  the  remark- 
able influence  of  hereditary  predisposition. 


790  RHEUMATISM. 

A.  E,.,  a  girl  of  fifteen,  was  admitted  to  St.  Mary's  Hospital,  May,  1880, 
for  extreme  mitral  disease  of  the  heart.  She  had  had  rhemiiatic  fever  four 
times.  Her  father  had  had  rheumatic  fever;  her  mother  had  also  had 
rheumatic  fever. 

Again :  F.  H.,  a  girl  of  seventeen,  was  admitted  into  St.  Mary's  Hos- 
pital with  a  fourth  attack  of  chorea.  One  month  before  this  last  attack  she 
had  acute  rheumatism  of  the  joints  for  the  first  time.  There  was  no  sign 
of  heart-aifection.  The  history  of  family  predisposition  was  strong.  Her 
mother  had  had  rheumatic  fever.  One  of  her  brothers  had  been  a  patient 
in  St.  Mary's  Hospital  with  rheumatic  fever,  again  with  mitral  disease  of 
the  heart,  and  after  that  with  chorea.  Another  brother  had  chorea,  but  no 
aifection  of  the  joints. 

A  third  example  may  be  given,  illustrating  the  persistence  of  the  rheu- 
matic taint  through  three  generations.  J.  P.,  a  girl  of  eleven,  was  admitted 
to  hospital  with  a  third  attack  of  chorea.  She  had  never  had  rheumatic 
arthritis,  and  there  were  no  signs  of  heart-aifection.  Her  mother  had  had 
rheumatic  fever  three  years  previously ;  her  father  had  also  had  rheumatic 
fever,  and  died  of  resultant  heart-disease  at  the  age  of  thirty.  The 
maternal  grandfather  and  grandmother  had  both  had  rheumatic  fever. 

Dr.  Goodhart^  records  a  remarkable  instance  of  heredity  and  consti- 
tutional predisposition.  Five  out  of  the  six  children  of  parents  both  of 
Avhom  were  rheumatic  had  either  joint-afPection  or  heart-disease.  All  the 
children  were  under  fifteen,  and  the  only  one  unaffected  was  a  baby  of  four- 
teen mouths.  The  eldest,  a  boy  of  fourteen,  had  rheumatic  fever  twice, 
and  mitral  regurgitation ;  a  second  boy  of  ten,  the  same ;  a  third  child,  a 
girl,  died  of  mitral  disease ;  the  fourth,  a  girl,  had  rheumatic  fever  after 
scarlatina,  followed  by  mitral  disease ;  the  fifth,  a  boy  of  four,  was  laid  by 
all  one  winter  with  joint-rheumatism. 

Steiner^  relates  a  still  more  extreme  instance,  where  of  the  twelve  chil- 
dren of  a  rheumatic  mother  eleven  had  rheumatism  before  the  aore  of 
twenty. 

It  would  seem  that  the  tendency  to  the  disease  is  intensified  by  inherit- 
ance from  both  parents  instead  of  one  only ;  and  this  double  inheritance 
also  appears  to  fiivor  the  development  of  the  disease  in  its  severer  and 
more  persistent  forms  :  this  is  perhaps  what  might  reasonably  be  expected. 

It  might  no  doubt  be  contended  that  the  occurrence  of  rheumatism  in 
several  members  of  a  family  is  due  to  the  influence  of  climate  and  locality 
rather  than  to  inherited  constitution.  A  careful  inquiry  into  this  point, 
however,  has  shown  that  this  is  not  so.  Individuals  of  the  same  rheumatic 
family  contract  the  disease  when  widely  separated  in  different  places  and 
under  different  sanitary  conditions,  and  change  of  residence  appears  to  have 
small  influence  on  the  result. 


1  Guy's  Hospital  Kcports,  vol.  xxv.  p.  106. 

2  Steiuer,  Diseases  of  Children,  Eng.  trans.,  p.  336. 


EHEUMATISM.  _  791 

These  facts  of  inheritance  show  the  importance  of  a  minute  investiga- 
tion of  the  patient's  life-history,  and  taint  of  the  family  on  both  sides,  in 
order  to  obtain  a  complete  survey  of  the  phenomena  and  relations  of  the 
rheumatic  state. 

Temperament. — Whether  the  rheumatic  diathesis  is  related  to  any 
special  type  of  bodily  conformation  or  temperament,  as  Dr.  Laycock  held, 
is  extremely  doubtful.  Mr.  Jonathan  Hutchinson  suggests  the  existence  of 
a  special  arthritic  diathesis  common  to  rheumatism,  gout,  and  arthritis 
deformans,  but  he  does  not  connect  it,  as  far  as  I  know,  with  any  special 
bodily  form  or  appearance.  Any  one  who  sees  rheumatism  on  a  large 
scale  would,  I  think,  confess  that  it  occurs  in  persons  of  every  variety  of 
build  and  complexion,  both  in  robust  and  delicate,  dark  and  light.  In 
children  it  is  often  associated  with  a  pale  complexion,  but  that  is  due  to 
the  anaemia  which  is  so  marked  a  feature  of  the  disease,  particularly  in 
early  life. 

Sex  has  a  marked  influence  in  predisposing  to  acute  rheumatism.  It  is 
more  frequent  in  men  than  in  women,  owing  probably  to  the  greater  ex- 
posure of  the  former  to  vicissitudes  of  weather  and  to  laborious  physical 
exertion.  The  statistics  of  the  Collective  Investigation  Committee  of  the 
British  Medical  Association  yield  in  655  cases,  including  all  ages,  but  chiefly 
adults,^  57,25  per  cent,  of  males  and  43.75  per  cent,  of  females.  In  chil- 
dren, however,  the  proportions  are  reversed :  acute  rheumatism  is  more 
common  in  girls  than  in  boys.  The  statistics  just  referred  to  give  26  girls 
to  25  boys  under  twelve ;  but  the  numbers  are  too  small  to  give  reliable 
results.  Dr.  Goodhart  found  in  68  cases  42  girls  and  26  boys,  or  nearly 
two  to  one ;  but  here  again  the  numbers  are  not  large.  The  records  of  the 
Children's  Hospital  in  Great  Ormond  Street^  for  sixteen  years  give  252 
girls  to  226  boys.  My  own  experience  shows  it  to  be  most  common  in 
girls,  and  this  is  supported  by  that  of  Drs.  Meigs  and  Pepper.^  The  greater 
liability  of  females  appears  to  continue  up  to  twenty ;  after  that  age  males 
preponderate. 

Age. — Rheumatism  is  extremely  common  in  early  life,  far  more  common 
than  is  generally  supposed,  owing  to  the  slight  development  of  the  joint- 
symptoms  causing  it  to  be  frequently  overlooked.  Yet  cases  of  rheumatism 
are  plentiful  in  the  wards  of  the  Children's  Hospital,  the  beds  are  largely 
filled  with  them  there,  and  in  patients  of  the  better  class  met  with  iu 
private  practice  they  are  by  no  means  rare. 

Rheumatism  is  met  with  occasionally  in  early  infancy,  and  it  becomes 
more  and  more  frequent,  and  the  joint-aflection  more  pronounced,  as  each 
year  of  life  passes,  up  to  six  or  seven,  continuing  from  this  period  up  to 
puberty  at  about  the  same  relative  frequency.     Henoch"*  records  a  case  iu 

1  Brit.  Med.  .Jour.,  Feb.  25,  1888,  p.  387. 

2  Tuckwell,  St.  Barth.  Hosp.  Hep.,  vol.  v.  p.  102. 
'  Diseases  of  Children,  7th  ed.,  p.  668. 

*  Diseases  of  Children,  p.  311. 


792  EHEUMATISM. 

a  child  ten  months  old,  in  which  there  was  well-marked  acute  articulai 
rheumatism,  accompanied  by  broncho-pneumonia  and  probably  by  pleurisy. 
Senator*  refers  to  two  other  cases  in  which  the  patients  were  still  younger, 
— one  recorded  by  Stager  in  a  child  four  weeks  old,  and  another  recorded 
by  Windeshofer  in  which  the  patient  was  an  infant  of  twenty-three  days 
only.  I  have  never  met  with  an  undoubted  instance  of  rheumatism  in  a 
child  under  two  years,  but  I  have  seen  several  cases  of  tenderness  of  joints 
and  tendons  in  children  a  few  weeks  or  months  old  which  were  probably, 
although  not  certainly,  rheumatic. 

Pathology  and  Pathological  Anatomy. — The  exact  method  in  which 
chill  acts  in  producing  rheumatism  is  extremely  obscure.  Several  hypoth- 
eses more  or  less  plausible  have  been  proposed  in  explanation.  Of  these 
one  of  the  most  favored  is  that  it  is  due  to  the  accumulation  of  lactic  acid 
in  the  blood,  as  originally  suggested  by  Dr.  Prout  and  supported  by  Todd. 
The  lactic  acid  is  supposed  to  act  as  a  direct  irritant  to  the  tissues,  as  the 
urate  of  soda  in  gout.  In  support  of  this  theory  there  are  certain  experi- 
ments by  Dr.  B.  W.  Richardson,  who  claimed  to  have  produced  endocarditis 
in  dogs  and  cats  by  injection  of  lactic  acid  into  the  peritoneal  cavity.  But 
the  production  of  endocarditis  without  distinctive  articular  inflammation 
would  not  be  conclusive  as  to  the  rheumatic  nature  of  the  morbid  state 
induced,  and  it  was  afterwards  shown  by  Reyher  that  in  dogs  the  cardiac 
valves  frequently  exhibited  similar  appearances  apart  from  any  artificial 
interference  of  poisonous  injection.  Sir  Walter  Foster^  related  two  cases 
in  which  the  administration  of  lactic  acid  for  diabetes  in  doses  of  from 
fifteen  to  seventy-five  minims  was  followed  by  attacks  which  closely  resem- 
bled acute  articular  rheumatism.  I  have  repeated  the  experiment  more 
than  once,  with  negative  results,  and  this  has  been  the  case,  I  believe,  with 
all  other  observers,  except  in  one  instance  recorded  by  Kuelz,^  in  which  pains 
in  the  hip  and  thigh  followed  the  administration  of  the  drug.  By  some — 
as  Senator,  for  example — it  has  been  supposed  that  the  lactic  acid  produces  its 
effect  by  its  action  upon  the  central  nervous  system,  and  that  the  disordered 
nerve-centres  react  upon  the  joints,  causing  pain,  fever,  and  trophic  changes. 
Another  theory  was  that  held  by  the  late  Dr.  Fuller, — viz.,  that  chill  disturbs 
the  nervous  system,  that  nutrition  is  thus  disturbed  likewise,  and  that  lactic 
acid  or  some  other  acid  of  irritant  character  is  retained  and  acts  as  a  poison, 
which  produces  the  phenomena  of  acute  rheumatism.  The  tendency  to 
thrombosis  which  is  a  notable  feature  of  the  disease  may  be  partly  due  to 
diminished  alkalinity  of  the  blood  from  this  cause. 

In .  speaking  of  the  etiology  of  the  disease,  mention  was  made  of  the 
theory  of  the  dependence  of  acute  rheumatism  upon  the  presence  of  micro- 
cocci, or  a  specific  fungoid  germ,  or  a  miasmatic  poison.    In  further  explana- 


^  Ziemssen's  Handbuch,  vol.  xvi.  p.  18. 

2  Brit.  Med.  Jour.,  Dec.  21,  1871. 

^  Quoted  by  Senator  in  Ziemssen's  Handbuch,  vol.  xvi.  p.  28. 


RHEUMATISM.  793 

tion  of  this  it  has  been  suggested  that  the  entrance  of  poison  in  this  way 
sets  up  endocarditis,  and  that  the  joint-symptoms  are  merely  the  result  of 
multiple  minute  embolisms.  It  seems  to  be  a  sufficient  answer  to  this  that 
endocarditis  may  be  entirely  absent,  and  therefore  the  material  for  multiple 
embolisms  wanting,  and  further  that  when  endocarditis  does  occur  it  is 
usually  sequent  to  the  arthritis, — not  antecedent.  Moreover,  the  existence 
of  such  embolism  has  not,  as  far  as  I  know,  yet  been  demonstrated.  ISIul- 
tiple  thromboses  might  more  reasonably  be  regarded  as  possible  causes, 
since  the  blood  has  undoubtedly  a  special  tendency  to  coagulate  in  the 
rheumatic  state ;  but  here  again  we  have  only  pure  hypothesis.  As  far  as 
present  knowledge  goes,  the  most  plausible  theory  is  that  the  normal  elimi- 
nation of  some  metabolic  product  is  interfered  with  by  the  action  of  cold, 
which  either  arrests  its  excretion  by  the  skin  or  checks  its  destruction  by 
oxidation ;  that  poisonous  matter  thus  accumulates  and  acts  as  an  irritant 
to  the  joints,  serous  membranes,  and  other  tissues.  It  is  possible  that  the 
peccant  matter  may  be  lactic  acid,  which  is  always  formed  as  paralactic  acid 
by  muscular  action ;  although  it  is  doubtful  whether  this  is  normally 
secreted  by  the  skin,  as  Berzelius  taught.  It  has  been  found  in  the  perspi- 
ration in  puerperal  fever,  and  in  the  urine ;  yet  its  existence  in  excess  in 
the  blood,  or  arrest  of  excretion,  has  not  yet  been  proved  in  acute  rheu- 
matism. 

The  existence  of  micrococci  and  bacilli  in  the  blood  and  serous  effusions 
in  rheumatism  has  been  lately  shown  by  Dr.  Mantle,^  but  the  specific 
nature  of  these  organisms  has  not  yet  been  demonstrated.  The  tendency 
to  the  formation  of  thromboses,  which  is  a  feature  of  acute  rheumatism, 
and  which  has  already  been  alluded  to  in  passing,  is  due  partly  to  the 
hyperinosis  which  exists,  partly  perhaps  to  the  lessened  alkalinity  of  the 
blood  from  the  neutralization  of  some  of  its  alkali  by  lactic  or  other  acid  or 
by  the  presence  of  bacteria ;  but  it  is  also  in  some  measure  dependent 
upon  obstruction  to  the  circulation  resulting  from  heart-lesion, — mitral  dis- 
ease or  pericarditis.  Thrombosis  not  unfrequently  occurs  in  a  large  vein, 
and  sometimes  in  the  cavities  of  the  heart.  I  have  seen  this  happen  in 
the  axillary  vein,  in  both  iliac  veins,  in  the  femoral  vein,  and  in  the  right 
auricle.  In  two  cases  it  was  followed  by  fatal  embolic  pneumonia.  Pos- 
sibly the  hemorrhages  of  rheumatic  purpura  may  be  due  to  capillary  throm- 
boses originating  in  this  way. 

Morbid  Anatomy. — The  changes  found  in  the  joints  post  mortem  arc 
often  slight ;  and  acute  rheumatism  is  so  rarely  directly  fatal  that  the 
observations  made  have  been  comparatively  few.  The  synovial  membranes 
are  hyperremic,  and  there  is  more  or  less  excessive  effusion  of  fluid  into  the 
cavities  of  the  joints  and  into  the  tissues  around.  The  fluid  in  the  joints 
may  be  ordinary  synovia,  or  be  diluted  by  serum  and  contain  blood-disks 
and  pus-cells.     Sometimes  minute  hemorrhages  can  be  seen, — especially  in 

'  British  Medical  Journal,  June  25,  1887,  p.  1381. 


794  RHEUMATISM. 

the  vascular  portion  of  the  membrane  where  it  joins  the  cartilages.  There 
may  be  in  rare  cases  suppuration,  or  ulceration  of  the  cartilages.  The 
latter  show  signs  of  inflammatory  change  in  globular  swelling  and  prolifer- 
ation of  the  cells  in  certain  portions.  In  the  case  of  children,  according  to 
Henoch,  the  parts  around  may  become  infiltrated  with  inflammatory  lymph, 
and  even  assume  a  bony  hardness,  and  actual  exostoses  may  be  found.  In 
children  too  often — more  rarely  in  adults — the  tendons  and  subcutaneous 
connective  tissues  are  studded  with  fibrous  nodules  from  the  size  of  a  hemp- 
seed  to  that  of  an  almond  or  even  larger,  which  were  first  described  by  Dr. 
Barlow  and  Dr.  Warner,  and  which  appear  to  be  so  closely  connected  with 
a  similar  condition  of  the  cardiac  valves.  They  occur  chiefly  in  the  neigh- 
borhood of  joints  or  tendons,  and  in  the  aponeuroses  and  fascia.  Micro- 
scopically they  exhibit  all  the  characters  of  newly-developed  fibrous  connec- 
tive tissue.  The  skin  may  show  the  remains  of  eruption,  such  as  erythema 
or  peliosis  rheumatiea.  The  throat  may  exhibit  the  redness  and  swelling 
of  acute  tonsillitis.  But  in  fatal  cases  of  rheumatism  the  chief  interest 
centres  upon  the  heart,  and  next  to  this  upon  the  pleurae  and  the  lungs. 
Endocarditis  and  pericarditis  are  of  course  commonly  the  grave  lesions  of 
acute  rheumatism,  and  pleurisy  and  pneumonia  are  occasionally  present. 
The  morbid  anatomy  of  these  changes  is  fully  given  elsewhere  in  the  arti- 
cles on  these  diseases.  There  is,  however,  one  condition  connected  with 
the  state  of  the  heart  and  its  appendages  which  deserves  mention  here,  as 
being  especially  prominent  in  the  rheumatic  inflammation  of  childhood.  I 
mean  the  extension  of  pericarditis  to  the  connective  tissue  of  the  anterior 
mediastinum.  This  results  eventually  in  the  matting  together  and  enormous 
thickening  of  these  parts,  which  become  converted  into  a  dense  fibrous  mass 
beneath  the  sternum.  The  tendency  in  childhood  is  to  plastic  exudation 
leading  to  adhesion  and  fibrous  thickening  rather  than  to  effusion  of  serous 
fluid.  The  extreme  distention  of  the  pericardial  sac  met  chiefly  in  later 
youth  is  unknown  in  early  childliood.  This  is  probably  connected  with  the 
more  subacute  and  recurrent  character  of  the  inflammation.  Purulent  effu- 
sion, again,  seems  to  be  as  uncommon  in  children  in  the  case  of  the  peri- 
cardium as  it  is  coimnon  in  the  pleura.  Another  morbid  appearance  met 
with  in  children  as  well  as  in  adults  is  the  existence  of  large  fibrinous 
coagula  in  the  heart  and  great  vessels,  previously  mentioned,  and  both  ante 
mortem  and  post  mortem  in  date. 

Symptoms. — In  defining  the  meaning  of  the  term  rheumatism  it  was 
pointed  out  that  a  study  of  the  disease  in  children  leads  to  a  broader  con- 
ception of  its  nature  and  compels  the  inclusion  within  its  scope  of  many 
morbid  affections  in  addition  to  the  artliritis.  This,  the  most  constant  and 
striking  feature  of  the  complaint  in  adults,  in  childhood  sinks  into  com- 
parative insignificance,  and  is  often  entirely  absent  in  an  attack  which  is 
undoubtedly  essentially  one  of  acute  rheumatism.  Moreover,  many  of  the 
phases  or  manifestations  of  rheumatism  which,  viewing  the  disease  from  the 
adult  stand-point,  we  are  accustomed  to  regard  as  complications  or  sequelae 


EHEUMATISM.  795 

of  a  central  joint-affection,  appear  in  childhood  as  initial  or  chief  phenom- 
ena. Arthritis  is  at  its  minimum,  endocarditis  at  its  maximum.  Endocar- 
ditis or  pericarditis  may  appear  first,  or  pleurisy,  or  chorea,  or  tonsillitis,  or 
nodules,  or  an  erythema,  or  an  arthritis,  and  these  may  be  grouped  in  any 
order,  in  any  number,  separated  by  varying  intervals  of  time.  In  early 
childhood,  as  Dr.  Barlow  has  well  remarked,  the  tendency  is  to  isolation 
and  separation  of  the  phenomena.  These  draw  more  closely  together  as 
time  passes  on ;  the  disease  tends  to  appear  as  a  whole,  instead  of  in  dis- 
jointed parts  ;  some  features  become  accentuated,  as  the  joint-affection,  others 
grow  less  constant  and  conspicuous  with  advancing  age,  as  the  tendinous 
nodules  and  chorea,  and  these  finally  disappear,  except  in  rare  instances, 
with  the  advent  of  adult  life. 

It  will  be  impossible  to  picture  the  disease  in  all  the  protean  forms 
afforded  by  varying  combinations  of  the  different  phenomena.  The  most 
useful  plan  will  be  to  consider  each  manifestation  and  symptom  apart,  to 
point  out  any  special  features  which  attach  to  them  in  early  life,  and  then 
to  give  some  of  the  more  common  combinations  which  occur  in  the  rheu- 
matism of  childhood. 

Arthritis. — The  comparative  slightness  of  this  symptom  in  the  case  of 
children  has  already  been  insisted  upon, — in  some  instances  a  little  tender- 
ness and  swelling  of  knees  or  ankles  or  wrists,  possibly  limited  to  a  single 
joint,  or  even  less  than  this, — mere  stiffness  and  tenderness  on  movement, 
or  even  a  slight  feverish  attack  only,  recognized  afterwards  as  rheumatic  by 
the  light  of  developing  heart-disease. 

The  following  example  illustrates  this  form.  M.  T.,  a  girl  three  years 
old,  was  observed  to  be  ailing  and  feverish  without  definite  signs  of  any 
precise  ailment.  Two  days  later  the  great  toe  of  one  foot  became  red, 
swollen,  and  tender ;  no  other  joints  were  affected,  and  it  was  supposed  at 
first  to  be  merely  chilblain.  Two  days  later  still,  both  ankles  were  tender 
and  very  slightly  swollen.  The  temperature  was  found  to  be  102.5°.  The 
condition  was  now  judged  to  be  rheumatic,  and  the  heart  was  examined. 
A  full  blowing  mitral  murmur  was  found  to  exist,  which  persisted  for 
many  weeks.  The  joint-affection  quickly  disappeared  with  rest  and  salicin 
treatment,  and  eventually,  after  many  weeks,  the  mitral  murmur  finally 
disappeared  also. 

In  other  cases,  again,  the  rheumatic  inflammation  is  limited  to  tendons 
or  their  sheaths,  as  in  stiff  neck,  wliich  is  occasionally  the  only  manifesta- 
tion of  genuine  rheumatism.  In  some  instances  this  gives  rise  to  prolonged 
torticollis,  as  in  a  case  recently  observed,  where  the  rheumatic  nature  of  the 
affection  was  shown  by  previous  arthritis  of  the  knees,  and  there  was  like- 
wise mitral  murmur  and  tonsillitis.  One  of  the  most  misleading  mani- 
festations of  rheumatic  joint-  or  tendon-affection  is  when  it  is  limited  to 
stiffness  of  the  hamstring  tendons  at  the  back  of  the  knee. 

The  following  cases  illustrate  this  form  of  rheumatic  arthritis.  A  little 
girl  four  years  old  had  difficulty  in  putting  down  the  heel  of  the  right  foot. 


796  RHEUMATISM. 

The  case  was  supposed  to  be  a  surgical  one  of  incipient  talipes  varus,  and 
the  limb  was  steadily  galvanized.  No  improvement  following,  the  patient 
was  referred  to  me  for  medical  treatment.  There  was  no  deformity,  but  the 
disinclination  to  walk  was  extreme :  the  heel  could  be  put  to  the  ground, 
but  the  knee  was  kept  bent.  On  examination,  both  knees  were  found  to 
be  tender,  especially  at  the  back  in  the  hamstring  tendons,  and  they  were 
slightly  swollen.  The  temperature  was  100°.  It  was  further  ascertained 
that  the  child  had  suffered  from  pain  and  stiffness  of  both  knees  and  ankles 
from  time  to  time  for  the  last  six  months.  There  was  no  cardiac  murmur, 
nor  other  sign  of  rheumatism.  But  the  mother  had  had  rheumatic  fever, 
and  the  condition  was  judged  to  be  a  rheumatic  arthritis.  Under  salicin 
and  citrate  of  potash  the  stiffness  and  retraction  of  the  heel,  which  had  lasted 
for  weeks  previously,  entirely  disappeared  in  a  day  or  two,  and  the  child 
walked  perfectly. 

In  a  parallel  instance  the  tenderness  and  stiffness  of  the  hamstring  ten- 
dons came  on  during  the  night,  and  the  child,  a  boy  of  five,  on  getting  out 
of  bed  in  the  morning  could  walk  only  on  the  tips  of  his  toes.  The  tem- 
perature was  103°.  The  heart  was  free,  the  only  other  sign  of  rheumatism 
being  attacks  of  tonsillitis.  But  the  history  of  inheritance  was  strong. 
The  mother  had  rheumatic  fever  with  pericarditis,  and  was  found  to  have  a 
loud  mitral  murmur.  The  child's  cousin  on  the  mother's  side  had  had 
rheumatic  fever  and  endocarditis.  A  cousin  on  the  father's  side  had  had 
nearly  the  whole  rheumatic  series, — viz.,  acute  rheumatism,  tonsillitis,  chorea, 
purpuric  erythema.  Salicin  and  citrate  of  potash  were  given,  and  in  three 
days  all  sign  of  stiffness  had  disappeared  and  the  temperature  was  normal. 
A  similar  case  was  seen  in  a  boy  of  eleven,  with  advanced  mitral  disease, 
but  no  history  of  rheumatic  arthritis.  It  got  well  in  like  manner.  There 
could  be  no  doubt  that  it  was  rheumatic ;  and  I  have  seen  other  examples 
of  this  rheumatic  tenderness  and  stiffness  of  the  hamstring  tendons,  causing 
walking  on  tiptoe  with  bent  knees,  which  seems  almost  diagnostic. 

Often,  however,  the  joint-symptoms  are  sufficiently  marked  to  attract 
attention,  and  both  wrists,  knees,  and  ankles,  and  possibly  fingers,  present 
the  typical  appearance  of  acute  articular  rheumatism.  The  older  the  child, 
the  more  nearly  does  the  affection  conform  to  the  adult  type  in  this  respect. 
I  have  rarely  seen  a  little  child  bound  hand  and  foot  with  rheumatic  inflam- 
mation of  the  joints,  unable  to  move,  as  in  a  typical  case  of  rheumatic  fever 
in  an  adult.  They  are  stiff  and  tender,  but  the  patient  usually  moves  about. 
Often  the  joint-symptoms  subside  in  a  day  or  two,  or  there  may  be  a  suc- 
cession of  relapses  in  almost  continuous  series.  The  articular  affection  shifts 
perhaps  from  one  joint  to  another,  and  tends  to  change  to  the  subacute  form 
and  to  relapse. 

The  temperature,  again,  differs  in  its  range  and  course  from  that  ob- 
served in  tlie  acute  rheumatism  of  grown  persons.  It  seldom  runs  high, 
rarely  above  102°  to  103°,  except  in  the  older  children, — more  often  100° 
to  101°,  and  this  febrile  rise  lasting  onlv  for  a  few  davs.      This  is  the 


RHEUMATISM.  797 

more  notable  because  it  is  at  variance  with  the  general  rise  of  tempera- 
tures in  childhood,  which  tend  to  be  more  easily  raised  and  to  range  higher 
than  in  later  life.  And,  as  anything  like  high  temperature  is  rare,  fatal 
hyperpyrexia  is  unknown,  and  one  element  of  immediate  danger  is  wanting. 
The  pulse-rate,  unless  there  be  accompanying  carditis,  is  but  slightly  raised, 
in  accordance  with  the  temperature. 

The  tongue  is  seldom  much  coated  or  dry,  except  in  severe  cases,  or 
unless  so-called  complications  are  present  causing  increased  fever  and  con- 
stitutional disturbance.  The  thickly-furred  or  diy  brown  tongue  met  with 
in  severe  cases  of  rheumatic  fever  is  never  seen  in  the  child.  The  urine  is 
hardly  aifected  in  the  milder  cases,  but  when  the  articular  affection  is  severe 
and  fever  high  it  becomes  darker,  acrid,  and  lithatic. 

Another  symptom,  which  is  so  marked  in  the  acute  rheumatism  of  adults 
as  to  form  one  of  the  diagnostic  signs,  is  wanting  in  the  case  of  children, — 
viz.,  the  profuse  acid  perspiration.  The  sweating  is  very  slight ;  the  patient 
is  never  seen  bathed  in  moisture  soaking  night-dress  and  pillow,  and  it 
is  not  sour-smelling.  The  sweat-eruptions  sudamina  and  miliaria,  like  the 
perspiration  which  produces  them,  are  also  wanting  in  young  children. 

Heart-Disease,  Endocarditis. — In  the  rheumatism  of  childhood  heart- 
disease  plays  the  anost  prominent  part.  Endocarditis  appears  with  the 
joint-affection  in  the  majority  of  cases,  and  a  small  proportion  of  children 
only  escape  it :  if  arthritis,  then  almost  certainly  endocarditis.^  But  often 
this  appears  alone,  the  sole  expression  at  the  moment  of  the  rheumatic  state, 
or  it  is  accompanied  by  the  eruption  of  subcutaneous  nodules  so  intimately 
associated  with  the  evolution  of  valvulitis  in  early  life,  or  by  chorea  or 
erythema.  As  I  have  pointed  out,  endocarditis  is  constantly  overlooked, 
because  the  significant  joint-affection  is  slight  or  wanting :  the  child  is  a 
little  wasted  and  feverish,  but  there  is  nothing  to  call  attention  to  the  heart, 
and  thus  an  insidious  inflammation  of  the  valves  goes  on,  and  is  probably 
not  discovered  until  long  after,  when  hypertrophy  and  dilatation  aud  loud 
murmur  proclaim  its  existence. 

As  a  rule,  the  endocarditis  is  subacute,  and  it  is  frequently  protracted 
and  relapsing ;  it  dies  down  aud  revives  again.  It  attacks  chiefly  the 
mitral  valve,  but  now  and  again  the  aortic  valves  suffer,  and  in  exceptional 
cases  they  are  alone  affected.  The  first  sign,  and  sometimes  the  only  sign, 
of  the  valvular  inflammation  is  a  soft  blowing  murmur,  usually  systolic,  at 
the  apex,  Tliis  may  gradually  disappear  after  a  few  weeks,  or  more  often 
may  increase  rapidly  in  distinctness,  so  as  to  become  loud  and  harsh  in  the 
course  of  a  few  days.  Yet  sometimes  the  murmur,  even  when  mitral,  may 
be  functional,  due  to  temporary  relaxation  of  papillary  muscles  and  conse- 
quent imperfect  closure  and  leakage;  and  this  may  disappear  as  strength 
and  muscular  tone  return.     Yet  the  fact  that  such  murmurs  appear,  as  a 

1  The  Collective  Investigation  Statistics  give  in  males  72  per  cent,  of  heart-affection  in 
children,  as  compared  with  4G  per  cent,  in  adults.     In  females  the  difference  is  much  less. 


798  RHEUMATISM. 

rule,  in  the  earliest  stage  of  the  rheumatic  attack,  before  serious'  debility 
of  the  cardiac  muscle  is  likely  to  have  occurred,  points  to  its  being  due  to 
valvular  inflammation  rather  than  to  functional  disturbance  from  paresis; 
and  the  disappearance  of  the  murmur  should  be  referred  to  resolution  of 
the  inflammatory  process  and  restoration  of  the  valve  to  its  normal  state. 
A  distinct  mitral  murmur  is  usually  organic,  indicative  of  endocarditis,  and 
commonly  persistent.  An  aortic  obstructive  murmur  is  in  like  manner  an 
almost  certain  indication  of  endocarditis.  An  aortic  regurgitant  murmur  is 
organic  without  exception. 

Another  cardiac  sign  indicative  of  the  development  of  endocarditis  and 
especially  prominent  in  childhood  is  a  reduplication  of  the  second  sound, 
audible  not  at  the  base, — as  in  the  doubling  from  increased  resistance  in  one 
arterial  system  as  against  the  other  met  with  in  the  systemic  obstruction  of 
Bright's  disease  on  the  one  hand  and  in  pulmonar\^  obstruction  on  the 
other, — but  at  the  apex  only.  This  reduplication  is  sometimes  accom- 
panied by  a  diastolic  murmur  after  the  second  of  the  two  parts  of  the 
double  sound.  These  signs  may  disappear ;  or  more  often  they  increase  in 
intensity  and  gradually  develop  into  the  presystolic  rumble.  They  are, 
indeed,  the  first  sign  of  mitral  stenosis,  and  certain  indications  of  the  super- 
vention of  endocarditis.  In  spite  of  the  development  of  these  signs  of 
valvulitis  going  on,  there  may  be  no  rise  of  temperature,  no  quickening  of 
pulse,  no  distress,  sometimes  a  pyrexia  of  one  or  two  degrees,  and  some 
excitement  and  quickening  of  the  heart's  action.  But  the  only  certain 
sign  of  the  commencement  of  endocarditis  is  that  afforded  by  changes  in 
the  heart's  sounds. 

Pericarditis. — It  is  stated  that  pericarditis  is  less  common  in  the  rheu- 
matism of  children  than  in  adults  :  it  is  in  reality  quite  as  frequent,  its 
occurrence  being  often  overlooked.  This  is  due  partly,  as  pointed  out  with 
regard  to  endocarditis,  to  the  slightness  of  the  associated  articular  symptoms 
and  to  its  occasional  occurrence  entirely  apart  from  them,  and  partly  to  the 
inflammation  being  generally  subacute  with  slightly-marked  symptoms  which 
do  not  command  attention.  Pericarditis  is  met  with  in  very  young  children 
even,  although  less  frequently  than  in  later  childhood.  Dr.  West  ^  records 
a  case  in  a  child  of  seven  months,  with  post-mortem  evidence  of  a  previous 
attack  at  the  age  of  four  mouths.  It  is  unnecessarv  to  ffive  a  detailed 
account  of  this  phase  of  rheumatism,  since  the  whole  subject  of  pericarditis 
is  treated  fully  clsewlrere. 

There  are,  however,  certain  special  features  connected  Avith  pericarditis 
as  it  occurs  in  connection  with  the  rheumatism  of  childliood  which  should 
have  l^rief  mention  here. 

In  the  first  place,  it  is,  I  think,  less  liable  to  occur  in  the  primary  attack 
of  articular  affection,  and  also,  like  endocarditis,  although  it  is  at  times 
extremely  acute,  this  is  comparatively  rare ;   and  it  has  a  characteristic 

'  Diseases  of  Infancy  and  Childhood.,  7th  cd.,  pp.  556.  557. 


RHEUMATISM.  799 

tendency  to  become  subacute,  chronic,  and  intermittent,  to  smoulder  on  and 
then  become  active  again,  with  the  advent,  perhaps,  of  a  fresh  wave  of 
joint-aifection,  or  a  fresh  eruption  of  fibrous  nodules,  or  the  supervention 
of  chorea. 

Pericarditis,  again,  although  usually  associated  with  joint-afTection,  may 
be  the  first  and  only  sign  of  the  rheumatic  state  at  the  time  of  its  occur- 
rence, and  be  followed  by  arthritis  or  other  phases  of  rheumatism  at  vary- 
ino;  intervals  :  or*  it  mav  be  the  last  of  the  series  of  rheumatic  events. 
Although  not  rare  in  the  early  period  of  this  disease,  it  is  most  common, 
or  at  any  rate  most  often  observed,  when  the  heart  has  already  become 
greatly  enlarged  by  hypertrophy  and  dilatation  ;  and  it  is  then  most  liable 
to  set  up  fever  and  palpitation,  with  excited,  turbulent,  irregular  action  of 
the  heart  and  quick  pulse,  sometimes  excessively  so, — from  one  hundred 
and  twenty  to  one  hundred  and  sixty  even, — with  cardiac  pain,  dyspnoea, 
restlessness,  and  distress.  Very  possibly,  however,  there  may  have  been 
pericarditis  before ;  it  does  not  leave  a  record  of  its  presence  behind  it,  like 
endocarditis.  This  late  pericarditis  not  infrequently  is  the  immediate  cause 
of  death  at  last. 

In  the  early  attacks,  however,  the  general  symptoms  are  usually  limited, 
except  in  the  rarer  acute  cases,  to  slight  fever,  with  a  moderately  accelerated 
pulse  and  respiration. 

The  physical  signs  of  pericarditis  are  the  same  as  in  adults, — friction 
heard  over  the  pr^cordia,  followed  by  dulness,  increased  in  intensity  and 
extended  according  to  the  amount  of  fluid  or  lymph  effused,  and  subsequent 
distention  and  thickening  of  the  pericardium.  This  is  sometimes  consider- 
able when  the  inflammation  has  been  repeated  or  persistent  and  extended 
to  the  connective  tissue  of  the  anterior  mediastinum,  causing  the  enormous 
thickening  previously  alluded  to  in  describing  the  morbid  anatomy. 

With  this  increase  of  dulness  there  is  also  some  muffling  of  the  heart's 
sounds  over  the  central  portion  of  the  cardiac  area,  simulating  that  produced 
by  effusion.  From  this  it  may  be  distinguished,  however,  partly  by  the 
less  distinctly  triangular  shape  of  the  dulness-area,  but  chiefly  by  the  fact 
that  the  apex  is  not  displaced  upwards,  as  in  serous  effusion,  and  the  heart's 
sounds  at  this  point  are  comparatively  sharp  and  clear.  But  as  with  general 
symptoms,  however,  so  with  physical  signs :  they  are,  as  a  rule,  not  pro- 
nounced in  the  primary  attack.  Instead  of  the  marked  changes  described 
above,  there  is  merely  the  double  friction-sound,  lasting  for  a  limited  period, 
and  disappearing  as  adhesion  takes  place,  to  be  renewed,  perhaps,  and  lead 
eventually  to  the  more  marked  changes  of  the  later  stage. 

Pkurmj  and  PneMmonia. — These  stand  next  to  the  affections  of  the 
heart  in  gravity  and  importance.  They  are  much  less  frequent,  however, 
and  it  is  doubtful  whether  pneumonia  can  claim  to  be  considered  a  certain 
phase  of  rheumatism.  It  occurs  chiefly  in  three  connections, — viz.,  in  a 
limited  form  as  an  accompaniment  of  pleurisy,  in  more  extensive  degree 
in  relation  to,  and  probably  largely  dependent  upon,  miti-al  disease  of  the 


800  EHEUMATISM. 

heart  and  pericarditis,  and  in  the  embolic  form  also  In  connection  with 
valvular  disease.  In  the  lobar  variety  associated  with  mitral  disease  it  is 
almost  always  on  the  left-  side. 

Pleurisy,  however,  undoubtedly  appears  as  a  distinct  expression  of  rheu- 
matism :  Lebert  found  it  in  ten  per  cent,  of  his  cases.  Like  pneumonia,  it 
is  most  common  on  the  left  side,  and  frequently  associated  with  pericarditis. 
In  the  latter  case  it  may  be  secondary,  but  when  it  occurs  alone  in  rheu- 
matic subjects,  or  as  one  member  of  a  series  of  rheumatic  phenomena,  it  is 
probably  a  direct  expression  of  rheumatism.  This  is  well  illustrated  by 
the  following  case.  A  boy  of  six,  who  had  been  exposed  to  chill  while 
travelling  in  severe  weather,  developed  pleurisy  of  the  left  side,  with  some 
local  pneumonia  on  the  fourth  day.  There  was  high  fever,  and  it  was  noted 
that  it  was  accompanied  by  profuse  sweating.  On  the  seventh  day  swelling, 
stiffness,  tenderness,  and  pain  appeared  in  all  the  joints  except  the  fingers 
and  toes,  and  he  went  through  a  well-marked  attack  of  articular  rheumatism. 
The  stitch  of  pleurisy  is  often  referred  erroneously  to  intercostal  rheumatism 
or  pleurodynia.  Pain  in  the  side  should  never  be  passed  over  with  a  hasty 
diagnosis  of  this  kind,  but  be  the  subject  of  careful  examination  with  the 
stethoscope.  The  general  symptoms  of  pneumonia  occurring  in  the  course 
of  rheumatism  are  usually  only  rise  of  temperature,  to  103°  or  104°  per- 
haps, and  somewhat  accelerated  respiration.  There  is  little  or  no  cough, 
no  characteristic  sputum,  even  in  the  case  of  adults, — nothing  to  call  atten- 
tion specially  to  the  state  of  the  lungs.  So  that  pneumonia  is  frequently 
only  discovered  accidentally  on  routine  examination  ;  and,  as  auscultation 
of  the  posterior  portion  of  the  chest  is  often  omitted  in  rheumatism  on 
account  of  the  pani  which  it  inflicts,  the  existence  of  the  inflammation  of 
the  lung  is  very  liable  to  escape  recognition.  The  physical  signs  diifer 
somewhat  from  those  of  ordinary  pneumonia.  There  is  bronchial  or  tubu- 
lar breathing,  but  fine  crepitation  is  not  commonly  found.  This,  however, 
is  usually  present  in  the  limited  embolic  form. 

Pleurisy  and  pneumonia  occurring  as  simple  inflammations  excited  by 
the  rheumatic  virus  usually  resolve  readily,  and  fluid  effiised  as  a  result  of 
the  former  is  reabsorbed,  unless,  as  in  some  eases,  it  becomes  purulent.  But 
when  dependent  upon  heart-disease  it  is  different :  the  pneumonic  consolida- 
tion and  pleuritic  effusion  are  liable  to  remain,  or  disappear  only  after  a 
lengthened  period. 

Bronchitis  is  a  less  frequent  symptom,  but  it  occurs,  according  to  Lebert, 
in  nine  per  cent,  of  cases. 

Tonsillitis. — There  can  be  no  doubt,  I  tliink,  tliat  children  who  are  prone 
to  articular  rheumatism  are  prone  also  to  tonsillitis, — that  it  often  ushers  in 
an  attack  of  articular  rheumatism,  or  occurs  during  its  course.  Trousseau 
recognized  a  rheumatic  sore  throat.  The  statistics  of  the  Collective  Inves- 
tigation Committee^  show  that  tonsillitis  occurred  as  an  antecedent  to  acute 

1  Coll.  Inv.  Record,  vol.  iv.,  18S8,  p.  71. 


"i?, 


Rheumatic  Nodules,  Erythema,  Chorea,  Double  Mitral  Murmur,  Ar- 
thritis.— W.  S.,  set.  four  years  and  three  months,  Hospital  for  Sick  Children,  Great 
Ormond  Street,  under  the  care  of  Dr.  Cheadle,  December  10,  1887. 


^' 


:<% 


Section  of  Subcutaneous  Tendinous  Nodule  in  Acute  'Rheumati.sm.  siidwtng 
Active  Proliferation  and  Cell-Infiltration  of  Fibrous  Tissue.— John  T.,  aet. 
seven  and  a  half  years,  Hospital  for  Sick  Children,  Great  Ormond  Street.  (.Chorea, 
artliritis,  endocarditis,  pleurisy,  nodules,  pericarditis. 


EHEUMATISM.  801 

articular  rheumatism  in  24.12  per  cent,  of  cases,  with  10  per  ceut.  of  sore 
throat  of  uncertain  nature.  This  only  gives  instances  iu  which  tonsillitis 
came  first  in  the  rheumatic  series ;  and  its  full  significance  is  only  realized 
vvlien  we  consider  that  the  throat-afPection  occurs  also  as  a  later  as  well  as 
an  initial  affection,  although  not  so  frequently,  and  that  it  occurs  apart 
from  articular  symptoms  in  rheumatic  subjects.  I  have  within  the  last  six 
months  seen  two  cases  iu  children  in  which  tonsillitis  followed  immediately 
after  articular  rheumatism,  endocarditis,  and  chorea,  and  one  in  which  it 
followed  articular  rheumatism  and  endocarditis;  coming  in  each  instance 
last  in  the  series.  In  another  case  repeated  attacks  of  tonsillitis  extend- 
ing over  several  years  followed  an  attack  of  acute  articular  rheumatism 
which  never  recurred,  but  which  was  succeeded  by  chorea  and  purpuric 
erythema.  So  that  there  can  be  no  hesitation  in  accepting  tonsillitis  as  a 
genuine  member  of  the  rheumatic  series.  The  tonsillitis  presents  no  special 
features :  it  is  accompanied  by  sharp  fever^  with  a  temperature  of  102°  to 
103°.  The  inflammation  extends  to  the  pharynx  and  soft  palate  not  unfre- 
queutly,  but  rarely  results  in  either  suppuration  or  ulceration. 

Fibrous  Nodules. — Dr.  Barlow  and  Dr.  Warner^  have  drawn  attention 
to  the  development  of  fibrous  nodules  in  the  subcutaneous  tissue  in  connec- 
tion with  rheumatism.  The  existeuce  of  these  nodules  had  been  previously 
noted  by  Dr.  Hillier  and  certain  German  and  French  observers,  and  I  had 
also  seen  them,  but  entirely  failed  to  appreciate  their  frequency  and  their 
great  pathological  importance.  They  are  extremely  common  in  children, 
but  are  rare  in  adults,  although  cases  of  their  occurrence  in  grown  persons 
have  been  noted  by  Dr.  Stephen  Mackenzie  and  Sir  Dyce  Duckworth.^  I 
have  observed  them  in  adults  twice  only :  in  one  of  these  cases  they  were 
extremely  numerous.  These  bodies  vary  in  size  from  that  of  a  pin's  head 
to  that  of  an  almond,  or  even  larger.  They  are  not  tender.  They  are 
found  chiefly  in  the  neighborhood  of  joints,  especially  at  the  back  of  the 
elbow,  about  the  margin  of  the  patella,  and  the  malleoli.  They  occur  also 
about  the  vertebral  spines,  the  spine  of  the  crista  ilii,  along  the  clavicle,  the 
extensor  tendons  of  the  hand  and  of  the  foot,  the  pinna  of  the  ear,  the 
temporal  ridge,  the  superior  curved  line  of  the  occiput,  and  the  forehead. 
I  have  seen  them  in  one  instance  on  the  flexor  tendons  of  the  palms,  as 
large  as  almonds,  and  quite  preventing  the  proper  use  of  the  hands  for  the 
time.  The  largest  crop  I  have  ever  observed  was  some  thirty  or  forty, 
chiefly  confined  to  the  front  of  the  chest,  in  relation  to  the  tendons  and 
fascia  of  the  intercostal  muscles.  They  sometimes  appear  in  successive 
crops,  sometimes  singly,  sometniics  multiple.  In  one  case  in  which  this 
point  was  noted  they  developed  in  tlie  course  of  ten  days ;  but  they  usually 
take  many  weeks  to  subside.  There  can  be  no  question  of  their  relation  to 
rheumatism :  out  of  a  large  number  of  cases  I  have  not  met  with  one  in 

'  Trans.  International  Medical  Congress,  1881,  vol.  iv.  p.  116. 
^  Clinical  Society's  Proceedings,  vol.  xv.,  1883. 
Vol.  I.— 51 


802  EHEUMATISM. 

which  they  did  not  occur  in  connection  with  some  rheumatic  manifestation. 
In  Drs.  Barlow  and  Warner's  cases  there  was  distinct  evidence  of  rheu- 
matism in  twenty-five  out  of  twenty-seven.  In  several  cases  also  there 
was  chorea,  and  frequently  erythema  marginatum.  Their  chief  association, 
however,  is  with  endocarditis  and  pericarditis ;  and  this  gives  them  an  espe- 
cial clinical  significance  and  value.  They  seem  to  appear  concurrently  with 
endocardial  inflammation,  and,  when  the  eruption  is  plentiful  and  recurrent, 
are  signs  of  great  import.^ 

Erythema. — Exudative  erythema  appears  as  one  of  the  phases  of  rheu- 
matism in  several  of  its  various  forms.  Of  these,  erythema  marginatum 
and  urticaria  are  the  most  common.  The  former  is  a  frequent  accompani- 
ment of  articular  rheumatism  in  children,  being  far  more  often  observed  in 
them  than  in  adults,  appearing  on  the  body  as  well  as  on  the  limbs.  Out 
of  eight  cases  of  acute  articular  rheumatism,  with  nodules  and  heart-disease, 
under  my  care  in  the  wards  at  Grreat  Ormond  Street  at  one  time,  three  have 
had  erythema  marginatum,  and  one  urticaria.  Dr.  Barlow  ^  gives  a  series 
of  striking  cases  in  which  the  marginate  or  urticarious  form  appeared  simul- 
taneously with  pericarditis,  or  immediately  preceded  it,  the  joint-affection 
following  later.^  Out  of  twenty-seven  cases  of  fibrous  nodules,  erythema 
papulatum  or  marginatum  appeared  in  eight.*  The  claim  of  erythema  no- 
dosum to  be  included  in  the  rheumatic  series  is  more  doubtful.  It  is,  no 
doubt,  usually  accompanied  with  pain  and  tenderness  of  joints,  closely  re- 
sembling a  rheumatic  arthritis,  and,  according  to  my  observation,  in  joints 
removed  from  the  site  of  eruption,  so  that  the  pain  cannot  always  be  due 
to  the  presence  of  swelling  on  unyielding  parts,  as  Dr.  Barlow  has  sug- 
gested. Yet,  as  he  justly  affirms,  until  this  form  of  erythema  is  found  asso- 
ciated with  heart-disease  or  other  attacks  of  undoubted  rheumatism,  we 
must  hesitate  to  accept  it  definitely  as  a  rheumatic  expression.  I  have,  how- 
ever, now  under  my  care  a  case  of  a  boy  of  two  and  a  half  years  with  ery- 
thema nodosum  on  the  shins  only.  He  has  had  pain  in  all  his  limbs,  and 
has  a  well-marked  mitral  murmur.  He  has  no  arthritis  ;  but  his  father  has 
rheumatism,  and  his  father's  sister  has  had  rheumatic  fever  twice. 

About  purpuric  erythema — the  peliosis  rheumatica  of  Schonlein — there 
can  be  less  doubt.  It  is  said  to  occur  almost  exclusively  in  young  adults ; 
but  I  have  seen  several  cases  in  young  children.  It  is  to  be  distinguished 
from  the  purpuric  eruptions  which  occur  in  nephritis,  pyfemia,  and  other 
forms  of  blood-poisoning,  in  morbus  cordis,  and  in  wasting  of  organic  dis- 
eases. The  special  characteristics  of  this  form  of  erythema  are  excellently 
portrayed  by  Dr.  Kennicott,^  who  shows  that  it  is  quite  distinct  from  a 

1  See  Endocarditis,  vol.  ii. 

2  Brit.  Med.  Jour.,  Sept.  15,  1883,  p.  313. 

'  It  is  possible  that  in  some  instances  the  erythema  may  he  due  to  the  toxic  action  of 
salicylate  of  soda,  quinine,  or  arsenic. 

*  Barlow  and  Warner,  Trans.  Int.  Med.  Cong.,  1881,  vol.  iv.  p.  118. 
6  American  Archives  of  Dermatology,  1876. 


RHEUMATISM.  803 

simple  purpura ;  and  with  this  view  I  fully  agree.  The  subcutaneous 
liemorrhages  which  form  a  conspicuous  feature  of  the  eruption  are  probably 
due  to  thrombosis  of  small  vessels,  as  in  blood-poisonings  ;  and  this  is  en- 
tirely consistent  with  the  rheumatic  connection,  for  in  rheumatism  the  blood 
is  hyperfibrinous,  and  thromboses  in  even  large  veins  occur  during  life,  and 
abnormal  coagula  after  death. 

Purpuric  erythema  may  develop  as  an  isolated  phenomenon  quite  apart, 
from  other  symptoms,  as  in  the  case  of  a  boy  of  eight  under  my  observa- 
tion who  had  had  acute  articular  rheumatism.  A  year  after  this  attack, 
having  in  the  mean  time  been  entirely  free,  he  got  a  severe  chill  from  stand- 
ing in  wet  grass  after  becoming  overheated  playing  cricket.  He  was  seized 
next  day  with  stiffness  and  tenderness  of  both  ankles,  and  the  legs  were 
covered  with  slightly  raised  purple  patches  interspersed  with  purpuric 
blotches.  These  were  chiefly  on  the  sides  of  the  ankles  and  lower  calf, — 
not  along  the  line  of  the  shin-bones, — and  the  raised  portions  were  smaller 
and  bluer  and  much  less  raised  than  those  of  erythema  nodosum,  and  more 
distinctly  hemorrhagic.  There  was  never  any  rise  of  temperature.  Under 
salicin  the  swelling  and  tenderness  disappeared  in  the  course  of  a  few  days, 
and  the  eruption  gradually  faded  away.  Later  the  boy  had  chorea  and 
repeated  attacks  of  tonsillitis.  The  heart  remained  unaffected,  and  no 
nodules  were  developed  at  any  time. 

Allied  to  this  condition,  perhaps,  is  hemorrhage  from  the  bladder,  which 
I  have  met  with  in  one  or  two  instances  associated  with  rheumatic  cystitis, 
but  never  in  children. 

Chorea. — That  there  is  some  connection  between  chorea  and  rheumatism 
is  generally  admitted.  The  question  of  such  connection  is  narrowed  to  one 
of  degree.  We  cannot  go  so  far  as  M.  Roger,  who  regarded  all  chorea  as 
of  rheumatic  origin.  All  cases  of  chorea  cannot  be  traced  to  rheumatism  : 
some  are  probably  entirely  apart  from  it.  Other  factors  are  concerned  in 
the  production  of  chorea.  But  in  a  very  large  proportion  there  is  a  re- 
markable association  with  the  rheumatic  state. 

The  neurotic  factor  is  no  doubt  an  important  one.  The  mobile  temper- 
ament of  children,  the  wider  expression  of  movement  insisted  on  by  Dr. 
Sturges,  the  large  preponderance  of  cases  in  girls  as  compared  with  boys, — 
nearly  three  to  one,^ — the  occurrence  of  the  affection  chiefly  in  quick,  emo- 
tional children  and  in  emotional  races,  tlic  agency  of  fright  or  mental  excite- 
ment as  an  immediate  exciting  cause,  all  point  to  a  nervous  factor.  Tlie 
statistics  of  the  Collective  Investigation  Committee^  yield  a  neurotic  family 
history  in  forty-six  per  cent. ;  but,  as  this  includes  fourteen  per  cent,  of 
chorea  itself,  and  disorders  such  as  sunstroke,  injury  to  spine,  sciatica, 
herpes  zoster,  tubercular  meningitis,  drunkenness,  i)aralysis,  etc.,  many  of 
which  are  purely  acicidental,  and  others  have  obviously  no  connection  with 

1  Coll.  Inv.  Eccord,  vol.  iii.,  1887,  p.  45. 

2  Ibid.,  p.  54. 


804  RHEUMATISM. 

an  unstable  nervous  system,  they  are  of  little  practical  value.  A  careful 
inquiry  into  all  my  own  cases  shows  distinct  inherited  neurosis  in  a  small 
proportion  only. 

The  existence  of  the  neurotic  or  emotional  factor  does  not  exclude  the 
existence  of  a  rheumatic  factor.  This  point  is  constantly  discussed  as  if 
the  two  were  mutually  antagonistic  or  destructive  and  it  were  a  question  of 
either  one  or  the  other.  I  believe  there  is  a  close  association  of  the  two, 
and  that  they  are  constantly  at  work  together. 

The  evidence  of  the  intimate  relation  of  chorea  to  rheumatism  is  con- 
clusive. In  the  first  place,  it  is  constantly  seen  as  a  sequel  or  an  accom- 
paniment of  acute  articular  rheumatism,  and  of  no  other  acute  affection 
except  scarlatina,  with  which  also  rheumatism  has  a  curious  connection. 
Again,  it  is  followed  in  certain  cases  by  acute  articular  rheumatism,  at 
varying  intervals. 

It  occurs  in  connection  with  simple  joint-pains,  w^hich  are  probably 
rheumatic,  since  exactly  similar  joint-pains  without  swelling  are  often  asso- 
ciated with  endocarditis  and  pericarditis.  It  occurs  also  in  conjunction 
with  endocarditis  and  pericarditis,  together  with  certain  other  affections  of 
rheumatic  nature,  such  as  subcutaneous  nodules  and  erythema,  or  with  these 
alone.  When  it  occurs  with  heart-disease  without  any  other  rheumatic 
manifestation,  the  morbid  changes  found  in  the  heart  are  exactly  those  met 
witli  in  rheumatic  inflammation, — viz.,  mitral  valvulitis  and  pericarditis. 

Looking  at  the  proved  connection  of  chorea  with  rheumatism  on  the  one 
hand  and  with  heart-disease  on  the  other,  the  association  of  the  two  affords 
presumptive  evidence  that  both  are  rheumatic. 

The  association  of  emotional  excitability  with  both  chorea  and  rheu- 
matism affords  further  presumption  in  the  same  direction.  The  greater 
frequency  of  chorea  in  girls  corresponds  with  the  greater  frequency  of  acute 
rheumatism  in  girls  and  the  prevalence  of  mitral  stenosis  in  young  women. 

Statistics  as  to  the  connection  of  chorea  with  rheumatism  are  numerous. 
We  may,  however,  at  once  place  on  one  side  those  which  deal  solely  with 
rheumatic  arthritis  which  is  either  antecedent  to  the  chorea  or  its  immediate 
accompaniment.  For  any  calculations  based  on  this  one  point  of  contact 
alone  must  obviously  be  inadequate,  since  they  take  no  account  of  the  cases 
in  which  chorea  comes  after  the  arthritis.  These  statistics,  moreover,  as  a 
rule,  deal  only  with  well-marked  attacks  of  articular  rheumatism  ;  they 
omit  also  to  weigh  the  presumptive  evidence  afforded  by  the  coexistence 
of  endocarditis  and  pericarditis,  of  subcutaneous  nodules,  of  erythema, 
and  of  inheritance.  The  statistics  of  the  Collective  Investigation  Com- 
mittee, recently  published,  upon  which  I  have  already  drawn,  are  of  higher 
value.  They  are  based  upon  439  cases,  and  give  24.4  per  cent,  of  ante- 
cedent rheumatic  arthritis  and  12.6  per  cent,  of  concurrent  or  immediately 
subsequent  arthritis,  making  a  total  of  37  per  cent,  unquestionably  rheu- 
matic. If  5.6  per  cent,  of  cases  with  vague  pains  probably  rheumatic 
were  included,  the  proportion  would  be  42.6  per  cent.     Yet  this  must,  in 


RHEUMATISM.  805 

the  nature  of  things,  be  still  below  the  mark,  since  the  cases  in  which 
arthritis  occurs  some  time  later  are  necessarily  excluded ;  and  the  evidence 
afforded  by  mitral  disease,  by  pericarditis,  by  fibrous  nodules,  by  erythema, 
by  tonsillitis,  apart  from  arthritis,  is  not  estimated.  When  these  occur  in 
combination,  their  cumulative  weight  as  evidence  of  rheumatic  connection 
is  considerable.  Dr.  Barlow  found  satisfactory  evidence  of  rheumatism, 
exclusive  of  family  history,  in  57.3  per  cent.  My  own  statistics,  taken 
with  minute  care  with  especial  regard  to  this  point,  and  including  in  several 
instances  many  years  of  the  after-history,  give  73  per  cent.  From  this, 
however,  some  reduction  must  be  made,  probably  of  20  to  25  per  cent,  of 
those  cases  in  which  family  history  is  the  only  evidence,  on  account  of  the 
normal  incidence.  This  would  bring  the  estimate  into  close  equality  with 
that  of  Dr.  Barlow,  Whether  a  given  case  of  chorea  is  rheumatic  or  not 
can  be  determined  only  by  a  comprehensive  survey  of  the  patient's  life- 
history. 

Chorea  may  occur  at  any  point  in  the  series  of  rheumatic  symptoms  : 
when  it  is  extreme  and  combined  with  severe  endocarditis  or  pericarditis  it 
is  of  great  gravity.  Nearly  all  fatal  cases  of  chorea  appear  to  be  thus  asso- 
ciated, and  to  be  rheumatic. 

Thrombosis  and  embolism  are  conditions  which  have  to  be  reckoned  wath 
in  the  course  of  rheumatism.  The  existence  of  hyperinosis  and  the  tendency 
to  the  formation  of  clots  has  been  mentioned  in  sjjcaking  of  the  pathology 
of  the  disease ;  and  this  is  sometimes  a  serious  source  of  danger.  I  do  not 
think  that  plugging  of  any  large  vessel  occurs  except  when  the  circulation 
is  interfered  with  and  slowed  by  the  concurrent  mitral  disease  or  pericarditis. 
I  have  twice  seen  fatal  consequences  follow.  In  one  case,  a  girl  of  seven, 
with  acute  arthritis  and  endo-pericarditis,  had  thrombosis  of  both  iliac  veins, 
followed  by  extreme  oedema  of  both  lower  extremities.  This  subsided  ;  but 
six  weeks  later,  on  jumping  up  to  look  out  of  the  window  at  a  passing  band, 
she  was  suddenly  seized  with  faintness  and  dyspnoea ;  disseminated  pneu- 
monia appeared  in  both  lungs,  of  which  she  died  in  a  few  days. 

In  the  other  case — one  of  rheumatic  pericarditis — thrombi  formed  in 
the  right  auricle,  accompanied  by  extremely  irregular  and  turbulent  action 
of  the  heart,  and  then  fatal  embolic  pneumonia. 

There  are  other  symptoms  associated  with  rheumatism  of  which  brief 
mention  must  be  made.  One  of  these  is  emotional  excitability.  It  is  a 
question  whether  this  is  a  direct  consequence  of  rheumatism,  or  only  a  part 
of  the  clironic  phase.  I  am  inclined  to  think  that  the  emotional,  neurotic 
disposition  goes  generally  with  the  tendency  to  rheumatism.  Rheumatic 
children  are,  apart  from  the  chorea,  abnormally  excitable :  they  are  restless, 
fidgety,  nervous. 

Meningitis  is  stated  to  occur  in  the  course  of  rheumatism,  and  cases  are 
quoted  by  Senator.^     It  is  possible  that  the  serous  membrane  of  the  brain 

1  Ziemssen's  Handbuch,  vol.  xvi.  p.  50. 


806  RHEUMATISM. 

may  be  stirred  up  to  inflammation  by  the  rheumatic  poison,  like  other  serous 
membranes,  but  I  have  not  met  with  such  a  case.  The  cerebral  symptoms 
observed  in  some  cases,  which  Trousseau  put  down  to  cerebral  rheuma- 
tism, appear  to  be  effects  of  pyrexia  or  pericarditis,  and  sometimes  nowadays 
of  salicylate  of  soda.  Night  fevers,  headaches,  and  incontinence  of  urine 
are  stated  by  Dr.  Goodhart  to  be  especially  common  in  rheumatic  children. 
I  have  not  observed  any  special  relation  of  these  conditions  to  rheumatism, 
but  the  association  with  nervous  excitability  and  anaemia  makes  the  connec- 
tion a  probable  one.  Anaemia  is  indeed  a  prominent  symptom  in  the  rheu- 
matism of  childhood.  It  is  perhaps  present  in  some  degree  in  ordinary 
cases,  but  it  is  remarkable  especially  when  there  is  serious  heart-disease, 
either  valvular  or  pericardial.  It  sometimes  progresses  to  an  extreme 
degree,  and  is  then  a  sign  of  grave  import.  Children  with  serious  heart- 
damage  from  endocarditis  or  pericarditis  suffer  in  nutrition  in  a  most 
striking  way ;  they  not  only  grow  extremely  pallid,  but  also  lose  flesh  and 
strength,  and  die  at  last  of  progressive  debility  and  heart-failure. 

It  has  been  shown  that  the  different  manifestations  of  rheumatism 
may  occur  in  various  combinations  and  in  various  order  of  succession.  Ex- 
amples of  some  of  the  slighter  forms  have  been  given  in  illustration  of 
different  points  previously.  More  complete  examples  of  the  chief  of  the 
different  series  of  rheumatic  events  are  briefly  shown  in  the  following  clin- 
ical examples. 

1.  Rheumatic  arthritis  first,  then  mitral  disease  followed  by  chorea  and 
pericarditis.     Family  history  of  rheumatism. 

A.  I.,  a  girl  of  thirteen,  admitted  to  St.  Mary's  Hospital,  January  26,  1885,  suffering 
from  chorea  and  morbus  cordis.  She  hud  had  three  attacks  of  rheumatic  fever,  the  last  six 
months  before.  .At  that  time  heart-disease  was  first  discovered.  Chorea  commenced  a  fort- 
night before  admission.  On  examination,  a  loud  mitral  regurgitant  murmur  was  found, 
with  thrill,  and  signs  of  considerable  hypertrophy  and  dilatation.  Nineteen  days  later 
severe  pericarditis  set  in  without  joint-symptoms.  "With  this  the  chorea  ceased,  and  she 
eventually  recovered.  Her  father  had  had  "  rheumatism,"  and  two  of  her  sistei-s  rheumatic 
fever. 

In  this  case  there  can  be  no  doubt  that  the  chorea  and  the  pericarditis 
were  rheumatic,  although  they  followed  six  months  after  the  arthritis. 

2.  Hheumatic  arthritis,  endocarditis  three  years  later,  then  arthritis 
again. 

E.  E.,  a  girl  of  twelve,  admitted  November,  1877,  to  St.  Mary's  Hospital  with  pyrexia, 
— temperature  103°, — palpitation,  and  dyspnoea.  There  was  no  murmur,  no  pericardial 
friction.  She  had  had  rheumatic  fever  three  years  before.  Her  father  had  had  rheumatic 
fever.  From  this  history  endocarditis  or  pericarditis  was  suspected.  Four  days  later  a  loud 
aortic  murmur  developed.  A  fortnight  later,  or  when  convalescent,  slight  swelling  and 
tenderness  of  one  ankle  appeared.  Two  years  later  still,  general  rheumatic  arthritis 
occurred. 

In  this  case,  again,  there  can  be  no  doubt  that  the  endocarditis  was 
rheumatic,  although  unaccompanied  at  the  time  by  arthritis. 


EHEUMATISM.  807 

3.  Chorea,  mitral  disease,  no  arthritis.  Family  history  of  rheuma- 
tism, 

H.  C,  a  boy  of  ten,  admitted  into  the  Hospital  for  Sick  Children,  June,  1878,  with 
mitral  stenosis,  regurgitation,  and  great  hypertrophy.  He  had  not  been  known  to  have 
any  joint-affection,  but  he  had  had  chorea  three  years  before.  His  mother  had  had  rheu- 
matic fever,  and  was  suffering  from  mitral  disease. 

The  chorea  and  mitral  disease  were  almost  certainly  of  rheumatic  origin, 
the  character  of  his  heart-disease  and  the  fact  of  the  mother  havino;  had 
rheumatic  fever  and  endocarditis  affording  strong  presumptive  evidence, 
although  the  patient  had  never  developed  articular  rheumatism. 

4.  Chorea,  mitral  disease.  No  history  of  articular  affection  in  patient 
or  family. 

5.  B.,  a  girl  of  nine,  admitted  with  a  third  attack  of  chorea.  No  cause  could  be 
assigned.  Physical  examination  disclosed  a  loud  mitral  murmur  with  hypertrophy.  She 
had  never  had  any  stiffness  or  tenderness  of  joints.  No  history  of  rheumatism  in  any  form 
in  the  family. 

Here  there  was  no  evidence  of  rheumatic  taint ;  yet  viewed  in  the  light 
of  the  constant  association  of  such  heart-affection  and  chorea  with  the  rheu- 
matic state,  the  most  probable  supposition  is  that  they  were  thus  connected. 
The  articular  affection  might  follow  later. 

The  next  example — where  the  joint-affection  appeared  last  in  the  series 
— throws  light  upon  such  cases  as  the  two  preceding. 

5.  Chorea,  mitral  disease,  then  arthritis  four  years  later.  Rheumatic 
family  history. 

A.  W.,  a  girl  of  sixteen,  admitted  to  St.  Mary's  Hospital  with  stiffness,  swelling,  and 
tenderness  of  wrists,  knees,  and  ankles.  She  had  never  had  any  joint-affection  before,  but 
four  years  previously  chorea.  On  phj'sical  examination,  marked  signs  of  mitral  disease  were 
found, — a  loud  regurgitant  murmur,  heaving  impulse,  extensive  prsBcordial  dulness,  show- 
ing the  heart-disease  to  be  of  old  standing  and  not  due  to  the  present  attack.  Her  mother 
and  her  mother's  sister  had  both  had  rheumatic  fever. 

Now,  this  case  was  almost  exactly  similar  to  the  two  preceding  up  to 
the  time  of  the  occurrence  of  the  joint-affection  four  years  after  the  chorea. 
Previous  to  this  the  case  would  probably  have  been  classed  as  non-rheu- 
matic. 

6.  Mitral  disease  first,  followed  by  arthritis  after  a  long  interval,  then 
chorea. 

K.  D.,  a  girl  of  eight,  admitted  to  St.  Mary's  with  advanced  mitral  disease  of  old  stand- 
ing, causing  palpitation  and  dyspnoea,  the  result  of  endocarditis  years  before.  Yet  she  had 
never  had  any  articular  affection  until  five  weeks  ago,  when  she  was  confined  to  bed  with 
stiff  and  tender  joints  for  ten  days.  Fourteen  days  after  admission  .she  developed  marked 
general  chorea. 

In  this  case  there  was  nothing  to  connect  the  endocarditis  in  any  way 
with  rheumatism  at  the  time  of  its  first  occurrence.     The  nature  of  tlio 


808  EHEUMATISM. 

case  was  not  proved  until  the  arthritis  and  chorea  betrayed  it  long  after- 
wards. 

These  cases  were  recorded  before  the  significance  of  nodules  and  erythema 
and  tonsillitis  as  signs  of  the  rheumatic  state  was  appreciated.  The  follow- 
ing recent  examples  show  a  much  fuller  series,  and  the  four  last  exhibit  the 
disease  in  its  gravest  and  most  fatal  form  in  childhood. 

7.  Chorea,  arthritis,  endocarditis,  second  chorea,  nodules,  tonsillitis,  ery- 
thema. 

~W.  L.  D.,  a  boy  of  eight,  admitted  to  the  Children's  Hospital  in  Great  Ormond  Street, 
November  11,  1887.  A  year  ago  lie  had  chorea,  brought  on  by  fright,  followed  six  months 
later  by  arthritis,  accompanied  by  endocarditis.  Six  months  later  still  he  was  admitted  for 
a  fresh  attack  of  chorea  and  tonsillitis.  There  was  a  fibrous  nodule  over  the  right  elbow, 
and  a  loud  double  mitral  murmur.  While  in  hospital  he  had  an  extensive  eruption  of 
urticarious  erythema. 

8.  Arthritis,  chorea,  nodules,  endocarditis,  slight  arthritis,  erythema. 

F.  M.,  a  boy  of  five,  was  admitted  on  March  8,  1888,  with  chorea.  He  had  had  two 
previous  attacks  of  rheumatic  fever.  Thei-e  was  a  mitral  regurgitant  murmur,  with  accen- 
tuation and  reduplication  of  the  second  sound  at  the  base.  Large  nodules  were  found  on 
both  malleoli,  others  of  different  sizes  on  the  condyle  of  the  femur,  the  patella;  clavicle, 
scapula,  extensors  of  fingers,  and  posterior  scalp.  Slight  tenderness  and  swelling  of  the 
left  wrist-joint  appeared  next  day,  but  subsided  quickly.  A  week  later  a  copious  eruption 
of  erythema  marginatum  appeared  on  the  back. 

9.  Chorea,  arthritis,  second  chorea,  second  arthritis,  copious  evolution  of 
nodules,  endocarditis,  erythema,  third  arthritis,  second  nodules,  fresh  endo- 
carditis, tonsillitis,  progressive  anaemia,  death. 

W.  S.,  a  boy  of  four,  admitted  to  Great  Ormond  Street,  December  8,  1887,  with  a 
second  attack  of  chorea,  and  pains  behind  the  knees.  The  first  ailment  was  chorea,  a  year 
ago.  No  heart-affection  observed  then.  Now  a  full  double  mitral  murmur.  A  plentiful 
crop  of  nodules,  some  as  large  as  the  end  of  a  little  finger,  on  the  knees,  elbows,  spine,  and 
scalp.  While  in  hospital  he  had  two  eruptions  of  erythema  marginatum.  In  seven  weeks 
he  was  discharged,  convalescent,  but  was  readmitted  three  weeks  later,  with  fresh  copious 
eruption  of  large  nodules,  fresh  arthritis,  and  fresh  endocarditis,  and  subsequently  tonsillitis. 
He  became  extremely  anaemic,  the  heart's  action  became  excited,  with  increased  heat  and 
slight  rise  of  temperature,  and  he  shortly  died  of  exhaustion  and  heart-failure.  No  post- 
mortem examination  could  be  obtained. 

10.  Arthritis,  endocarditis,  fresh  arthritis,  abundant  nodules,  erythema, 
pericarditis,  death. 

A.  C.  B.,  a  boy  of  eleven,  admitted  for  articular  rheumatism.  A  loud  systolic  mitral 
murmur,  also  a  diastolic  over  sixth  space,  and  increased  area  of  cardiac  dulness.  A  numerous 
crop  of  subcutaneous  nodules  was  found  on  the  extensors  of  the  fingers,  elbows,  knees,  mal- 
leoli, and  spine.  Marginate  erythema  followed,  then  fresh  nodules  began  to  be  developed ; 
anajmia  increased  remarkably,  and  the  temperature  rose;  pericarditis  set  in,  accompanied  by 
marked  anaemia  and  distress,  with  vomiting,  and  the  child  died  four  days  afterwards.  Post- 
mortem examination  showed  the  pericardium  adherent  throughout,  greatly  thickened,  the 
mitral  valve  rigid  and  thickened,  the  aortic  valves  covered  with  a  fringe  of  recent  vege- 
tations. 


RHEUMATISM.  809 

11.  Chorea,  second  chorea,  then  arthritis,  endocarditis,  unusually  large 
eruption  of  nodules,  emotional  attacks,  fresh  chorea,  fresh  crop  of  nodules, 
progressive  anaemia,  pleurisy,  pericarditis,  and  death. 

J.  T.,  a  boy  of  seven,  brought  in  for  articular  rheumatism.  He  had  had  two  attacks 
of  chorea,  the  last  three  months  before.  A  large  number  of  nodules,  from  the  size  of  a  pea 
to  that  of  a  nut,  formed  a  most  striking  feature  of  the  case.  They  were  found  abundantly 
on  the  occiput,  the  spinous  processes,  the  wrists,  flexors  of  hands,  the  ankles,  and  the  feet. 
Twenty-five  were  counted  in  all.  Endocarditis  followed,  culminating  in  double  mitral  dis- 
ease. Occasional  emotional  attacks  of  crying  and  laughter.  Fresh  evolution  of  nodules, 
and  progressive  anaamia,  followed,  then  pleurisy,  persistent  pericarditis,  lasting  two  months, 
and  death.  The  whole  course  after  admission  lasted  eight  months.  Post-mortem  revealed 
adherent  pericardium  with  enormous  thickening,  especially  in  front,  granulations  on  aortic, 
mitral,  and  tricuspid,  with  thickening  of  the  two  former. 

12.  Articular  rheumatism,  chorea,  pleurisy,  pericarditis,  death. 

M.  B.,  a  girl  of  fifteen,  admitted  to  St.  Mary's  with  extreme  chorea,  following  articular 
rheumatism.  The  chorea  was  so  violent  that  she  could  be  fed  only  with  great  difficulty, 
and  she  was  quite  unable  to  speak.  In  order  to  take  the  temperature,  two  nurses  had  to 
restrain  her :  it  was  103.4°.  It  was  almost  impossible  to  examine  the  heart,  owing  to  the 
extreme  jactitation,  but  great  dulness  was  made  out  over  the  cardiac  area,  with  friction  at 
one  point,  and  muffling  of  the  sounds.  The  diagnosis  was  acute  rheumatic  chorea  with  peri- 
carditis. The  girl  died  a  few  hours  later.  Post-mortem  examination  revealed  extreme  dis- 
tention of  the  pericardium  with  purulent  fluid. 

Diagnosis. — There  are  few  diseases  in  which  diagnosis  is  more  easy  and 
certain  than  in  a  well-marked  attack  of  acute  articular  rheumatism  in  an 
adult.  The  swollen,  tender  joints,  the  profuse  sour  sweating,  the  mere  atti- 
tijde  of  the  patient,  lying  still  and  motionless,  afraid  to  move  hand  or  foot, 
are  in  themselves  alniost  sufficient  to  distinguish  it.  In  cihildren,  however, 
we  rarely  see  this  typical  extreme  arthritic  form :  it  is  not  common  in  older 
children  even  before  the  age  of  puberty ;  in  very  young  children  it  is  un- 
known. The  diagnosis  of  rheumatism  in  early  life,  when  arthritis  is  at 
its  minimum  and  fever  and  sweating  are  not  pronounced,  is  often  difficult 
enough,  and  in  many  cases  it  is  only  by  a  complete  and  careful  survey  of 
the  whole  history  of  the  patient  that  a  correct  conclusion  as  to  the  nature 
of  the  attack  can  be  attained. 

If  the  articular  affection  is  distinctly  present,  the  tender,  painful,  swollen 
joints,  with  a  faint  blush  of  redness  on  them  perhaps,  the  tendency  to 
sweating,  the  rise  of  temperature  to  from  100°  to  103°,  the  behavior  of  the 
inflammation  in  shifting  from  one  joint  to  another,  declining  in  a  few  days 
and  then  reappearing,  arc  characteristic.  When  the  tcndci'ness  and  swelling 
are  extremely  slight,  confined  to  a  single  joint,  or  in  a  tendon  or  fascia,  or 
if  there  is  merely  a  little  stiffness,  it  is  occasionally  difficult  to  decide 
whether  the  affection  is  really  rheumatic  or  not,  altliougli  the  mere  existence 
of  anything  of  the  kind  is  in  itself  in  the  case  of  a  cliild  very  suggestive  of 
rheumatism.  Su(;h  conditions  are  usually  rheumatic,  and  are,  it  is  to  be 
remembered,  genuine  rheumatism,  bearing  with  it  all  the  possibilities  of  car- 
diac inflammation.    How  constantly  these  cases  must  be  overlooked  is  shown 


810  EHEUMATISM. 

by  the  fact  that  out  of  six  hundred  and  fifty-five  cases  of  all  ages  given  in 
the  statistics  of  the  Collective  Investigation  Committee  ^  thirty-two  only  were 
in  children  under  ten ;  yet,  as  I  said  l)efore,  it  is  one  of  the  commonest 
diseases  in  the  wards  of  a  children's  hospital,  and  not  infrequent  in  private 
practice.  The  discovery  of  a  fibrous  nodule,  or  the  rash  of  erythema,  or  a 
mitral  murmur,  or  pericardial  or  pleuritic  friction,  or  that  the  patient  has 
had  a  previous  attack  of  rheumatism  in  any  form,  or  inherits  a  family  taint 
of  it,  will  help  to  solve  the  question.  All  these  points  should  be  minutely 
inquired  into,  and  in  every  case  the  heart  carefully  examined  day  by  day. 
There  are  one  or  two  affections  which  might  be  mistaken,  and  indeed  now 
and  again  are  mistaken,  for  acute  rheumatism.  One  of  these  is  infantile 
paralysis.  In  certain  cases  of  this  disease  there  is  at  first  extreme  tender- 
ness of  the  affected  limbs,  and  sometimes  also  a  little  swelling  of  the  foot 
and  ankle,  if  the  legs  are  affected.  It  may  be  distinguished,  however,  by 
the  flexed  muscles,  the  helpless  rolling  of  the  limb  on  movement,  the  pitiful 
inability  of  the  child  to  move  it  except  by  lifting  it  with  the  hands,  and 
the  absence  of  sign  of  heart-affection  or  other  rheumatic  symptom. 

Another  condition  which  is  frequently  mistaken  for  rheumatism  in 
adults  is  pysemia.  It  is  not  common  in  children,  but  it  does  occur,  and  in 
them,  as  in  adults,  is  distinguished  by  hectic  sweats  and  temperature,  by  the 
existence  of  some  local  suppuration,  and  by  the  course  of  the  disease.  An 
acute  suppuration  of  joints,  of  obscure  origin,  but  possibly  septic,  not  infre- 
quent in  young  infants,  has  some  resemblance  at  first  to  a  rheumatic 
arthritis.  The  greater  pain  and  swelling,  and  usually  greater  fever  and 
constitutional  disturbance,  with  the  eventual  presence  of  pus,  serve  to  dis- 
tinguish it  from  true  rheumatism. 

Scrofulous  affections  of  the  joints  are  liable  to  be  mistaken  at  the  outset, 
but  they  may  be  recognized  usually  by  their  steady,  uushifting  character. 
Rheumatism  in  a  child  may  be  persistent,  but  it  is  shifting  and  changeable. 

The  tender  swellings  of  limbs  and  oedema  of  ankles  met  with  in  certain 
cases  in  connection  with  rickets,  and  which  I  have  shown  to  be  essentially 
scorbutic,^  are  often  put  downi  as  rheumatic.  They  sometimes  affect  the 
tissues  around  joints,  as  well  as  the  periosteum  of  the  long  bones  and  the 
muscles,  but  they  may  generally  be  distinguished  without  difficulty  by  the 
condition  of  the  gums,  the  various  hemorrhages  usually  present,  the  normal 
or  subnormal  temperatures,  and  the  fact  of  the  child  being  fed  upon  scurvy 
diet.  In  simple  rickets,  wlien  extreme,  there  is  bone-  and  muscle-tender- 
ness ;  but  the  existence  of  the  obvious  signs  of  rachitis  is  sufficient  to 
show  its  nature.  There  is  one  condition  connected  with  rickets,  however, 
which  is  sometimes  taken  as  rheumatic,  and  indeed  has  been  styled  so  by 
some  authors,  although  it  is  not  in  any  way  connected  therewith, — viz.,  the 
swelling  of  the  dorsum  of  the  foot  and  back  of  the  hands  which  occurs 


1  Coll.  Inv.  Kecord,  vol.  iv.,  1888,  p.  67. 

2  Lancet,  Nov.  16,  1878,  vol.  ii.  p.  685. 


RHEUMATISM.  811 

in  the  tetany  or  carpo-pedal  contractions  of  young  rickety  children.  The 
tumefaction  ajipears  to  be  due  to  the  pressure  of  muscles  in  tonic  contrac- 
tion, exactly  analogous  to  that  produced  by  a  tight  bandage. 

There  is  a  disease  of  the  bones  developed  in  congenital  svjjhilis  which 
in  some  degree  simulates  rheumatism, — viz.,  inflammation  of  the  ends  of 
the  long  bones  where  the  shaft  joins  the  epiphysis.  There  is  tenderness  and 
occasionally  swelling  of  a  joint,  with  effusion,  and  possibly  suppuration. 
The  affection  is  one  attending  the  first  explosion  of  the  congenital  disease, 
— within  the  first  three  months ;  and  the  age  is  almost  in  itself  diagnostic. 
The  existence  or  history  of  other  signs  of  syphilis,  such  as  characteristic 
eruption,  snuffles,  wasting,  cranial  bosses,  or  tabes,  renders  its  recognition 
easy.  A  certain  amount  of  arthritis  with  extravasation  of  blood  into  the 
joints  and  serous  effusion  around  them,  with  a  rise  of  temperature,  is  said  to 
occur  occasionally  in  haemophilia  and  purpura  hsemorrhagica.  The  diag- 
nosis from  a  rheumatism  accompanied  by  a  purpuric  erythema  would  appear 
to  be  difficult,  but  the  history  of  bleeding,  with  the  graver  symptoms  and 
longer  course,  serves  to  separate  them  from  the  light  and  transient  disturb- 
ance of  rheumatic  purpura.  If  the  joint-affection  has  passed,  or  is  alto- 
gether absent  at  first,  the  determination  of  the  rheumatic  or  non-rheumatic 
nature  of  other  manifestations  is  a  matter  of  more  nicety. 

When  endocarditis  arises  in  a  child,  there  is  always  a  strong  prima  facie 
presumption  that  it  is  of  rheumatic  nature  :  from  fifty  to  eighty  per  cent,  can 
be  traced  to  rheumatism,  according  to  the  investigations  of  Roger,  Goodhart, 
and  myself.  If  with  the  cardiac  inflammation  we  have  a  group  of  symp- 
toms known  to  be  associated  with  rheumatism, — chorea,  fibrous  nodules, 
erythema,  or  tonsillitis, — whether  any  or  all  of  these  have  occurred  recently 
or  cropped  up  from  time  to  time  at  intervals  through  months  or  years, 
the  cardiac  inflammation  is  almost  certainly  rheumatic.  The  presence  of 
one  of  these  fibrous  nodules  alone  is  almost  absolutely  diagnostic.  The 
coexistence  of  chorea  would  have  great  weight,  although  not  absolutely 
conclusive ;  the  concurrence  of  two  conditions  each  so  closely  connected 
with  rheumatism  is  necessarily  of  much  significance.  The  same  holds  good 
with  regard  to  pericarditis :  it  is  almost  always  rheumatic  in  children,  and 
the  coexistence  of  nodules  or  chorea  or  a  series  of  other  rheumatic  phe- 
nomena would  fix  the  diagnosis.  As  to  the  rest,  the  tonsillitis  aud  ery- 
themas (all  except  perhaps  purpura  rheumatica)  are  less  strongly  and 
constantly  identified  with  the  disease,  and  the  value  of  their  corroborative 
testimony  would  depend  much  upon  their  combination  and  other  circum- 
stances. 

I  do  not  know  that  fibrous  nodules  arc  ever  foimd  apart  from  arthritis 
or  chorea  or  heart-disease ;  but  they  are  associated  with  no  other  morbid 
condition  except  rheumatism. 

The  claims  of  erythema  and  tonsillitis  to  be  considered  as  rheumatic 
phenomena  have  been  stated  in  speaking  of  the  symptoms.  In  case  of  tlicir 
appearance  alone,  collateral  evidence  would  have  to  be  sought  as  to  the 


812  RHEUMATISM. 

existence  of  other  more  accepted  signs,  either  at  the  moment  or  at  some 
previous  time. 

The  existence  or  absence  of  a  strong  family  predisposition  to  acute  rheu- 
matism in  its  different  phases  would  be  evidence  of  much  weight  and  would 
have  to  be  duly  considered. 

In  all  these  cases  one  phase  or  symptom  alone  must  not  be  relied  upon  : 
a  comprehensive  survey  of  the  whole  available  evidence  from  all  sources 
must  be  examined  and  appraised. 

But  always  in  the  case  of  children,  whether  unmistakable  arthritis  be 
present  or  there  be  merely  a  stiff  and  painful  tendon,  or  an  unexplained 
febrile  attack,  or  chorea,  or  tonsillitis,  or  erythema,  it  is  most  essential  to 
bear  in  mind  the  possibility  of  having  to  deal  with  rheumatism,  and  to 
examine  the  heart  carefully  day  by  day.  It  has  happened  over  and  over 
again  in  such  circumstances  that  a  cardiac  murmur  or  a  friction-sound  has 
been  discovered,  betraying  an  endocarditis  or  pericarditis  never  even  sus- 
pected, its  presence  not  having  been  suggested  by  any  marked  fever  or 
ordinary  sign  of  rheumatism.  It  is  impossible  to  urge  too  strongly  the 
necessity  for  the  most  watchful  care  on  this  vital  point. 

Prognosis. — The  prognosis  of  acute  rheumatism  in  a  first  attack  is 
unquestionably  favorable,  at  any  rate  as  to  its  immediate  issue.  The  gen- 
eral direct  mortality  is  only  about  three  and  a  half  per  cent.,^  and  it  is 
probably  less  in  children  than  in  adults.  The  latter  are  exposed  to  the 
danger  of  hyperpyrexia,  a  risk  that  barely  seems  to  exist  for  the  former, 
possibly  because  it  occurs  chiefly  in  those  given  to  alcoholic  excess. 

Now  and  again,  in  rare  cases,  children  do  die  in  the  primary  attack 
from  acute  heart-disease,  or  from  thrombosis  and  embolism.  As  a  rule, 
however,  in  a  first  attack  the  joint-symptoms  quickly  get  well,  the  endocar- 
ditis or  pericarditis  subsides,  and  if  there  be  tonsillitis  or  erythema  they 
seldom  persist  many  days.  Should  chorea  be  present,  it  may  linger  on  and 
relapse,  but  usually  it  passes  off  in  the  course  of  a  few  weeks. 

If  the  first  attack  clears  up  quickly,  if  at  most  only  a  soft  cardiac 
murmur  at  the  base  of  hsemic  character  has  been  developed,  or  even  if  a 
mitral  murmur  has  appeared  and  subsided,  it  may  be  hoped  that  little  per- 
manent damage  has  been  done.  But  even  then  it  is  necessary  to  give  a 
cautious  forecast  of  the  future.  It  is  only  by  careful  examination  for  long 
afterwards  that  the  extent  of  cardiac  mischief  can  be  safely  estimated. 
If  a  mitral  or  aortic  murmur  does  not  die  away,  or  reappears  and  grows 
distinct,  and  signs  of  dilatation  and  hypertrophy  follow,  there  is  certainly 
serious  valvular  mischief.  Owing  to  the  greater  liability  to  endocarditis 
and  pericarditis  in  early  life,  the  risk  of  permanent  damage  to  the  heart- 
structures  is  greater  also.  Compensation  is  no  doubt  more  perfect  if  the 
lesion  is  small,  and  more  quickly  attained  Avith  children  than  -with  adults ; 
but,  on  the  other  hand,  if  the  valvular  injury  is  great,  the  subsequent 

1  Senator,  in  Ziemssen's  Handbuch,  vol.  xvi.  p.  56. 


RHEUMATISM.  813 

changes  of  hypertrophy  and  perhaps  of  dilatation  also  progress  more 
rapidly,  owing  to  the  more  ready  growth  of  tissues  in  the  young  and  their 
more  yielding  character.  The  hypertrophy,  however,  outstrips  the  dilata- 
tion. 

And  in  prognosis  it  must  be  borne  in  mind  that  the  danger  is  not  over 
with  the  subsidence  of  the  primary  attack ;  it  lies  partly  in  the  after-effects 
of  the  heart-affection,  and  less  in  the  severity  of  the  primary  attack  than  in 
the  frequent  immediate  relajises  or  the  return  of  the  disease  at  longer  in- 
tervals. I  have  already  stated  that  in  children  the  cardiac  inflammation 
has  a  tendency  to  go  on  smouldering  in  subacute  form,  and  thus  by  chronic 
changes  or  frequent  repetition  to  produce  a  grave  cumulative  result.  If 
there  have  been  previous  attacks  of  rheumatism,  and  especially  if  the 
heart-valves  have  been  already  injured,  the  prognosis  is  much  less  favorable 
than  in  a  first  attack.  The  cardiac  inflammation  is  apt  to  revive,  and  the 
mischief  to  valves  or  pericardium  to  increase.  The  worst  cases  are  those 
in  which  the  heart  already  shows  signs  of  great  enlargement,  evidenced  by 
heaving,  diffused  impulse,  and  increased  area  of  cardiac  dulness.  Fresh 
endocarditis  and  pericarditis  are  then  especially  apt  to  supervene,  often 
accompanied  by  pleurisy ;  dyspnoea  and  rapid  action  of  the  heart  follow, 
there  is  progressive  anaemia,  and  the  patient  sinks  from  failure  of  his  em- 
barrassed and  Aveakened  heart.  Probably  in  such  cases  there  is  myocarditis. 
Pleurisy  and  pneumonia  are  apt  to  occur  also  ;  they  are  chiefly  dei^eudent 
upon  the  heart-lesion  and  consequent  impediment  to  the  circulation,  and 
this,  of  course,  adds  to  the  gravity  of  the  prognosis.  Vomiting  is  an  un- 
favorable sign  when  it  occurs  persistently  in  the  course  of  pericarditis. 
Marked  aneemia  is  a  sign  of  evil  omen  :  it  is  one  of  the  most  striking 
results  of  cardiac  rheumatism  in  children.  It  is  as  characteristic  of  mitral 
disease  and  pericarditis  of  children  as  it  is  of  aortic  regurgitation  in  adults. 

The  congested  face  so  frequently  seen  in  patients  with  mitral  disease 
is  rarely  met  with  in  children  :  they  arc  always  pallid  and  bloodless,  and 
emaciated  instead  of  being  full-fleshed. 

In  these  cases  in  children,  too,  dropsy  is  only  occasionally  met  Avith  :  it 
is  comparatively  rare  to  see  a  child  hopelessly  swollen,  waterlogged  from 
dilatation  of  the  right  heart  sequent  to  mitral  disease. 

Another  symptom  Avhich  I  have  come  to  regard  as  of  very  grave  inn)ort 
is  the  copious  and  repeated  evolution  of  fibrous  nodules.  They  go  especially 
with  chronic  valvulitis  and  pericarditis  ;  and  so  long  as  the  nodules  continue 
to  appear  there  is  reason  to  fear  progressive  heart-mischief  from  a  similar 
sub-inflammatory  process  in  the  fibrous  tissue  of  valves  and  pericardium. 
Such  cases  do  badly,  as  a  rule :  they  have  constant  and  repeated  relapses, 
progressive  heart-mlscliicf,  and  progressive  aufemia.  Nearly  all  I  have 
seen  liave  proved  fatal  in  tlie  course  of  a  few  months.  Three  such  examples 
have  been  described  in  the  clinical  cases  previously  given.  Another  danger 
is  copious  effusion  into  the  pericardium  :  this  can  be  estimated  by  the  in- 
creasing dulness,  muffling  of  the  heart-sounds,  and  upward  displacement  of 


814  •  EHEUMATISM. 

the  aj)ex-beat.  Yet  this  is  far  less  commou  tlian  in  adults :  an  adhesive 
pericarditis  with  subsequent  fibrosis  is  the  rule  with  children,  rather  than 
one  with  copious  effusion ;  although  I  have  twice  seen  this  fatal  in  young 
girls  about  the  age  of  puberty.  A  less  common  sign  of  the  greatest  gravity 
is  the  supervention  of  dropsy,  indicating  extreme  dilatation  of  the  right 
heart.  In  one  instance  under  my  observation  this  followed  a  fresh  attack, 
— simple  acute  dilatation  without  valve-lesion  ;  this  is,  however,  more  com- 
mon after  scarlatinal  nephritis  than  after  acute  rheumatism. 

Another  symptom  which  always  adds  to  the  gravity  of  the  prognosis  is 
the  supervention  of  extreme  chorea, — i.e.,  chorea  so  severe  that  the  patient 
can  hardly  be  kept  in  bed  or  obtain  sleep  on  account  of  the  violence  of  the 
jactitations, — especially  if  the  child  is  a  female  approaching  the  age  of 
puberty. 

The  statistics  available  are  not  quite  satisfactory,  since  they  make  ante- 
cedent arthritis  the  sole  test  of  rheumatism;  yet  these  appear  to  show  a 
special  relation  to  exist  between  fatal  chorea,  rheumatism,  and  the  age  of 
puberty,  in  girls.^  The  coexistence  of  endocarditis  or  of  old  valv^ular  disease, 
and  still  more  of  pericarditis,  especially  if  accompanied  by  signs  of  effusion, 
with  embarrassed,  quick,  irregular  action  of  the  heart,  and  dyspnoea,  or  of 
very  active  plastic  inflammation,  renders  the  condition  more  dangerous  still. 
In  such  cases  the  prognosis  must  always  be  serious  and  doubtful ;  and  the 
expectation  of  favorable  issue  will  depend  chiefly  upon  the  decline  of  the 
cardiac  symptoms,  the  power  of  taking  food,  and  of  rest  in  sleep. 

The  occurrence  of  thrombosis  adds  a  fresh  element  of  danger.  As 
previously  stated,  I  have  twice  seen  death  take  place  in  children  from  pul- 
monary embolisms  and  pneumonia  due  to  thrombosis, — in  one  instance  of 
both  iliac  veins,  in  the  other  of  the  right  auricle. 

Lastly,  there  must  be  considered  the  possibility,  if  attacks  of  arthritis 
are  repeated,  of  permanent  alterations  in  one  or  more  joints,  such  as  thicken- 
ing and  ankylosis.  These  events  are,  according  to  my  experience,  rare  in 
early  life.  In  cases  where  suppuration  follows  a  so-called  rheumatic  attack 
it  is  probable  that  the  condition  was  really  pyaemic. 

Treatment. — The  principles  upon  which  a  case  of  acute  rheumatism 
with  arthritis  should  be  treated  at  the  outset  are — first,  to  prevent  fresh 
chill  to  the  surface ;  secondly,  to  keep  the  affected  parts  at  rest,  so  as  to 
lessen  the  flow  of  blood  there  and  friction  of  pai'ts,  and  thus  to  lighten 
inflammation  and  relieve  pain.  This  applies  not  only  to  the  joints,  but 
more  still  to  the  heart.  Dr.  Sibson's  observations  show  how  important  a 
means  this  is  of  modifying  the  after-effects  of  endocarditis.  Thirdly,  to 
modify,  if  possible,  by  specific  remedies,  the  fever  and  neutralize  the  irri- 
tant effects  of  the  rheumatic  poison  on  the  fibrous  tissues  of  joints  and 
tendons ;  fourthly,  to  prevent,  if  possible,  the  inflammation  of  the  endo- 
cardium and  the  pericardium,  or,  if  this  has  set  in,  to  minimize  and  arrest 

^  Sturges,  Chorea,  pp.  77-80. 


RHEUMATISM.  815 

it ;  and  lastly,  to  relieve  pain  directly  by  anodynes  if  necessary.  It  may 
be  thought  that  many  of  these  ends  cannot  be  attained  with  certainty ;  and 
indeed  the  statements  made  as  to  the  effects  of  remedies  in  rheumatism  are 
in  some  respects  conflicting  and  unsatisfactory.  Yet  there  is  evidence  that 
most  if  not  all  of  the  objects  laid  down  can  be  some  of  them  effected  with 
certainty  and  others  greatly  aided  by  the  use  of  remedies.  In  the  last 
twenty  years  great  progress  has  been  made  in  this  respect. 

If  the  tongue  is  coated  or  the  bowels  are  constipated,  a  dose  of  one  to 
three  grains  of  calomel  should  be  given  at  the  outset, — an  excellent  pre- 
liminary to  other  treatment.  To  insure  against  chill  and  give  rest,  the 
patient  should  be  kept  in  bed,  either  between  blankets  or  in  a  flannel  night- 
dress, until  some  time  after  the  temperature  has  become  normal  and  all 
symptoms  have  ceased.  The  tender  joints  should  be  placed  in  easy 
positions,  propped  by  soft  pillows,  and  wrapped  in  a  little  soft  cotton-AA'ool, 
but  not  covered  with  oiled  silk  or  gutta-percha,  as  is  usually  done :  this 
overheats  the  parts,  and  also,  by  keeping  in  acrid  perspiration,  increases  the 
local  irritation.  If  necessary,  the  weight  of  the  bedclothes  may  be  sup- 
ported by  a  cage.  If  the  pain  and  tenderness  are  great,  a  little  liquor  opii 
sedativus  may  be  sprinkled  on  the  cotton-wool,  or,  better  still,  the  joints 
wrapped  in  light  bandages  kept  wet  with  a  lotion  containing  ten  grains  of 
bicarbonate  of  soda  and  ten  drops  of  liquor  opii  sedativus  to  the  ounce  of 
water.     This  is  far  more  effectual  than  any  application  of  belladonna. 

The  application  of  cold  in  the  form  of  water-dressings  is  advocated  by 
Senator,^  or  even  of  ice,  by  Esmarch  f  but  of  this  practice  I  have  no  expe- 
rience. It  is  stated  to  be  safe,  to  relieve  pain,  and  to  lessen  the  duration  of 
the  joint-symptoms. 

Another  plan  which  has  been  highly  commended  for  the  relief  of  pain 
is  the  hypodermic  injection  of  a  one-per-cent.  solution  of  carbolic  acid  under 
the  skin  over  the  affected  joints,  and  the  application  of  carbolizcd  oil  (one 
in  fifteen). 

The  application  of  blisters,  which  certainly  are  of  great  service  in  re- 
lieving pain  by  reducing  effusion,  in  adults,  is  not  suited  to  children  :  the 
remedy  is  generally  worse  than  the  disease. 

In  early  life  the  arthritis  is  seldom  severe  enough  to  require  such 
applications.  It  will  be  frequently  found  sufficient  to  apply  the  alkaline 
opiate  lotion  and  keep  the  part  at  rest.  In  the  more  chronic  cases  it  may 
be  worth  while  to  secure  this  by  the  application  of  a  s[)lint. 

The  fever  and  pain  of  the  arthritis  of  rheumatism  can  be  subdued  most 
quickly  by  the  use  of  salicin  or  salicylate  of  soda.  There  is  a  very 
general  agreement  on  this  point,  although  opinions  are  still  divergent  as  to 
their  ultimate  effect  on  the  duration  of  the  disease  and  the  prevention  of 
cardiac  inflammations. 


'  Ziemssen's  Randljuch,  Ena;.  trans.,  vol.  xvi.  p.  C8. 
*  Quoted  by  Senator,  op.  cit. 


816  RHEUMATISM. 

I'lie  statistics  recently  published  by  the  Collective  Investigation  Com- 
mittee/ based  on  six  hundred  and  fifty-five  cases,  give  an  average  duration 
of — fever,  8.65  days;  pain,  10.18  days;  whole  attack,  19.03  days. 

Salicylate  of  soda  freely  administered  hardly  ever  fails  to  bring  down 
temperature  and  relieve  the  pain  of  rheumatism  in  the  course  of  twenty- 
four  to  forty-eight  hours ;  ^  but  there  are  several  drawbacks  to  its  use.  In 
the  first  place,  it  sometimes  sets  up  nausea  and  vomiting  to  a  distressing 
degree.  It  has  also  a  depressant  effect  upon  the  heart ;  the  pulse  loses 
strength,  and  the  first  sound  of  the  heart  becomes  faint,  so  that  in  ten  cases 
observed  by  Dr.  Greenhowit  was  almost  inaudible.  It  also  produces  in 
certain  cases  deafness,  buzzing  in  the  ears,  vertigo,  delirium.  In  extreme 
instances  the  symptoms  have  been  alarming,  such  as  great  prostration, 
violent  delirium,  albuminuria,  collapse.  These  results  occur  much  less 
frequently  in  children  than  in  adults ;  yet,  in  view  of  the  proneness  to  heart- 
affection  in  the  young,  it  is  well  to  use  a  depressant  drug  with  caution. 
But  in  truth  it  is  only  occasionally  in  children  that  the  pain  and  fever  are 
sufficiently  important  to  require  its  administration.  If  the  joint-symptoms 
are  severe,  however,  and  temperature  much  raised,  salicylate  of  soda  will 
reduce  them  more  quickly  than  any  other  remedy.  It  should  be  given  for 
the  first  twenty-four  or  forty-eight  hours,  and  after  that  saliciu  be  substituted 
for  it ;  for  salicin  has  little  if  any  of  the  evil  properties  of  salicylate  of  soda, 
although  it  appears  to  act  through  its  conversion  into  salicylic  acid  in  the 
blood,  through  the  action  of  ptyalin  or  other  ferment.^  Possibly  it  acts 
less  violently  because  more  gradually  passed  into  the  circulation ;  it  cer- 
tainly produces  its  effect  more  slowly.  In  all  but  the  most  severe  cases 
salicin  is,  then,  preferable  to  salicylate  of  soda,  and  may  be  given  for  a 
day  or  two  in  doses  of  five  to  eight  grains  every  three  to  four  hours  to  a 
child  of  five,  mixed  with  water  and  syrup  of  orange. 

The  salicin  should  be  continued  in  less  frequent  doses  for  some  days 
after  all  symptoms  have  ceased,  or  a  relapse  is  liable  to  occur.  These  reme- 
dies will  serve  the  purpose  of  reducing  the  temperature  and  the  arthritis, 
but,  unfortunately,  they  seem  neither  to  prevent  the  occurrence  of  carditis 
nor  to  arrest  or  modify  it  Avhen  developed.  The  statistics  adduced  at  the 
debate  on  this  subject  at  the  Medical  Society  of  London  in  1881  shovred  no 
distinct  power  of  salicylates  or  salicin  to  prevent  heart-affection.  It  would 
have  appeared  probable  that  a  drug  which  cut  short  the  arthritic  manifesta- 
tions of  the  rheumatic  poison  would  also  prevent  or  arrest  wliat  are  believed 
to  be  similar  changes  in  the  cardiac  valves  and  pericardium ;  but  this  has 
not  proved  so,  and  I  have  observed  that  the  evolution  of  nodules,  whiclx 


^  Eeport  of  Collective  Investigation  Committee,  vol.  iv.,  1888,  p.  75. 

"^  The  Eeport  previously  quoted  records  twenty-two  cases  out  of  two  hundred  and 
ninety-six  treated  by  salicylates  and  salicin  in  which  they  were  ineflPectual.  The  doses 
given  were  probably  too  small  and  at  too  long  intervals. 

3  Senator,  in  Ziemssen's  Handbuch,  Eng.  trans.,  vol.  xvi.  p.  1040;  postscript  by  Dr. 
Buchanan  Baxter. 


EHEUMATISM.  817 

may  be  taken,  perhaps,  as  the  external  index  of  what  is  going  on  in  the 
fibrous  tissues  of  the  heart,  continues  to  develop  in  spite  of  the  steady 
administration  of  salicin.  The  only  treatment  which  can  claim  to  show  good 
evidence  of  poM'er  in  this  respect  is  that  by  alkalies.  Statistics  are  not 
always  reliable,  but  the  cumulative  weight  of  several  independent  results  is 
considerable. 

Fuller  had  nine  cases  of  heart-disease  only  out  of  four  hundred  and 
seventeen  cases  treated  by  alkalies,  Chambers  nine  out  of  one  hundred  and 
seventy-four,  Dickinson  one  out  of  forty-eight.  On  the  other  hand,  the 
two  latter  observers  had  five  out  of  twenty-six  and  thirty-four  out  of  one 
hundred  and  thirteen  in  patients  treated  in  other  ways.^  INIoreover,  the 
influence  of  alkalies  in  mitigating  the  joint-symptoms  and  shortening  their 
course  appears  distinctly  favorable,  although  much  less  decided  and  rapid 
than  that  of  salicin  and  the  salicylates.  The  recent  statistics  of  the  Collec- 
tive Investigation  Report^  give  an  average  duration  of  fever  13.23  days, 
pain  19  days,  whole  attack  36.3  days, — much  more  prolonged  than  cases 
under  salicylates  and  salicin  given  above.  Alkalies  should,  then,  be  given 
in  combination,  salts  of  soda  in  preference  to  those  of  potash,  as  being  less 
depressant.  AVith  the  salicylate  of  soda,  six  to  ten  grains  of  bicarbonate  of 
soda ;  the  same  with  the  salicin.  The  amount  of  alkali  must  be  regulated 
by  the  state  of  the  urine ;  enough  should  be  given  to  keep  it  neutral  or 
slightly  alkaline.  If,  however,  endocarditis  or  pericarditis  come  on,  the 
salicylates  or  salicin  should  be  at  once  stopped,  and  the  alkali  given  in  freer 
doses, — ten  to  fifteen  grains  every  four  hours,  with  half  a  drachm  of  syrup 
in  half  an  ounce  of  water.  In  severe  and  obstinate  cases  of  endocarditis 
or  pericarditis,  when  there  is  high  temperature,  palpitation,  cardiac  dyspnoea, 
and  distress,  quinine  should  be  given  in  addition,  in  doses  of  two  to  three 
grains  every  four  hours  for  a  child  five  years  old.  This  may  be  done  by 
giving  ten-grain  doses  of  citrate  of  soda,  two  grains  of  quinine,  and  five 
grains. of  citric  acid;  or  the  acid  hydrobromate  of  quinine  may  be  given 
every  four  hours  alternately  with  the  alkali.  This  salt  is  extremely  soluble 
(ten  grains  to  one  drachm),  so  that  the  dose  can  be  administered  in  a  single 
teaspoonful  of  water ;  and  it  has  also  the  advantage  of  being  less  liable  to 
cause  sickness  than  the  sulphate. 

Many  other  drugs  have  been  advocated  in  the  treatment  of  rheumatism, 
some  of  which  are  useless,  others  harmful,  or  even  dangerous.  Among 
the  latter  must  be  mentioned  antimony,  aconite,  and  veratria.  Their  action 
on  the  joint-condition  is  uncertain,  and,  although  the  two  latter  have  dis- 
tinct antipyretic  properties,  the  fact  that  they  are,  like  antimony,  heart- 
depressants,  and  of  even  more  dangerous  power,  negatives  their  use  in  this 
disease,  especially  in  children. 


1  The  statistics  of  the  Collective  Investigation  Committee,  unfortunatelj',  give  no  in- 
formation on  this  point. 

2  Coll.  Inv.  Rep.,  vol.  iv.,  1888,  p.  75. 
Vol.  I.— 52 


818 


RHEUMATISM. 


Colchicum  has  not  the  same  specific  infl.uence  in  rheumatism  as  in  gout. 
As  with  so  many  other  drugs,  cases  have  been  recorded  in  which  it  has 
seemingly  helped  to  shorten  the  attack ;  but  it  is  depressant,  and  the  relief 
of  arthritis  can  be  effected  better  by  other  means. 

Iodide  of  potassium  is  quite  inefficient,  or  rather  it  would  seem  to  have 
a  retarding  effect,  the  cases  treated  with  salicylates  and  iodide  together  show- 
ing, in  the  Collective  Statistics  referred  to,  the  highest  average  duration. 

Nitre  and  lemon-juice,  each  highly  extolled  at  one  time,  are  distinctly 
inferior  to  salicin,  the  salicylates,  and  alkalies. 

In  cases  of  high  temperature  favorable  results  follow  the  use  of  antipy- 
rin,  which  is  advocated  by  Frankel,  who  reports  on  thirty-four  cases ;  and 
I  have  seen  equally  good  results  follow  the  use  of  antifebrin ;  but  I  have 
never  had  occasion  to  use  these  drugs  in  the  case  of  children.  Under  both 
I  have  seen  serious  syncopal  attacks  occur  in  adults,  and  I  should  hesitate 
to  use  them  at  all  freely  with  little  children. 

In  my  hands  the  results  with  salol  have  been  unfavorable.  It  appears 
to  combine  the  objectionable  qualities  of  salicylic  and  carbolic  acids,  of 
which  it  is  a  compound,  without  marked  effect  upon  the  arthritis. 

The  following  table,  obtained  from  the  very  valuable  Report  of  the  Col- 
lective Investigation  Committee  so  often  referred  to,  drawn  up  by  Dr. 
Whipham,  gives  the  relative  results  of  different  forms  of  treatment : 


Average  Duration  (in  Days)  op 

Treatment.  Fever.  Pain.  Attack. 

Salicylates  (sodium  or  potassium) (173  cases.)  (171  cases.)  (167  cases.) 

8.65  days.  10.18  days.  19.03  days. 

Salicylic  acid (9  cases.)  (9  cases.)  (9  cases.) 

13.8  days.  10.7  days.  10.7  days. 

Salicin (14  cases.)  (14  cases.)  (14  cases.) 

9.28  days.  15.07  days.  23.92  days. 

Alkalies (26  cases.)  (26  cases.)  (26  cases.) 

13.23  days.  19.0  days.  36.30  days. 

Alkalies  and  then  salicylates (22  cases.)  (22  cases.)  (21  cases.) 

11.54  days.  13.90  days.  22.22  days. 

Salicylates  and  alkalies  (combined) (12  cases.)  (11  cases.)  (13  cases.) 

10.83  days.  15.54  days.  84.92  days. 

Salicylates  and  then  alkalies (19  cases.)  (18  cases).  (17  cases.) 

10.78  days.  13.16  days.  30.64  days. 

Salicin  and  alkalies (3  cases.)  (3  cases.)  (3  cases.) 

11.6  days.  19.3  days.  24.0  days. 

Salicylates  and  potassium  iodide (7  cases.)  (6  cases.)  (7  cases.) 

17.14  days.  24.16  days.  46  days. 

Salicylates  and  iron (18  cases.)  (19  cases.)  (18  cases.) 

11.77  days.  10.89  days.  27.7  days. 

Salicylates  and  tonics (16  cases.)  (16  cases.)  (16  cases.) 

8  days.  10.18  days.  18.68  days. 

Alkalies  and  opium (8  cases.)  (8  cases.)  (8  cases.) 

10.75  days.  12.60  days.  18.75  days. 

Salicylates,  then  iron  and  quinine (5  cases.)  (5  cases.)  (6  cases. ) 

10  days.  13.8  days.  20.33  days. 


RHEUMATISM.  819 


Average  Duration  (in  Days)  of 


Treatment.  Fever.  Pain.  Attack. 

Salicylates  and  opium (10  cases.)  (11  cases.)  (9  cases.) 

9.9  days.  8.45  days.  30.3  days. 

Salicylates  and  blisters (Teases.)  (7  cases.)  (6  cases.) 

6.14  days.  12  days.  15.83  days. 

Alkalies  and  then  quinine (6  cases.)  (6  cases.)  (5  cases.) 

13.5  days.  21.6  days.  35  days. 

Salicylates  and  quinine (6  cases.)  (6  cases.)  (6  cases.) 

10.5  days.  17  days.  31.6  days. 

It  has  been  said  that  when  endocarditis  or  pericarditis  comes  on,  the 
alkaline  treatment  should  be  adopted,  as  giving  the  best  results,  salicylates 
or  salicin  being  discontinued,  and  quinine  substituted  if  the  temperature 
runs  high.  Warm  poultices  to  the  prsecordia  may  be  useful  in  endocarditis, 
but  I  can  see  no  advantage  to  be  gained  by  the  application  of  blisters  or 
leeches,  as  advocated  by  some.  There  is  no  connection  between  the  circula- 
tion in  the  skin  and  that  of  the  endocardium.  With  pericarditis  it  is  dif- 
ferent :  there  the  superficial  vessels  have  free  communication  with  those  of  the 
parietal  pericardium,  and  local  depletion  of  the  surface  must  directly  relieve 
the  hypersemia  of  the  serous  membrane  below.  At  the  outset  of  pericar- 
ditis, one  to  three  leeches,  according  to  the  age  of  the  child,  are  often  of 
distinct  service.  Care  must  be  taken  that  the  bleeding  from  the  leech-bites 
does  not  go  on  too  freely  after  their  removal.  I  have  twice  seen  serious  en- 
feeblement  of  the  heart  from  too  great  loss  of  blood  through  carelessness  in 
this  respect.  Blisters,  on  the  other  hand,  seem  of  chief  value  when  there  is 
effusion ;  not  in  the  early  stage  of  active  inflammation.  They  cause  children 
annoyance  and  distress,  and  should  not  be  resorted  to  without  good  reason. 

If  in  endocarditis  or  pericarditis  the  action  of  the  heart  is  rapid  and 
turbulent,  three  to  five  drops  of  tincture  of  digitalis  may  be  given  every 
four  hours  to  a  child  of  five  years  for  twelve  or  twenty-four  hours,  after 
which  it  should  be  given  less  frequently.  Yet  it  must  be  administered 
cautiously  :  it  is  a  dangerous  remedy  when  there  is  much  pericardial  effusion, 
or  if  the  heart  is  greatly  embarrassed  by  thickened  adherent  pericardium. 
When  the  palpitation  is  due  to  feebleness  or  dilatation,  digitalis  has  great 
power  to  steady  and  give  tone  and  force  to  the  cardiac  contractions.  Although 
stimulants  should  be  avoided  if  possible,  they  are  sometimes  necessary  when 
signs  of  heart-failure  appear.  In  such  cases  they  may  be  given  freely  to 
the  amount  of  three  ounces  of  wine  and  one  and  a  half  ounces  of  brandy 
in  the  twenty-four  hours.  Alcohol  is  wonderfully  well  borne  by  children ; 
and  it  is  to  be  noted  that  it  ]iroduces  little  excitement,  but  rather  acts  as  a 
sedative.  For  young  (children  it  is  one  of  the  best  of  sedatives,  often  as 
effectual  as,  and  more  safe  than,  opium. 

A  remedy  of  immense  value  in  most  stages  and  forms  of  rheumatic 
fever  is  opium.  It  may  be  required  to  ease  pain  and  restlessness  and  pro- 
duce sleep.     It  may  be  given  freely  in  doses  of  one  to  three  minims  every 


820  KHEUMATISM. 

four  hours  for  a  child  of  five  years,  if  there  is  no  concurrent  pneumonia  or 
bronchitis.  The  vomiting  which  sometimes  sets  in  at  the  close  of  pericar- 
ditis should  be  combated  by  ice,  by  small  doses  of  hydrocyanic  acid  and 
soda,  and  by  the  substitution  of  nutrient  enemata  for  twelve  hours  for  food 
by  the  mouth.  If  chorea  is  severe,  and  the  patient  cannot  get  sleep  on 
account  of  the  constant  movement,  chloral  and  bromide  may  be  given  in 
doses  of  five  grains  of  each  in  syrup  of  orange  every  four  hours  uutil 
drowsiness  comes  on. 

Once  in  my  experience  obstinate  sleeplessness  was  found  to  depend  upon 
pain  caused  by  the  incessant  jactitation  of  an  arm  of  which  the  wrist  was 
swollen  and  tender  from  acute  arthritis  :  bandaging  the  arm  to  the  side  in 
a  comfortable  position  relieved  the  difficulty  for  the  time,  and  the  adminis- 
tration of  salicin  quickly  removed  the  joint-tenderness,  and  sleep  followed 
without  narcotic. 

When  the  temperature  has  come  down  and  remained  normal  for  a  week, 
iron  should  be  given  for  the  anaemia  which,  as  has  been  stated  already,  is  so 
marked  in  the  rheumatism  of  childhood.  The  citrate  of  iron  in  doses  of  five 
to  six  grains,  with  ten  to  fifteen  grains  of  citrate  of  soda  and  syrup  of  ginger 
in  half  an  ounce  of  water,  should  be  given  as  a  precaution  against  relapse, 
especially  if  there  has  been  any  cardiac  inflammation  ;  or  citrate  of  iron  and 
quinine  five  grains  ^vith  citrate  of  soda  or  potash  in  the  same  way,  with  two 
drachms  each  of  water  and  chloroform-water ;  but  in  this  case  five  grains 
of  citric  acid  or  a  teaspoonful  of  lemon-juice  must  be  added,  to  prevent  the 
precipitation  of  the  quinine  by  the  excess  of  alkali  which  is  practically 
always  present  in  the  soda  or  potash  salt.  If  the  anaemia  is  extreme,  or  the 
chronic  symptoms  persist,  arsenic  should  be  given  with  iron  in  the  form  of 
two  drops  of  liquor  potassii  arsenitis  in  two  drachms  of  wine  of  iron  twice  a 
day  after  food.  This  is  the  most  efficient  of  all  drugs  in  the  restoration  of 
red  blood-corpuscles  :  it  should  not,  however,  be  prescribed  until  all  symp- 
toms of  active  inflammation  are  over,  for  it  stirs  up  hypersemia  in  skin  and 
mucous  membranes,  as  evidenced  by  the  reddened  conjunctiva  and  tongue 
and  flushed  skin  produced  by  full  doses  of  the  drug,  and  may  presumably 
aifect  fibrous  structures  and  serous  membranes  in  like  manner. 

The  erythema  goes  with  the  subsidence  of  the  other  symptoms,  and 
requires,  as  a  rule,  no  special  treatment.  Tonsillitis  yields  to  salicylates 
and  salicin  with  great  readiness. 

The  diet  in  cases  of  rheumatism  does  not  call  for  the  close  limitation 
which  is  usually  enforced.  When  the  temperature  is  raised,  and  acute 
symptoms  are  present,  it  should  consist  entirely  of  beef  tea  or  broth  with 
milk.  In  cases  of  great  anaemia  or  prostration,  Valentine's  meat  juice,  or 
even  raw  meat  pulp  itself  if  it  can  be  taken,  should  be  given  as  blood- 
restorers  ;  and  self-digesting  foods,  or  peptonized  milk,  are  most  useful.  As 
the  fever  declines,  light  pudding,  eggs,  bread-and-butter,  and  tea  may  be 
permitted ;  and  thus  the  patient  may  })ass  on  to  fish  or  meat. 

Large  quantities  of  sugar  are  theoretically  objectionable,  as  tending  to 


RHEUMATISM.  821 

favor  lactic  fermentatiou.  The  patient  should  rest  in  bed  for  at  least  ten 
days  after  all  acute  symptoms  have  finally  disappeared,  so  as  to  insure 
against  chill  and  preserve  extreme  quietness  of  cardiac  action. 

Prevention. — A  child  who  has  once  had  acute  rheumatism  is  prone  to 
have  it  again,  the  tendency  gradually  becoming  less  as  age  increases.  A 
child  born  of  rheumatic  stock  has  also  a  special  liability  to  the  disease.  In 
both  cases  precautions  should  be  taken  to  protect  those  who  are  thus  predis- 
posed from  overheating,  chill,  and  over-fatigue,  the  great  sources  of  rheuma- 
tism. To  this  end,  the  child  should  not  be  kept  too  tenderly,  but  should  be 
kept  out  of  hot,  close  rooms,  should  live  in  a  cool  and  even  temperature, 
should  be  clothed  in  woollen  next  the  skin,  while  the  body  is  hardened  by 
tepid  salt-water  baths  and  vigorous  friction.  In  case  of  accidental  exposure 
to  cold  or  wet,  brisk  exercise  should  be  taken  until  a  full  glow  of  warmth 
is  experienced,  and  damp  clothes  changed  at  the  earliest  moment.  When 
heated  or  overtired  by  severe  exertion,  standing  about  in  cool  air  should  be 
carefully  avoided,  and  the  body  protected  against  chill  by  an  extra  covering 
until  it  cools  down  again.  Damp  air  and  cold  soil  and  variable  climate 
should  be  avoided.  When  circumstances  permit,  the  rheumatic  child  should 
be  removed  to  a  dry,  warm  climate,  with  sandy  soil,  in  a  situation  not  over- 
crowded with  trees,  exposed  to  sunlight,  and  with  a  free  circulation  of  air. 


CHRONIC   RHEUMATISM. 

Chronic  Rheumatism  is  rare  in  children, — much  more  rare  than  in 
adults.  It  is  to  be  distinguished  from  the  relapsing  form  of  acute  rheuma- 
tism, where  fresh  exacerbations  of  a  mild  kind — sometimes  nothing  more 
than  stiffness  and  vague  pains  without  swelling — recur  from  time  to  time. 
But  in  certain  cases  affections  of  the  joints,  such  as  effusions  or  ankylosis, 
do  remain  in  chronic  form  after  an  acute  attack.  Henoch  speaks  of  exos- 
toses and  bony  formations  in  tlie  muscles  and  tendons  as  liable  to  be  devel- 
oped in  rheumatic  children,  occasionally  to  such  a  degree  as  to  convert  a 
large  part  of  the  muscular  and  tendinous  system  into  a  bony  mass,  rendering 
almost  every  movement  of  the  body  impossible. 

For  inveterately  chronic  cases,  medicinal  baths  of  sulphuretted  waters, 
or  brine  baths,  or  hot  springs  of  other  kinds,  afford  the  most  hopeful  treat- 
ment, the  more  stimulating  waters  or  the  simpler  warm  baths  being  used, 
according  as  the  promotion  of  absorption  or  the  relief  of  pain  is  the  chief 
object.  Wrapping  the  joints  in  wool  imprcguuted  witli  })ine  oil,  Avhich 
keeps  up  a  constant  mild  stimulation,  is  an  excellent  })laii  in  slighter  cases. 
For  the  more  confirmed  and  severe,  small  blisters  repeated  from  time  to 
time,  or  the  application  of  oleate  of  mercury  in  mild  form  (from  two  to  five 
per  cent.),  are  more  useful.  Other  counter-irritants,  such  as  the  tincture 
of  iodine  painted  over  the  joint,  or  a  stimulating  and  anodyne  liniment  of 


822  RHEUMATISM. 

chloroform  and  belladonna,  have  their  place  in  treatment.  Internally, 
iodide  of  potassium  affords  perhaps  some  help  in  reducing  the  chronic  con- 
gestion of  the  parts  and  the  resultant  exudation. 


KHEUMATOID   ARTHRITIS. 

Definition. — A  chronic  disease  of  the  joints,  characterized  by  slow 
inflammatory  and  degenerative  changes  of  the  articular  structures,  and 
leading  to  distortion  and  other  deformity. 

Etiology. — Rheumatoid  arthritis  (arthritis  deformans)  can  hardly  be 
called  a  child's  disease,  for  it  is  as  rare  in  childhood  as  acute  rheumatism  is 
common,  yet  it  must  not  be  passed  over  without  brief  mention.  Sir  A. 
Garrod  affirms  that  he  has  seen  it  in  severest  form  in  children  of  ten  or 
twelve  years ;  Dr.  West  records  a  few  cases,  and  speaks  of  it  as  most  rare. 
I  have  seen  three  cases  in  little  children  which  presented  all  the  symptoms 
of  rheumatoid  arthritis.  Seeing  that  rheumatoid  arthritis  sometimes  re- 
mains as  a  chronic  sequel  of  genuine  rheumatism,  it  might  be  expected  to 
be  more  common  in  children  than  it  is ;  yet  I  have  never  seen  it  in  this 
relation.  In  each  instance  which  has  come  under  my  observation  it  resulted 
from  the  direct  and  sustained  operation  of  certain  potent  causes,  cold,  damp, 
feeble  health,  and  other  depressing  conditions. 

Pathology  and  Morbid  Anatomy. — This  must  be  presumed  to  be  the 
same  as  that  met  with  in  similar  conditions  in  adults,  although  I  know  of 
no  instance  in  which  this  has  been  actually  verified  by  post-mortem  exami- 
nation. The  condition  is,  no  doubt,  one  of  chronic  inflammatory  changes 
affecting  all  the  joint-structures,  cartilages,  bones,  synovial  membrane,  liga- 
ments, and  extending  even  to  tendons  and  muscles.  There  is  more  or  less 
complete  absorption  of  the  cartilages,  wearing  away  of  the  denuded  bones, 
formation  of  new  bony  growths  along  the  free  margins  of  the  cartilages, 
and  the  ossification  may  extend  to  the  tendons  and  capsule.  With  these 
changes  are  associated  wasting  and  fatty  degeneration  of  the  muscles  and 
tendons  related  to  the  joint. 

Symptoms. — TJie  disease  exhibits  no  special  features  in  the  case  of 
children.  It  is  associated  with  the  smaller  joints  of  the  extremities,  the 
form  found  in  youuger  adult  patients,  as  contrasted  with  tliat  affecting  the 
larger  joints,  wliieh  is,  I  think,  solely  a  senile  change.  It  begins  probably 
iu  the  same  way  with  fugitive  articular  pains,  then  stiffness,  especially  after 
the  joints  have  not  been  moved  for  some  time,  as  first  thing  in  the  morning. 
Then  comes  a  little  swelling  of  tlie  articular  ends  of  the  bones,  with  per- 
haps slight  tenderness.  Next  follows  some  displacement,  owing  to  altered 
shape,  the  formation  of  nodules,  excrescences,  and  erosion  of  cartilage,  and 
the  parts  grate  on  movement. 

Perhaps  the  most  striking  part  of  the  affection  is  the  singular  wasting 


•    RHEUMATISM.  823 

of  the  muscles  which  are  in  relation  to  the  joint.  This  is  best  seen  in  the 
hands,  which  are  most  often  the  first  parts  aflPected,  when  the  atrophy  of 
the  extensors,  together  with  the  deflection  of  the  phalanges  to  the  ulnar  or 
less  commonly  to  the  radial  side,  and  the  flexing  of  the  fingers,  gives  the 
hand  the  peculiar  claw-like  appearance  which  is  absolutely  characteristic. 
With  this  are  thinning  and  glossiness  of  skin  over  the  afiected  parts. 

All  these  changes  are  occasionally  met  with  in  their  typical  form  in 
children,  and,  inasmuch  as  they  differ  in  no  respect  from  the  symptoms  met 
with  in  adults,  require  no  detailed  description  here. 

There  is  now  at  the  Hospital  for  Sick  Children,  under  the  care  of  my 
colleague  Dr.  Sturges,  a  little  boy  three  years  old  who  presents  the  charac- 
teristic signs  of  rheumatoid  arthritis.  The  child  has  had  swellings  of  the 
joints  with  tenderness  since  the  age  of  eighteen  months.  The  fingers,  wrists, 
elbows,  shoulders,  knees,  and  ankles  are  all  affected.  In  the  larger  joints 
there  is  slight  effusion,  and  in  the  elbow  and  shoulder  crepitus  on  move- 
ment. The  ends  of  the  phalanges  are  enlarged.  The  muscles  related  to 
the  affected  parts  are  very  greatly  wasted.  The  lymphatic  glands  in  the 
arms  are  greatly  enlarged.  The  child  has  signs  of  rickets ;  and  the  question 
has  been  raised  as  to  whether  the  condition  might  not  be  connected  with  this 
affection  or  with  congenital  syphilis.  I  examined  the  child  several  times, 
and  came  to  the  conclusion  that  the  case  was  one  of  genuine  rheumatoid 
arthritis. 

Diag-nosis. — It  is  extremely  difficult  to  distinguish  rheumatoid  arthritis 
from  the  more  chronic  or  subacute  forms  of  genuine  rheumatism  until  the 
characteristic  deformities  Have  been  developed.  Indeed,  in  many  cases 
arthritis  deformans  would  appear  to  be  a  later  development  or  sequela  of 
the  acute  form.  But  when  the  enlargement  of  the  joints,  the  crepitus  on 
movement,  the  w^asting  of  muscles,  the  thinned  glossy  skin,  and  the  distor- 
tion of  the  fingers  arise,  there  is  no  further  difficulty  in  determining  the 
exact  nature  of  the  disease. 

Prognosis. — Cases  of  this  kind  are  so  rare  in  children  that  but  scanty 
means  of  forming  a  judgment  as  to  its  course  and  issue  are  available.  The 
prognosis  in  the  case  of  a  child  might  fairly  be  expected  to  be  more  favor- 
able than  with  an  adult ;  and  one  or  two  cases  where  the  attacks  have  been 
slight  have  apparently  ended  in  recovery  more  or  less  complete. 

But  in  the  more  severe  cases  rheumatoid  arthritis  is  as  persistent  as 
with  adults ;  although  it  is  capable  of  being  modified  by  treatment  and  is 
attended  with  no  immediate  danger  to  life.  The  feeble  health  with  which 
it  is  associated  is  a  cause  ratlier  than  a  consequence  of  the  disease. 

Treatment. — The  affection  being  especially  associated  with  enfeebled 
general  health,  all  lowering  or  drastic  treatment  is  not  only  useless,  but 
positively  injurious.  I  have  often  observed  serious  aggravation  of  all  the 
symptoms  to  follow  severe  treatment  by  purges,  alkalies,  and  colcliicura, 
with  low  diet,  prescribed  under  the  mistaken  impression  that  the  disease 
to  be  dealt  with  was  true  gout,  or  genuine  rheumatism,  and  on  the  otlier 


824  EHEUMATISM. 

hand  have  seen  remarkable  improvement  result  from  the  change  to  more 
tonic  treatment  and  more  generoas  diet.  Everything  which  tends  to  im- 
prove general  health  and  nutrition  is  beneficial  in  rheumatoid  arthritis.  A 
warm,  dry,  sunny  climate,  simple  nutritious  food,  and  warm  clothing  are 
of  the  first  importance.  And  locally  as  well  as  generally  all  severe 
measures  are  hurtful.  The  joints  will  not  bear  blisters  or  strong  stimu- 
lating applications  or  counter-irritants.  These  tend  to  increase  the  morbid 
changes  going  on  in  and  around  the  joints.  A  weak  solution  of  iodine 
with  glycerin — fifteen  drops  of  the  former  and  a  drachm  of  the  latter  to 
the  ounce  of  water — may  be  applied  under  oiled  silk  or  the  pine-oil  wool, 
but  nothing  more.  Gentle  rubbing  and  exercise  of  the  joint  help  to  keep 
the  movement  free.  Much  benefit  sometimes  follows  the  administration  of 
iodide  of  potassium  and  arsenic.  Three  grains  of  the  latter,  with  two 
drops  of  liquor  potassii  arsenitis  and  two  drachms  of  wine  of  iron  in  six 
drachms  of  water,  may  be  given  twice  a  day.  In  children  cod-liver  oil  may 
be  added  with  advantage. 

But  the  means  which  do  most  good  are  hot  baths,  especially  those  of  a 
stimulating  kind,  such  as  the  sulphur  waters  and  brine  and  mud  baths.  If 
circumstances  preclude  the  patient  from  visiting  the  natural  warm  springs, 
sulphur  baths  made  by  adding  four  ounces  of  sulphur  or  of  sulphate  of 
potassiiun  to  thirty  gallons  of  water  will  often  answer  the  purpose  sufii- 
cientlv  well. 


MALARIA. 

By   F.   FOECHHEIMEE,   M.D. 


Malaeia  is  becoming  of  great  importance  to  iis,  as  physicians  and 
scientists,  from  year  to  year.  Those  who  follow  the  theoretical  aspect  of 
the  question  find  themselves  more  interested  as  they  get  more  deeply  in- 
volved in  trying  to  solve  its  mysteries.  To  the  practitioner,  there  is  so 
much  that  is  necessary  even  in  his  routine  of  daily  work,  the  disease  itself, 
its  various  manifestations,  its  relations  to  other  diseases,  etc.,  that  the 
chapter  on  malaria  is  of  the  utmost  importance.  This  has  always  been  the 
case,  but  at  the  present  day  the  subject  has  additional  value,  for  no  practi- 
tioner can  go  through  his  work  without  seeing  a  greater  or  less  number  of 
cases  of  malaria.  If  he  lives  in  a  malarial  district,  he  becomes  familiar 
with  the  disease ;  if  he  does  not,  the  cases  are  brought  to  him  for  cure,  in 
this  day  of  rapid  transit,  on  account  of  the  fact  that  he  lives  in  a  non- 
malarial  district.  In  this  way,  at  times,  he  sees  even  those  most  violent 
forms  which  are  seen  only  where  the  poison  is  most  intense  and  active.  It 
is  said  that  malaria  and  civilization  are  antagonistic ;  yet  in  this  country 
this  can  hardly  be  said  to  be  true ;  but  medical  geography  does  prove  that 
malarial  districts  are  constantly  shifting,  so  that  a  region  that  has  been 
looked  upon  as  perfectly  safe  suddenly  becomes  malarial  (the  valley  of  the 
Connecticut  River,  for  instance,  or  parts  of  the  Atlantic  coast),  and  in  the 
course  of  a  practitioner's  lifetime  it  may  become  highly  necessary  for  him 
to  be  able  to  distinguish  the  various  forms  of  malaria.  At  present  the 
term  "malaria"  is  frequently  used  as  a  charitable  mantle  to  cover  sins 
in  diao-nosis.  Indeed,  it  has  become  one  of  the  fashionable  diseases :  as 
our  forefathers  took  their  after-dinner  pills  or  their  blue  mass  for  bilious- 
ness, so,  to-day,  the  household  is  incomplete  without  sugar-  or  gelatin-coated 
pills  of  quinine.  These  arc  taken  indiscriminately  by  old  and  young,  by 
strong  and  weak,  and  for  everything:  it  is  all  malaria, — the  dyspepsia 
of  the  worn-out  merchant,  the  hysterics  of  the  esthetic  damsel,  or  the  colic 
of  the  baby.  After  all,  we,  as  physicians,  are  to  be  blamed  for  this,  as  it 
is  so  easy  to  tell  a  patient,  and  so  satisfactory  to  him,  "You  are  suffering 
with  a  slight  attack  of  malaria,  which  a  few  doses  of  quinine  will  relieve." 
But  with  this  comes  an  amount  of  mental  indifference  as  to  diagnosis, 
which  has  allowed  an  abomination  like  "  typho-malaria"  to  obtain  full 

825 


82fi  MALARIA. 

swing,  and  which  has  cost  many  a  patient  his  life  in  that  the  physician  was 
mentally  incapable  or  unwilling  to  draw  his  lines  strict  enough. 

When  it  comes  to  children,  we  find  the  laxity  still  greater ;  for  it  is 
only  comparatively  recently  that  tlie  whole  of  the  study  of  children's  dis- 
eases has  been  elevated  above  anything  that  would  deal  with  more  than 
teething,  growing  pains,  or  worms.  As  a  result,  the  literature  referring  to 
children  will  be  found  very  meagre ;  yet  sufficient  has  been  done  to  show 
that  excellent  observers  have  been  on  the  alert  and  have  watched  many  of 
the  interesting  manifestations  of  this  poison  in  children,  some  of  which 
seem  to  be  peculiar  to  them. 

Definition. — By  malaria  is  meant  a  series  of  clinical  pictures  due  to  a 
specific  poison.  These  clinical  pictures  have  been  divided  into  various 
groups  which  have  been  characterized  by  the  type  of  fever  that  accom- 
panies them  :  in  this  way  we  have  the  intermittent,  the  remittent,  and  the 
continuous  forms.  It  has  been  found,  however,  that  well-marked  attacks  of 
malaria  exist  without  the  production  of  fever,  so  that  forms  occur  in  which 
the  symptoms  may  be  of  any  one  of  these  types — i.e.,  intermittent,  remit- 
tent, or  continuous — without  being  characterized  by  an  elevation  of  tem- 
perature. As  will  be  seen  when  we  come  to  the  discussion  of  intermittents, 
these  divisions  are  again  subdivided ;  so  that  there  is  room  for  sufficient 
classification,  which,  however,  is  of  comparatively  little  importance. 

Etiology  and  Pathology. — Scientists,  all  over  the  world,  are  now  try- 
ing to  specify  what  the  poison  is,  its  habitat  and  its  proj^erties.  It  is  hut 
just  to  say  that  up  to  the  present  time  we  are  justified  in  the  conception 
tiiat  it  is  some  lower  form  of  life,  which  has  eluded  scientific  proof  fully 
to  establish  its  acceptance.  As  early  as  1717,  Lancisi^  stated  that  malaria 
was  due  to  parasites  which  entered  the  blood ;  and  from  that  time  to  this 
many  things  have  been  found,  accused,  and  then  not  found  guilty.  It  is 
within  the  memory  of  all  of  us  (1866)  how  positively  our  own  countryman 
Salisbury  had  discovered  the  essence  of  malaria,  and  what  a  pitiftd  end  his 
wonderful  and  fearful  experiences  took.  It  would  lead  us  too  far  to  make 
note  of  all  the  researches  into  what  always  proved  an  ignis-fatmis,  so  that 
we  start  in  the  historical  development  of  the  subject  with  a  something  that 
seems  at  least  tangible.  In  1879,  Klebs  and  Tommasi-Crudeli  published 
their  researches^  in  which  they  had  investigated  the  air,  the  soil,  and  the 
water  of  the  Pontine  Marshes.  They  found  a  great  number  of  lower  forms 
of  life, — cocci,  bacteria,  alg?e,  variously-shaped  bodies.  Of  all  of  these 
there  were  left  bacilli,  only,  after  culture.  These  bacilli  were  from  four 
to  six  micro-millimetres  in  length,  they  were  mobile,  and  some  contained 
spores  and  aerobics.  When  a  pure  culture  of  these  Avas  injected,  in  large 
quantity,  into  the  veins  of  a  rabbit,  the  animal  got  a  fever.  Objections 
were  raised  to  these  experiments  as  follows :   animals  that  live  in  these 

^  See  Laveran,  Traite  des  Fievres  palustres,  Paris,  1884. 
^  Arch.  f.  Experiment.  Path.,  July,  1879. 


MALARIA.  827 

malarial  regions  do  not  suffer  with  malarial  affections ;  so  many  mate- 
rials, when  injected  into  the  blood-vessels,  produce  fever ;  it  was  not 
proved  that  these  animals  experimented  upon  had  anything  like  intermit- 
tent fever;  and,  lastly,  the  methods  used  were  not  above  suspicion  as  to 
their  scientific  exactness.  Crudeli '  proves  that  fever  can  be  given  to 
rabbits  by  inoculation,  that  they  have  a  chill,  and  that  during  the  chill 
the  animal  contains  the  bacillus  malarise ;  that  pure  cultures  of  the  bacillus 
can  be  made  by  taking  blood  from  the  spleen  of  the  animal  inoculated, 
and  that  these  cultures,  in  their  turn,  will  produce  fever.  This  is  a  com- 
plete chain  of  evidence ;  but,  unfortunately,  other  experimenters  have  been 
unable  to  verify  these  results  completely.  Some  find  nothing  in  the  blood, 
others  have  not  even  been  able  to  verify  the  possibility  of  causing  malarial 
attacks  in  animals  by  the  injection  of  affected  blood.  These  investigations 
have,  however,  led  to  the  discovery  of  a  something  in  the  blood  which 
seems  to  be  practically  of  great  importance.  Laveran  was  the  first  to 
describe  bodies  in  connection  with  the  red  corpuscles  of  the  blood  (1881), 
and  of  these  he  claims  that  there  are  various  kinds,  two  cystic  and  two 
mobile,  representing  different  stages  of  the  same  parasite.  Body  No.  1  is 
semilunar,  containing  pigment,  often  attached  to  the  red  corpuscle,  and 
somewhat  larger  than  it.  Body  Xo.  2  is  spherical,  and  varies  in  size, 
being  sometimes  as  large  as  a  red  corpuscle,  at  other  times  veiy  much 
smaller,  and  also  containing  pigment.  Both  bodies  possess  amoeboid  move- 
ment, and  bodies  Xos.  3  and  4  are  formed  from  them.  Xo.  3  is  simplv 
Xo.  1  or  2  with  cilia,  and  Xo.  4  are  the  cilia  or  filaments  themselves  de- 
tached from  their  cysts,  representing  the  fully-developed  form  of  the 
parasite.  In  1883,  ]\Iarchiafava  and  Celli  puljlished  their  researches  which 
eventually  led  them  to  accept  as  the  cause  for  malaria  the  so-called  Plas- 
modium malarise.  AVe  make  an  abstract  of  their  latest  communications 
(1886).  There  are  found  in  the  red  corjDUseles  of  the  blood,  in  subjects 
suffering  with  malaria,  micrococci  and  masses  of  protoplasm,  with  all 
the  characteristic  properties  of  protoplasm.  These  bodies  take  up  certain 
aniline  coloring-matter, — fuchsin,  methyl-  or  gentian-violet, — and  should  be 
examined  fresh.  Within  them  there  is  found  reddish  or  black  pigment,  due 
to  their  action  upon  haemoglobin,  and  not  a  part  of  their  natural  structure. 
When  blood  is  taken  from  patients  suffering  from  malaria  and  injected  into 
the  veins  of  healthy  subjects,  the  result  is  infection  with  malaria  ;  aud  these 
same  bodies  will  be  found  in  the  infected  sul)ject.  Marchiafava  aud  Celli 
claim  to  have  seen  the  micro-organism  in  division,  and  in  this  wav,  they 
think,  reproduction  takes  ])]acc.  They  admit  that  Laveran  has  seen  the 
right  thing,  but  claim  that  his  interpretation  is  incorrect,  and  look  upon  the 
various  figures  which  he  has  given  as  representing  different  states  or  stages 
of  their  plasniodium.  It  was  impossible  to  cultivate  the  plasmodium,  and 
examination  of  soil  resulted  negatively,  although  the  micrococcus  was  found, 

»  Practitioner,  1880. 


828  MALARIA. 

but  not  pathogenic  as  to  animals.  If  we  look  back  upon  the  investigations 
made,  it  will  be  seen,  then,  that  we  have  two  series, — the  one  referring  to  a 
bacillus,  the  second  referring  to  a  protoplasmic  body  which  is  now  accepted 
as  the  Plasmodium.  The  former  series  seems  to  have  been  dropped  by 
investigators.  Whether  or  not  a  bacillus  or  micrococcus  will  be  found 
as  forerunner  of  the  j)lasmodium,  as  is  hinted  at  in  the  publications  of 
Marchiafava  and  Celli  and  more  definitely  expressed  in  an  article  by  Von 
Sehlen,  remains  to  be  seen.  The  latter  series  has  been  favorably  commented 
upon,  and  been  taken  up,  so  far  as  diagnostic  value  is  concerned,  by  many 
authors  (Welch,  Councilman,  Osier,  Von  Sehlen).  In  the  most  recent  com- 
munications made  by  Crudeli^  he  states  positively  that  the  plasmodium,  or 
pseudo-plasmodium,  as  he  calls  it,  is  the  result  of  the  Klebs  and  Crudeli 
bacillus.  This  "plasmodium'^  can  be  produced  by  a  variety  of  poisons 
acting  upon  the  red  corpuscle,  typhus  and  scarlatina,  and  in  progressive 
anaemia.  He  had  come  to  the  conclusion  that  the  blood-changes  combined 
with  the  great  quantity  of  pigment  were  characteristic  of  malaria ;  but  the 
paper  of  Rosenstein  has  convinced  him  of  the  contrary.  These  researches 
still  require  verification,  but  they  show  that  even  the  diagnostic  value  of 
the  Plasmodium  malarise  is  denied  by  excellent  observers.  Although  we 
are  not  justified,  in  the  present  condition  of  the  question,  in  saying  that  the 
Plasmodium  produces  malaria,  we  can  state  that  it  is  found  in  one  form  or 
another  in  greater  or  less  numbers  in  every  case  of  malaria.  From  this  it 
will  be  seen  how  veiy  important  the  subject  is  from  a  practical  stand-point. 
Cases  have  been  reported  (Councilman)  in  which  the  absence  of  the  plas- 
modium in  the  blood  was  sufficient  to  disestablish  a  diagnosis,  and  in  my 
own  experience  two  cases  have  occurred  which  have  conclusively  proved  to 
me  the  importance  of  examining  the  blood  in  doubtful  malarial  cases.  The 
one  case  was  an  atypical  typhoid  fever,  in  which,  as  there  was  a  strong 
tendency  to  an  intermittent  type  of  fever,  the  diagnosis  of  intermittent  fever 
had  been  made,  corrected  by  the  repeated  failure  to  find  the  plasmodium, 
and  in  which  the  patient  finally  died  of  a  perforation  of  the  intestines.  The 
typhoid  lesions  and  perforations  Avere  all  demonstrated .  by  the  autopsy. 
The  other  case  was  one  in  which  the  diagnosis  of  typhoid  had  been  made, 
and  in  which*  the  plasmodium  was  found  during  a  chill  and  the  case 
promptly  relieved  by  a  large  dose  of  quinine.  Not  only  in  grave  cases  like 
these,  but  also  in  comparatively  mild  ones,  neuralgias,  intestinal  troubles, 
etc.,  the  Plasmodium  can  he  demonstrated,  and,  with  patient  search,  a  posi- 
tive diagnosis  can  always  be  arrived  at.  On  account  of  their  practical  im- 
portance, we  have  had  copied  the  excellent  figures  given  by  Councilman  in 
his  article  published  in  vol.  i.  of  the  '*  Transactions  of  the  Association  of 
American  Physicians  and  Pathologists,"  and  also  an  illustration  from  Osier's 
paper. 

There  are  several  things  to  be  remembered  in  searching  for  this  lower 

J  Deutsche  Med.  AVoch.,  1887,  p.  993,  and  Berlin.  Klin.  Woch.,  1887,  p.  695. 


MALARIA. 


829 


form  of  life.     The  nearer  the  chill  the  blood  is  taken,  the  surer  We  are  of 
finding  the  organism,  as  it  finds  its  maximum  development  about  the  time 


"^«8iiiiP" 


PiGJiENTED  Body  in  Red  Blood-Corpuscle  :  outlined  with  camera  {-^  Zeiss,  C  eye-piece) 
by  Dr.  J.  P.  C.  Griflfith  ;  illustrating  some  of  the  changes  during  an  hour  and  a  half's  obser- 
vation, a,  at  11.45,  slow  alterations  in  outline,  and  the  pigment-granules  are  in  active  dancing 
motion,  o',  12.15.  a",  12.25,  body  has  rotated  as  well  as  altered  its  shape,  a"',  12.30.  a",  12.40. 
a",  1  o'clock,  a",  1.02.  (From  "  Hsematozoa  of  Malaria,"  by  Wm.  Osier,  M.D.,  British  Medical 
Journal,  March  12, 1887.) 

of  the  chill.    In  order  to  see  the  plasmodium,  the  blood  must  be  spread  out 
in  a  very  thin  layer  and  then  looked  at  with  a  power  not  below  500-600 


Section  of  Kidney,  showing  Small  Vein  of  the  Pia  JIater  filled  with  Pigmented 

Small     Vein     containing     Pig-       Hyaline   Bodies.     From  a  case  of  comato.se  malarial  fever. 
MENTED  Hyaline  Bodies  and  Pii;-       Zeiss,  obj.  I'g,  oc.  2.    (Councilman.) 
menteu  Leucocyte.    Zeiss,  obj.  ^, 
00.  2.    (Councilman.) 

diameters.     Staining  is  not  necessary,  but  brings  out  the  contours  better, 
and  fuchsin  or  methvl-violet  can  be  used.     The  blood  must  first  be  dried 


830 


MALARIA. 


while  passing  the  thin  cover  or  slide  over  the  flame  of  a  spirit-lamp  several 
times.  The  organisms  cannot  be  kept  for  a  very  long  time  unless  they  are 
mounted  in  balsam.  Morphologically,  only  the  organisms  within  the  red 
corpuscle  are  characteristic.  I  have  several  times  found  the  crescentic 
bodies  described  by  Osier  in  the  blood  of  perfectly  healthy  individuals. 
Whether  a  great  number  of  these  present  in  the  blood  or  in  some  other 
fluid,  as  the  urine,  in  which  I  have  also  found  them,  would  alone  be  suffi- 
cient to  establish  a  diagnosis  of  malaria,  it  is  too  early  to  say.  I  have  seen 
the  Plasmodium  in  very  mild  forms  of  malarial  trouble,  as  well  as  in  the 
very  severe ;  but  the  more  the  blood-corpuscles  are  examined  with  high 
powers  the  more  fully  am  I  convinced  that  a  great  many  bodies  are  found 
there  which  have  been  only  incompletely  described,  and  which  to  the  super- 
ficial observer  might  seem  to  be  the  plasmodium.  It  is,  therefore,  neces- 
sary before  beginning  to  look  for  the  abnormal  to  make  one's  self  perfectly 
familiar  with  the  normal  appearance :  this  should  be  done  by  using  the  same 
methods  employed  for  detecting  the  plasmodium,  and  with  the  strongest 
lenses  at  one's  command. 

If  we  are  to  seek  for  the  poison  in  the  soil, — and  all  observers  agree  that 
this  is  its  natural  habitus, — it  will  readily  be  understood  that  certain  con- 
ditions favor,  and  others,  on  the  other  hand,  retard,  its  growth.  Thus,  tem- 
perature and  moisture  seem  to  be  the  quantities  increasing  or  diminishing 
malarial  attacks.  It  is  not  surprising,  therefore,  to  see  how  various  authors 
differ  as  to  the  time  when  most  cases  are  met  with,  inasmuch  as  they  live  in 
different  climates  and  environments.  A  casual  glance  at  reports  made  from 
a  few  sources  will  be  instructive  as  to  when  the  greatest  number  of  cases 
occur. 


Months. 

Country. 

Author. 

•July,  August,  September 

Southern  Eussia. 

P.  Werner,  Beobachtungen  iiber  Ma- 
laria, Berlin,  1887. 

April  and  May     .... 

Sweden. 

Geissler,  Schmidt's  Jahrbiicher,  1880, 
Bd.  civ.  p.  78. 

August  to  October   .    .    . 

Italy. 

Geissler,  Schmidt's  Jahrbiicher,  1886, 
Bd.  ccxi.  p.  72. 

February  to  September  . 

Northern  Germany. 

Bohn,  Handbuch  der  Kinderkrankhei- 
ten,  Gerhardt,  vol.  ii.  p.  448. 

With  us,  it  seems,  there  are  two  maxima,  one  in  the  spring  and  one  in 
the  early  fall,  although  there  is  no  month  of  the  year  in  which  we  do  not 
see  some  cases,  either  domestic  or  imported.  A  glance  at  this  short  table 
will  show  that  in  all  of  these  authors  the  maxima  come  at  a  time  when  the 
temperature  is  not  at  the  lowest. 

So  far  as  moisture  is  concerned,  this  seems  to  be  absolutely  necessary ; 


MALARIA.  831 

reports  are  common  where  malaria  has  appeared  after  a  flood,  and,  per 
contra,  where  it  has  disappeared  after  the  complete  drainage  of  swamps. 
Xo  better  exemplification  of  the  latter  fact  conld  be  asked  for  than  the  table 
published  by  Asche^  concerning  the  number  of  cases  of  malaria  in  the 
Algerian  garrison  at  Boria.  This  little  place,  surrounded  by  swamps, 
caused  a  great  number  of  deaths  among  the  soldiers  garrisoned  there :  as 
soon  as  drainage  and  cultivation  were  resorted  to,  the  mortality  and  mor- 
bidity diminished,  to  be  increased  immediately  the  swamps  were  allowed  to 
fill  up  again.  In  1865,  nine  hundred  and  fifty-eight  cases,  with  five  deaths, 
were  observed  ;  while  in  1880  there  were  only  two  hundred  and  forty-seven 
cases,  with  two  deaths.  The  statement  is  also  made  that  those  who  attended 
to  the  manual  labor  of  draining  suffered  most.  There  is  no  doubt  that  civi- 
lization and  cultivation  are  antagonistic  to  the  intense  forms  of  malarial 
intoxication,  but  cause  an  increase  in  the  milder  forms.  There  is  not  a 
sewer  or  a  gas-pipe  put  down  in  any  of  our  cities  built  upon  malarial  ground 
which  does  not  cause  an  epidemic,  more  or  less  localized.  The  same  can 
be  said  for  the  digging  of  foundations  in  soil  which  has  been  heretofore- 
covered  with  grass  and  is  upturned,  exposing  to  the  air  the  malarial  poison 
which  has  lain  dormant  for  years.  Speaking  from  a  local  stand-point, 
those  people  suffer  most  from  malaria  who,  from  their  position  and  wealth,, 
should  suffer  least.  This,  of  course,  is  true  only  of  cities ;  in  the  country 
every  one  is  alike,  those  living  in  villages  perhaps  suffering  less  than  those 
in  the  open. 

It  is  an  accepted  idea  by  both  people  and  practitioners  living  in  malarial 
districts  that  infection  is  more  liable  to  take  place  between  the  hours  of 
sunset  and  sunrise ;  and,  although  it  seems  impossible  to  settle  this  scien- 
tifically, there  are  many  observations  which  seem  to  show  the  truth  of 
this  view.  So  far  as  children  are  concerned,  this  would  seem  a  reasonable 
explanation  for  the  comparative  immunity  infants  enjoy,  as  they  are  not 
liable  to  be  exposed  to  the  poison  at  the  above-mentioned  time.  There  is  no 
doubt  of  the  fact  that  malaria  sweeps  along,  causing  epidemics,  to  places 
which  have  been  non-malarial ;  ^  and,  so  far  as  the  geographical  distribu- 
tion of  the  disease  is  concerned,  it  can  be  safely  said  that,  at  present,  few 
countries  are  entirely  free  from  it.  Indeed,  the  picture  is  so  variable  that 
statements  made  ten  years  ago  regarding  the  medical  geography  of  malaria 
could  not  be  accepted  to-day.  The  tropics  and  su})tropics  furnish  us  with 
the  most  violent  forms ;  the  temperate  zones  produce  a  great  number  of 
cases,  but  not  so  intense ;  and  even  those  countries  lying  far  to  the  north  do^ 
not  seem  to  be  entirely  free. 

Morbidity. — Malarial  poisoning  spares  neither  age  nor  sex.  The  effect 
of  malaria  upon  pregnant  women  is  frequently  that  of  i)r{)ducing  mis- 
carriage,— whether  from  general  intoxication  or  from  infection  and  death 


'  Schmidt's  Jahrbiicher,  1885. 

^  See  Strieker,  Die  Infectionslvrankhciten. 


832  JIALAEIA. 

of  the  foetus  it  is  difficult  to  say.  A  great  many  cases  are  on  record  in 
which  children  have  been  born  showing;  the  eyidences  of  intra-uterine 
affection  (cachexia,  dropsy,  enlargement  of  the  spleen,  etc.),^  or  haye  been 
taken  sick  with  chills  and  fever  shortly  after  birth.  The  period  of  infancy 
seems  to  be  comparatively  exempt,  but  far  more  cases  occur  during  this 
period  than  is  supposed,  as,  for  a  great  many  reasons,  they  are  overlooked. 
Werner^  says,  "  Mortality  among  children  is  enormously  great,  especially 
among  infants."  ]More  statistic  data  in  this  direction  would  be  very  desirable, 
but  with  the  proviso  that  infants  be  examined  carefully.  All  authors  agree 
that  in  children  the  period  of  from  two  to  seven  or  eight  years  furnishes 
the  greatest  number  of  cases,  and  that  in  the  beginning  of  an  epidemic 
cliildren  are  the  first  to  be  affected.  After  the  seventh  or  eighth  year  of  life 
their  chances  of  infection  are  about  the  same  as  those  of  adults. 

Pathological  Anatomy. — The  prime  and  principal  lesion  of  malaria 
is  that  of  the  blood.  The  latter  is  the  carrier  of  infection,  as  has  been 
repeatedly  demonstrated  by  injections  made  upon  man,  causing  typical 
attacks  in  the  subject  receiving  malarial  blood.^ 

This  poison  may  act  in  two  ways  :  first,  generally  ;  second,  locally.  Its 
general  effect  may  be  summed  up  as  that  of  the  introduction  of  almost  any 
foreign  substance  into  the  circulation, — the  production  of  chills,  fever,  etc. 
This  series  of  symptoms  is  preceded  by  a  period  of  incubation,  which  accord- 
ing to  different  authorities  may  var}'  from  a  few  hours  to  a  few  years,  but 
in  the  average  number  of  cases  is  represented  by  two  weeks.  The  local 
effects  are  due  to  an  especial  development  of  the  virus  at  given  places, — 
the  spleen,  the  liver,  the  brain,  the  blood-vessels,  etc.  In  these  localities 
the  great  c|uantity  of  poison  is  demonstrated  by  its  results,  pigment,  and, 
from  the  fact  that  symptoms  of  a  local  nature  are  produced,  we  are  justified 
in  the  conclusion  that  wherever  the  latter  occur,  there  a  localization  of  the 
malarial  poison  has  taken  place  (neuralgias,  for  instance).  The  effect  of 
the  poison  upon  the  blood  is  a  destruction  of  red  corpuscles,  an  increase 
in  pigment  (directly  depending  upon  it),  and  a  diminution  in  albumen. 
The  effect  upon  organs  or  tissues  in  which  the  poison  or  its  results  are 
lodged  is  the  production  of  irritative  changes  leading  to  hyperplasia  or 
hypertrophy.  With  these  data  in  view,  the  lesions  are  readily  understood. 
Of  all  the  organs  in  the  body,  the  spleen  suffers  earliest  and  most.  During 
an  attack  the  spleen  is  enlarged ;  this  enlargement  disappears,  as  a  rule, 
when  the  fever  disappears,  to  reappear  with  the  next  attack,  and  finally  to 
become  more  or  less  permanent.  This  enlargement  is  due  to  hypertrophy 
and  the  deposit  of  pigment.  Frequently  there  is  inflammation  in  the  cap- 
sule, sometimes  peri-spleuitis  ;  rarely  the  enlargement  becomes  large  enough 
to  cause  rupture.  The  liver  also  becomes  enlarged,  but  later  than  the 
spleen  :  this  enlargement  is  due  to  a  similar  process,  but  is  characterized  by 

^  See  Duchek,  Prag.  Yierteljahresschrift,  I808.  and  Bazin,  Gazette  des  Hopitaux,  1871. 
2  Loc.  cit.  ^  Gerhardt  and  others. 


MALARIA.  833 

an  enormous  deposit  of  pigment,  especially  around  the  radicles  of  the  hepatic 
vein. 

The  disintegration  of  the  red  corpuscles  gives  rise  to  an  almost  endless 
number  of  changes.  In  very  many  places  the  lymphatic  spaces  around 
the  vessels  are  filled  with  pigment,  so  that  the  contours  of  the  vessels  are 
emphasized, — as  in  the  brain ;  at  other  times  there  is  more  or  less  difflise 
deposit  of  this  coloring-matter  in  the  kidneys  and  the  skin.  On  account 
of  nutritive  changes  in  the  blood,  the  vessel-walls  frequently  become  weak- 
ened, and  then  hemorrhages  follow,  under  the  skin,  into  the  cavities  of  the 
body,  or  with  the  secretions.  For  the  same  reason,  possibly,  we  have  dis- 
turbances in  the  digestive  apparatus,  although  they  may  set  in  so  early  as  to 
be  explained  by  a  localization  of  the  poison  or  lack  of  digestive  power  on 
account  of  fever.  As  a  final  result  of  the  change  in  constitution  of  the 
blood,  we  have  hydremia  or  anaemia,  with  all  its  manifestations,  local  and 
general.  This,  with  or  without  the  deposit  of  pigment,  gives  rise  to  what 
is  known  as  the  malarial  cachexia. 

Local  disturbances,  of  great  importance  to  the  pediatrician,  are  quite 
common  in  the  bronchial  tubes,  so  that  it  may  hapj)en  that  the  patient  sur- 
vives his  attack  of  malaria  but  succumbs  to  catarrhal  pneumonia,  the  sequel 
to  the  malarial  bronchitis.  In  the  pernicious  forms  the  lesions  are  char- 
acteristic, enlargement  of  the  spleen,  changes  in  the  brain,  hemorrhagic  in- 
farctions, etc.,  usually  being  found.  The  kidneys  are  more  or  less  affected; 
even  in  mild  forms  this  is  often  the  case,  and  very  few  patients  with  chronic 
malarial  poisoning  will  be  observed  without  some  more  or  less  appreciable 
change  present  in  the  urine.  Those  who  have  seen  most  of  the  pernicious 
forms  claim  that  there  is  a  positive  change  in  the  heart ;  the  myocardium  is 
rendered  softer,  and  its  color  is  changed. '  Recovery  from  this  is  possible, 
although  the  case  is  very  much  complicated  by  its  presence.  Endocarditis 
occurs  in  some  very  mild  forms  also,  but  is  not  very  common. 

From  this  brief  recital  of  pathological  changes  it  will  be  seen  that  there  is 
hardly  a  tissue  or  an  organ  in  the  body  which  may  not  be  attacked  by  this 
poison ;  indeed,  there  are  but  few  poisons  that  man  is  infected  with  Avhicli 
may  produce  such  general  changes.  It  will  also  be  seen  that  diagnosis  must 
frequently  present  difficulties,  and  how  very  important  the  plasmodium  will 
become  when  its  absolute  value  as  a  diagnostic  feature  has  been  positively 
settled. 

SYMPTOMATOLOGY. 

I.  Intermittens. — This  is  by  far  the  most  common  form  of  malarial 
poisoning  we  have  to  deal  with.  The  attack  presents  itself  in  three  di- 
visions :  first,  the  chill ;  second,  the  fever ;  third,  the  sweat.  When  the 
attack  presents  itself  every  day,  it  is  called  quotidian  ;  every  other  day, 
tertian  ;  cveiy  fourth  day,  quartan.  There  are  also  double  forms, — double 
quartan,  for  instance,  in  wliich  there  is  an  attack  on  two  successive  days  and 
one  day  without  an  attack,  or  double  quotidian  or  tertian.  In  double  quo- 
tidian we  have  two  chills  daily, — one  in  the  morning,  one  in  the  evening; 
Vol.  I.— 53 


834  MALARIA. 

in  double  tertian  one  chill  daily,  but  the  time  of  chill  alternating  every  other 
day.  In  children  the  quotidian  form  is  most  common  :  Bohn  gives  the  com- 
parative frequency  of  the  three  forms  as  3:2:1,  although  this  must,  of 
necessity,  vary  with  the  epidemic.  The  attack  usually  comes  on  between 
ten  o'clock  in  the  morning  and  one  in  the  afternoon.  It  will  be  understood 
that  this  is  the  case  in  the  great  majority  of  instances  :  there  is  no  time  in 
the  twenty-four  hours  when  a  chill  may  not  come  on,  but  for  practical  pur- 
poses it  is  always  best  to  assume  that  an  attack  will  follow  the  rule  and  not 
the  exception.  Authors  differ  very  much  as  to  this  rule,^  and  possibly  the 
time  when  infection  has  taken  place  or  the  method  of  infection  may  have 
something  to  do  with  the  different  observations  that  have  been  made.  If 
anything  has  been  established,  it  is  the  liability  to  relapses.  Here,  again, 
the  time  of  relapse  has  been  subject  to  very  much  discussion.  Children  are 
more  liable  to  relapses  than  adults,  and,  depending  upon  the  type  of  attack, 
these  are  most  common  on  the  seventh,  the  fourteenth,  and  the  twenty-first 
day  :  this  is  true  especially  of  the  quotidian  and  tertian  forms.  The  quartan 
form  has  a  tendency  to  relapse  on  the  eighth  day,  although  changes  of  type- 
from  quartan  to  tertian  or  quotidian  are  by  no  means  uncommon. 

There  are  two  forms  of  the  intermittent  type, — the  pernicious  and  the 
mild  form.  In  the  pernicious  form,  which  is  not  rare  in  infancy  and  child- 
hood, the  patient  is  taken  sick  suddenly.  The  child  has  been  perfectly  well, 
and  suddenly  may  go  into  convulsions.  Before  this  the  parents  may  have 
observed  that  the  child  is  restless,  that  it  has  assumed  a  bluish-pale  color, 
perhaps  that  it  has  vomited  or  has  had  one  or  two  loose  passages.  The 
physician  who  comes  in  will  see  a  patient  well  nourished,  in  convulsions, 
with  a  very  high  temperature  (104°-108°  F.  in  the  rectum) ;  he  will  exam- 
ine the  patient  carefully  and  find  nothing,  except  perhaps  an  enlarged  spleen, 
and  this  by  no  means  constant.  The  convulsions  may  continue,  the  patient 
is  soporose  or  comatose,  the  pupils  are  contracted  or  one  is  dilated  and  the 
other  is  contracted,  lividity  occurs  over  the  whole  body,  the  extremities  get 
cold,  and  this  first  attack  may  end  fatally.  Or  the  convulsions  gradu- 
ally diminish  in  intensity  and  number,  the  extremities  grow  warmer,  the 
bluish  color  disappears,  the  temperature  begins  to  fall,  consciousness  returns 
between  the  convulsions,  and  towards  evening  the  child  seems  comparatively 
well.  The  same  attack  may  come  again  the  next  day,  either  weaker  or 
stronger, — usually  the  latter,  and  may  then  end  the  patient's  life.  Or  the 
attack  comes  on  simply  as  an  attack  of  coma  in  an  otherwise  healthy  child, 
from  which  condition  the  patient  never  rallies,  lying  for  from  one  to  three 
or  four  days,  and  then  dying  from  asthenia,  oedema  of  the  brain,  or  other 
complications.  The  convulsive  form  may  leave  the  child  in  this  comatose 
condition  and  the  termination  be  in  the  same  way  as  in  the  case  where  coma 
sets  in  immediately.  Rarely  do  these  pernicious  forms  terminate  in  the 
development  of  the  benign  intermittent,  and  the  prognosis  is  almost  invari- 

^  See  Griesinger,  Die  Infectionskrankheiten,  Virchow  and  Bohn,  loc.  cit. 


MALARIA.  835 

ably  a  fatal  oue.  The  absence  of  any  positive  symptoms  renders  it  impos- 
sible to  make  a  diagnosis  with  any  great  amount  of  certainty.  There  is  no 
doubt  that  a  great  many  children  die  of  this  form  in  whom  the  diagnosis 
of  convulsions,  congestion  of  the  brain,  etc.,  satisfies  the  practitioner.  The 
importance  of  searching  for  the  plasmodium  malarise  in  these  forms  cannot 
be  too  strongly  dwelt  upon. 

In  the  benio;n  forms  of  chills  and  fever  we  must  discriminate  two  al- 
most  entirely  separate  clinical  pictures, — the  one  occurring  in  infants  and 
the  one  occurring  in  older  children.  In  infants  we  rarely  have  a  com- 
plete attack, — i.e.,  one  made  up  of  chill,  fever,  and  sweat.  It  is  either 
one  of  these  alone,  or,  most  commonly,  two  together.  The  one  link  which 
is  most  commonly  missing  is  the  chill,  the  one  which  is  always  present  is 
the  fever.  It  is  stated  that  very  young  infants  do  have  chills  (Bohn  and 
others),  and  I  have  repeatedly  been  assured  by  physicians  practising  in  very 
malarial  districts  that  they  have  seen  infants  shake  like  grown  people.  I 
have  never  seen  in  an  infant  a  true  chill  produced  by  malaria  :  it  has  always 
been  represented  by  something  showing  symptoms  of  cold  on  the  part  of  the 
child,  but  always  fragmentary,  and  not  like  a  well-developed  chill.  This 
fragment  of  a  chill  manifests  itself  as  follows.  The  child  begins  to  yawn, 
or  stretches  itself  as  if  it  were  very  tired ;  with  this  there  is  a  change 
of  expression  and  color  about  the  face.  The  nose  becomes  pinched,  cold ; 
the  eyes  sink  in  and  have  bluish  lines  about  them ;  the  lips  are  blue,  and 
the  little  one  looks  very  tired.  With  this,  the  finger-  and  toe-nails  become 
cyanotic,  and  if  this  occurs  after  a  meal  the  patient  vomits  or  feels  nauseated. 
All  this  belongs  to  the  mildest  manifestations  of  a  chill.  The  next  step  is 
the  involvement  of  the  nervous  system.  Here  there  is  twitching  of  the 
eyelids  or  of  the  extremities,  associated  with  what  has  been  described  above, 
which  causes  the  physician  to  fear  the  next  step  in  development,  convulsions. 
A  great  many  infants  have  convulsions  at  the  onset  of  any  acute  affection, 
and  we  frequently  find  that  in  intermittens  the  chill  is  represented  by  a 
convulsion,  which  is  then  followed  by  the  next  stage.  These  convulsions, 
naturally,  cause  very  much  anxiety,  because  in  and  of  themselves  they 
are  dangerous,  and  for  the  reason  that  at  first  the  physician  does  not  know 
whether  he  may  not  be  dealing  with  something  very  much  more  serious  than 
an  ordinary  attack  of  chills  and  fever.  After  the  convulsions  have  ceased, 
— and  they  do  this,  as  a  rule,  after  a  short  time,  not  exceeding  a  few  hours, 
the  first  oue  being  usually  the  severest, — there  comes  the  period  of  fever. 
During  the  chill  period  the  temperature  has  gone  rapidly  up  to  103°-108° 
F.  (rectal),  and  remains  there  throughout  the  whole  period  of  fever,  sinking 
very  gradually  towards  the  end  of  this  period,  and  after  from  three  to  five 
hours  reaching  normal  or  subnormal.  With  tiiis  fever  there  is  more  or  less 
restlessness,  the  patient  is  very  much  flushed,  feels  very  dry,  is  fretful  and 
cries  very  much,  and,  as  in  the  previous  stage,  may  have  gastro-intestinal 
disturbances.  The  sweat  that  follows  is  profuse  when  it  does  occur,  and, 
although  the  little  patient  seems  exhausted,  the  appetite  returns  and  tlie 


836  MALAEIA. 

patient  seems  perfectly  well.  Yet  after  one  or  two  attacks — and  this  is  true 
of  older  children  as  well — the  cachexia  begins  to  manifest  itself.  The  pa- 
tients lose  their  natural  color,  they  are  pale,  sometimes  jaundiced,  listless, 
languid,  have  lost  their  appetite,  and  do  not  take  as  much  interest  in  their 
surroundings  as  has  been  their  custom.  With  this  there  is  developed  the 
enlargement  of  the  spleen.  It  is  rare,  according  to  my  experience,  not  to 
find  the  spleen  enlarged  in  the  malaria  of  children ;  yet  excellent  observers 
have  made  statements  to  the  contrary.^  It  will  be  remembered,  in  this  con- 
nection, that  negative  proof  of  the  enlargement  of  the  spleen — by  palpation, 
for  example — must  not  be  taken  as  final ;  for  there  are  numbers  of  cases  on 
record  in  which  the  spleen  was  examined  intra  vitam  and  pronounced  not 
enlarged,  and  yet  post-mortem  examination  revealed  a  very  large  but  very 
soft  spleen.^  Besides,  we  must  bear  in  mind  that  the  spleen  in  malaria, 
especially  in  the  beginning  of  the  disease,  is  enlarged  at  certain  times  only, 
to  return  to  its  normal  condition  after  four  or  five  hours.  It  will  be  seen, 
then,  that,  with  the  exception  -of  the  fever,  not  one  of  the  features  of  a  char- 
acteristic attack  is  always  present  in  infants.  But  we  have,  in  addition, 
other  forms  in  which  the  poison  seems  to  localize  itself  in  a  special  spot. 
These  will  be  described  in  connection  with  intermittens  in  older  children. 

The  intermittens  of  older  children  does  not  differ  materially  from  that  of 
adults.  They  are  able  to  describe  their  sensations,  and  they  react  like  adults. 
There  might  be  added  to  this  that  the  cachexia  develops  much  earlier  with 
them  than  in  adults,  and  that  the  gastro-intestinal  tract  is  more  liable  to 
become  affected,  constipation,  however,  being  more  common  than  diarrhoea. 
They  are  subject  to  all  the  forms  that  are  found  in  adults,  and  with  them  it 
is  sometimes  exceedingly  difficult  to  arrive  at  a  diagnosis.  It  is  in  them 
especially  that  we  have  intermittent,  non-febrile  conditions  producing  the 
most  fantastic  combinations  of  symptoms.  All  these  combinations  can  be 
classified  so  as  to  give  a  summary  of  the  various  symptoms,  but  it  is  almost 
impossible  to  describe  what  collections  of  symptoms  can  be  present  in  an  in- 
dividual case.  The  Germans  call  the  form  without  fever  intermittens  lar- 
vata, — a  very  good  name.  We  might  call  all  these  foi-ms  bastard,  although 
some  are  very  mvich  more  dangerous  than  frank,  well-developed  cases. 

Manifestations  on  the  Part  of  the  Nervous  System. — There  is  not  a  nerve 
in  the  body  that  seems  exempt  from  affection  by  malaria.  If  we  look  at 
the  brain  and  cord  and  its  membranes,  we  see  meningitis,  oedema  of  the 
brain,  peculiar  forms  of  insanity.  The  form  of  meningitis  most  commonly 
seen  is  the  cerebro-spinal.  I  have  described  some  cases  in  connection  with 
and  developing  from  torticollis  intermittens.^  Since  that  time  I  have  seen 
several  other  cases  in  which  I  was  al)le  to  demonstrate  the  presence  of  the 
Plasmodium,  so  that,  to  my  mind,  there  was  no  doubt  as  to  the  malarial 

1  L.  Emmett  Holt,  Amer.  Jour,  of  Obstetrics,  and  Diseases  of  Children,  1883,  xvi.,  for 
instance. 

2  Sclmeidler,  .Jahrbuch  fiir  Kinderheilkunde,  N.  F.,  xiv.,  1879. 

3  Archives  of  Pediatrics. 


MALARIA.  837 

nature  of  the  affection.  Ziemssen^  says  there  should  be  no  difficulty  in 
differentiating-  the  two  diseases ;  yet  there  can  be  no  doubt  that  some,  if 
not  a  great  many,  cases  of  sporadic  cerebro-spinal  meningitis  are  due  to 
malaria.  Sometimes,  however,  the  cerebral  meninges  alone  are  affected, 
and  we  have  the  clinical  picture  of  an  acute  lepto-meningitis.  It  is  very 
rare  for  all  these  cases  to  develop  as  such  in  the  beginning ;  they  come  from 
well-marked  cases  of  intermittens,  as  a  rule,  with  decided  tendency  to  the 
production  of  symptoms  on  the  part  of  the  nervous  system.  The  prog- 
nosis, although  bad,  is  by  no  means  so  unfavorable  as  in  other  forms  of 
meningitis. 

CE^ema  of  the  brain  is  not  uncommon  in  the  violent  forms,  or  as  termi- 
nating a  long-continued  cachectic  case.  A  slight  accession  of  temperature 
or  a  complication  arising  will  be  the  predisposing  cause  and  be  followed  by 
death. 

The  mental  disturbances  of  malaria  in  children  are  not  so  uncommon 
as  we  were  accustomed  to  believe  from  the  description  of  Griesinger  and 
Bohn.  Walliser^  found  eighty-eight  cases  out  of  eleven  hundred  of  all  ages, 
and  of  these  ov^er  one-half  were  children  under  ten  years  of  age.  Of  these, 
seven  died  of  convulsions  during  the  acme  of  the  disease.  Various  mental 
disturbances  have  been  observed  in  children.  Somnolence  is  especially 
well  marked  in  infants ;  after  the  second  or  third  attack  they  go  to  sleep, — 
a  sleep  from  which  there  is  no  waking, — and  die  in  this  condition.  Kraepe- 
lin^  divides  the  psychoses  of  malaria  into  three  groups  :  1,  those  forms 
that  take  the  place  of  regular  attacks  of  intermittens  or  alternate  with  them  ; 
2,  those  that  take  upon  themselves  a  remitting  or  continuous  character  after 
fever  or  mental  attacks;  3,  non-intermitting  attacks  after  intermittens. 
Ten  per  cent,  of  all  his  cases  were  children.  Post-mortems  revealed  oedema 
and  hypersemia  of  the  central  organs,  sometimes  deposit  of  pigment.  In 
half  of  the  cases  active  melancholia,  with  fear,  a  tendency  to  destruction, 
and  hallucinations  were  the  principal  symptoms.  In  about  one-third  of 
the  cases  the  paroxyms  were  preceded  by  an  aura,  sometimes  tenderness 
over  the  cervical  vertebrse.  In  two  cases  there  were  epileptic  seizures 
followed  by  coma.  In  one-fourth  of  the  cases  there  Avas  mania  accompanied 
by  ideas  of  grandeur.  The  paroxysm  lasted  for  several  hours,  and  the  whole 
disease  persisted  four  weeks  in  thirty-two  per  cent.,  less  than  a  week  in 
twenty  per  cent.  It  was  rare  to  find  cases  lasting  longer  than  months  or 
for  one  year.  All  the  adults  recovered  entirely,  and  of  the  children  only 
the  seven  cases,  convulsive,  mentioned  before,  died. 

In  the  cerebro-spinal  system  of  nerves,  the  symptoms  that  are  produced 
usually  manifest  themselves  as  neuralgias.  Frequently  the  attacks  of  pain 
are  not  accompanied  by  fever,  but  very  often  carefully-repeated  measure- 
ments of  temperature  will  show  that  there  is  a  slight  elevation.     The  fifth 


1  Handbuch  d.  Speciellen  Path.  u.  Therap.,  article  "Cerebro-spinal  Meningitis." 

2  Schmidt's  Juhrbiicher,  1871,  Bd.  clxxx.  p.  58.  »  Ibid.,  1882. 


838      ■  MAI.AEIA.    ■ 

pair  of  nerves  is  the  one  most  commonly  affected.  AVe  have  supra-  or 
infra-orbital  neuralgia,  frontal  or  occipital  headache,  pain  in  the  teeth  and, 
sometimes,  along  the  side  of  the  nose.  Xeuralgias  of  the  sciatic  nerve, 
the  intercostal  nerves,  and  the  nerves  of  the  stomach  are  by  no  means  un- 
common. Then  there  is  that  peculiar  form  of  nervous  aflFection  which  has 
been  called  torticollis  intermittens.  There  are  three  states  of  this  condition, 
the  first  being  purely  that  of  torticollis,  the  second  absolutely  intermittent 
with  high  fever  or  continuous,  and  the  third  with  brain-  or  cord-complica- 
tions presenting  the  picture  of  a  cerebro-spinal  meningitis.  The  patient  is 
attacked  at  a  certain  time  in  the  day  with  pain  in  the  back  of  the  head  and 
along  the  upper  part  of  the  spinal  column.  "With  this  there  is  torticollis. 
The  attack  lasts  for  from  two  to  five  or  six  houre,  and  then  the  patient  feels 
perfectly  well.  This  is  the  mildest  form.  The  next  day  the  attack  repeats 
itself,  and  behaves  in  every  respect  like  an  ordinary  intermittens.  The 
forms  described  above  may  run  into  one  another,  and,  although  at  first  veiy 
amenable  to  treatment,  may  develop  so  as  to  be  beyond  control.  I  have 
seen  sixteen  cases  of  this  description  in  children,  and  possibly  many  more 
before  my  attention  was  attracted  by  one  very  well  marked  intermittent 
case.  I  should  say,  therefore,  that  a  great  many  cases  will  run  a  favor- 
able course  even  without  treatment  of  any  sort.  These  cases  have  been 
described  by  numerous  authors  (Henoch,  Bierbaum,  Bohn,  L.  Emniett  Holt, 
and  others),  and  must  be  looked  upon  as  well-recognized  forms  of  inter- 
mittens. The  relation  which  they  bear  to  meningeal  troubles,  to  which 
I  would  call  especial  attention,  makes  them  of  especial  importance. 

So  far  as  concerns  the  nerves  of  special  sense,  there  are  no  observations 
on  record  which  go  to  show  that  they  are  especially  affected.  It  is  not 
uncommon  for  patients  to  complain  of  peculiar  sensations  of  taste,  or  that 
they  hear  noises,  etc.  All  this,  ho^^'ever,  can  be  explained  by  other  means 
than  bv  taking  into  consideration  special  lesions  of  the  nerves. 

There  are  also  disturbances  of  the  vaso-motor  nerves  which  cause 
peculiar  svmptoms.  Among  these,  special  reference  is  made  to  intermittent 
swellings,  especially  well  marked  about  the  joints,  and  sometimes  within 
them.  They  give  rise  at  times  to  great  pain,  at  other  times  they  are  pain- 
less. On  account  of  their  ill-defined  character,  they  are  sometimes  con- 
founded with  hysterical  joint-lesions  or  tubercular  affections.  Where  en- 
largement of  the  spleen  exists,  the  diagnosis  is  easy ;  where  it  is  absent, 
anti-malarial  treatment  will  make  clear  the  nature  of  the  malady. 

Affections  of  the  Respiratory  Apparatus. — The  whole  of  the  respiratory 
tract,  from  the  mucous  membrane  of  the  nose  to  the  alveoli  of  the  lung, 
may  suffer  from  malarial  poison.  Sometimes  we  observe  true  intermittent 
attacks  of  coryza,  or,  combined  with  this,  pharyngitis  or  enlargement  of  the 
tonsils.  One  alone,  or  all  combined,  may  exist.  The  most  common  form 
of  catarrhal  trouble  due  to  malaria  is  a  subacute  or  chronic  condition  ex- 
tending over  the  whole  mucous  membrane  of  the  pharynx,  nose,  and  eyes. 
We  also  have  attacks  of  epistaxis :  these  may  become  dangerous  to  life  on 


MALARIA.  839 

account  of  great  loss  of  blood  during  the  attack,  or  on  account  of  repeated 
attacks.  It  is  adv^isable  to  examine  the  nose  in  these  cases  ;  for  frequently 
there  will  be  found  that  peculiar  ulceration  upon  the  septum  which  is 
readily  treated.  In  order  to  prevent  relapses,  however,  the  general  condi- 
tion must  be  taken  into  consideration.  In  the  larynx  there  are  produced  a 
series  of  symptoms  resembling  croup.  Briand^  has  described  this  affection 
as  attacks  of  high  fever  coming  on  at  more  or  less  regular  intervals,  com- 
bined with  intense  redness  of  the  pharynx,  hoarseness,  stridor,  and  dyspnoea. 
These  paroxysms  may  last  for  hours ;  and  the  whole  affection  resembles  croup. 
Although  he  calls  attention  to  the  difficulty  in  diagnosis,  there  ought  to  be 
no  such  difficulty  if  the  time  of  attack,  enlargement  of  the  spleen,  perio- 
dicity, and  intervals  of  almost  perfect  health  be  taken  into  consideration. 
Briand  says  that  the  prognosis  is  very  much  better  than  in  croup,  because 
the  disease  can  be  readily  treated.  Attacks  of  bronchitis  more  or  less 
diffuse,  as  the  only  symptoms  of  malarial  infection,  also  occur.  If  they 
are  in  the  capillary  bronchi,  they  may  become  very  dangerous.  As  it  is, 
they  must  always  be  carefully  watched,  and  the  patient  be  given  the  full 
benefit  of  liberal  treatment. 

So  far  as  the  relations  of  pneumonia  to  malaria  are  concerned,  there 
may  be  several  positions  taken.  There  are  those  who  assert  that  malarial 
poisoning  may  produce  pneumonia ;  then,  again,  those  who  maintain  that 
pneumonia  develops  in  patients  having  malaria,  and  therefore  takes  upon 
itself  a  malarial  type.  While  there  can  be  no  doubt  that  pneumonia  (catar- 
rhal) is  produced  by  a  multitude  of  causes,  diphtheria,  measles,  typhoid 
fever,  etc., — i.e.,  by  the  special  poisons  of  these  diseases, — it  has  yet  to  be 
proved  that  malaria  is  one  of  these.  For  fear  of  being  misunderstood,  let 
us  say  that  nothing  which  has  been  attributed  to  malaria  (bacilli,  micro- 
cocci, Plasmodium)  has  ever  been  found  in  patients  who  have  died  of  malarial 
pneumonia,  although  everything  points  to  the  fact  that  the  poison  of  malaria 
could  act  in  the  same  way  as  that  of  any  other  disease.  However  this  may 
be,  there  is  a  distinct  clinical  picture  in  which  patients  have  pneumonia  the 
symptoms  of  which  take  upon  themselves  quotidian,  tertian,  or  quartan  ex- 
acerbations. These  exacerbations  are  as  to  fever  and  the  concomitant  sub- 
jective and  objective  signs  of  pneumonia.  This  form  is  not  more  dangerous 
than  any  ordinary  form ;  the  exacerbations,  as  a  rule,  become  M'caker  from 
day  to  day,  and  finally  disappear,  or  are  readily  prevented  by  the  use  of 
quinine.  Almost  the  same  clinical  picture  is  presented  when  a  croupous 
pneumonia  develops  in  a  patient  already  malarial. 

Manifedations  in  the  Alimentary  Trad. — Very  few  cases  of  intermittens 
occur  without  some  symptoms  being  produced  in  the  alimentary  canal ;  but 
these  complications  have  been  treated  of  before,  and  we  now  refer  to  those 
forms  in  which  the  syni])toms  on  the  part  of  the  alimentary  canal  are  the  prin- 
cipal manifestations.     The  stomach,  the  small  intestine,  and  the  large  intes- 


1  Gazette  des  Hopitaux,  1883,  No.  40. 


840  MALARIA. 

tine,  either  alone  or  together,  may  be  the  seat  of  disturbance  which  alone  goes 
to  make  up  an  attack.  On  the  part  of  the  stomach  we  have  the  symptoms 
of  dyspepsia,  either  constant  or  intermittent.  These  attacks  are  entirely 
independent  of  any  food  that  is  taken.  The  little  patient  may  be  fed  in 
the  most  approved  and  physiologically  correct  manner,  and  yet  the  attacks 
continue.  That  form  which  manifests  itself  in  attacks  of  vomiting  is  very 
peculiar ;  the  child  may  be  in  perfect  health,  playing  about,  happy  and  jolly, 
when  it  is  suddenly  taken  with  the  ordinary  symptoms  of  nausea.  Then 
vomiting  comes  on.  After  four  or  five  hours,  the  child,  although  looking 
dragged  out,  seems  perfectly  well,  its  appetite  returns,  and  it  remains  well 
until  the  next  attack  comes  on.  With  this  there  may  be  a  slight  elevation 
of  temperature  (101°-102°  F.),  the  spleen  is  usually  enlarged,  as  it  is  in 
every  form  of  malaria  in  children,  and  when  these  attacks  continue  the 
little  patient  suffers  very  much  so  far  as  general  health  is  concerned.  It 
may  be  well  to  state  that  all  the  symptoms  coming  from  the  alimentary 
tract  in  malaria  are  most  easily  controlled  by  quinine. 

On  the  part  of  the  intestine  we  have  diarrhoeas.  These  are  of  two 
kinds,  the  large  and  watery  stools  and  the  small,  slimy,  bloody  ones.  The 
attacks  consist  simply  in  having  these  stools.  There  is  no  pain,  as  a  rule, 
except  in  the  large  intestinal  variety  ;  the  patient  does  not  suifer  incon- 
venience, and  after  the  attack  is  over  he  is  perfectly  well.  The  diag- 
nosis of  these  gastro-intestinal  forms  is  readily  made ;  the  fact,  alone,  that 
all  the  remedies  which  usually  control  diarrhoea,  combined  with  proper  diet, 
fail,  is  sufficient  to  cause  the  practitioner  to  suspect  that  he  is  dealing  with 
malaria.  The  prognosis  is  favorable  in  all  these  forms.  I  have  seen 
little  patients  who  have  suffered  for  months  from  the  large  intestinal  variety 
apparently  in  good  health.  It  must  not  be  forgotten,  however,  that  there 
may  be  deeper  lesions  present  in  the  intestines  which  may  lead  to  very 
unpleasant  complications, — tuberculosis,  peritonitis,  etc.  In  the  violent 
forms  as  they  are  found  in  the  tropics,  all  grades  and  characters  of  intesti- 
nal lesions  have  been  observed,  from  the  simple  loss  of  epithelium  to  the 
most  perfectly  pronounced  diphtheritic  process.  Fortunately,  these  hope- 
less forms  are  very  rare  in  civilized  countries. 

Manifestations  on  the  Part  of  the  Organs  of  Circulation. — It  seems 
strange  that  attacks  on  the  part  of  the  heart  are  so  rarely  noticed.  They 
are  certainly  very  rare ;  otherwise,  more  cases  would  be  found  recorded  in 
the  literature  of  malaria.  An  irregular  distribution  of  blood  is  noticed  in 
that  form  in  which  vertigo,  with  congestion  of  the  face,  is  the  only  symptom. 
This  dizziness  is  the  only  thing  the  patient  complains  of,  but  it  returns 
with  the  same  regularity  that  characterizes  all  these  forms.  Another  form 
consists  in  regularly-recurring  attacks  of  palpitation  of  the  heart,  easily 
controlled  by  quinine. 

A.  S.  Smith  ^  has  put  upon  record  a  case  of  "  malarial  affection  simu- 

1  New  York  Medical  Eecord,  xxx.,  Nov.  20,  1886. 


MALARIA.  841 

lating  Basedow's  disease."  A  boy  of  eleven  years  was  suddenly  taken  sick 
in  the  evening  with  enlargement  of  the  thyroid  gland,  which  disappeared 
the  next  morning.  The  next  evening  this  returned,  and  with  it  palpitation. 
Over  the  thyroid  gland  there  was  heard  a  loud  systolic  bruit.  The  pulse 
was  110,  temperature  101.5°  F.  The  spleen  was  very  much  enlarged. 
After  ten  days  of  energetic  treatment  with  quinine,  all  these  symptoms  were 
removed  permanently. 

Manifestations  on  the  Part  of  the  Urinary  Organs. — The  two  principal 
manifestations  of  attacks  in  the  urine  are  hsematuria  or  albuminuria  and 
glycosuria.  In  regard  to  the  first,  it  consists  of  the  appearance  of  blood  in 
the  otherwise  normal  urine.  This  blood  is  discharged  with  or  without  pain, 
depending  upon  the  fact  that  it  coagulates  in  small  or  large  masses,  is 
usually  of  a  bright-red  color,  and  its  loss  does  not  affect  the  patient  very 
much.  In  the  urine  of  patients  suffering  from  haematuria  intermittens  is 
found  the  plasmodium  malarise,  but  especially  are  found  in  great  numbers 
those  crescentic  bodies  referred  to  under  the  heading  of  etiology.  In  a  few 
cases  I  have  seen  intermittent  albuminuria  without  blood.  Contrary  to  the 
experience  of  some  authors,  I  have  found  kidney-complications  compara- 
tively common  in  children,  the  most  common  form  being  a  subacute  or 
even  chronic  albuminuria,  in  which  the  urine  is  almost  characteristic  of  the 
disease.  When  it  is  passed  it  is  of  a  brownish  color ;  and  when  it  stands 
for  a  little  while,  a  brownish-black  deposit  settles,  over  which  the  urine  is 
perfectly  clear.  If  this  deposit  is  examined  under  the  microscope,  it  will 
be  found  to  be  made  up  of  small  masses  of  pigment,  concerning  whose 
nature  or  origin  nothing  is  known.  Besides  this  we  find  casts,  amorphous 
urates,  or  crystalline  forms.  The  urine  always  contains  albumen  in  variable 
quantity,  from  a  trace  to  two  per  cent,  or  over.  These  cases,  as  a  rule,  are 
of  slow  recovery,  but  the  prognosis  is  not  bad.  They  are  not  affected  by 
quinine,  but  removal  to  a  non-malarial  climate  gives  relief  in  a  very  short 
time. 

No  cases  are  on  record  in  which  glycosuria  represents  the  principal  symp- 
tom of  the  attack.  But  the  importance  of  examining  the  urine  for  sugar 
is  shown  in  the  following  table  of  Bardel,  quoted  by  Blau :  ^ 

In  134  quotidian  cases  glycosuria  was  found  29  times,  =  22  per  cent. 
"   122  tertian  cases  "  "         "      17      "      =  14         " 

"     76  quartan  cases  "  "         "      11      "      =  14         " 

"     11  pernicious  cases        "  "         "      32      "      =  80        " 

"     40  well-marked  cachectic  individuals  glycosuria  was  found  32  times  =  80  per  cent. 

Jaccoud  and  Vallin  assert  that  this  temporary  diabetes  may  become  per- 
manent. This  must  certainly  occur  very  rarely.  In  tlie  first  place,  diabetes 
is  not  common  in  childhood,  and,  secondly,  malaria  is  very  common  ;  so  that 
the  relation  of  one  to  the  other,  in  childhood,  must  be  extremely  remote. 

1  Schmidt's  Jahrbiicher,  Bd.  cciv.,  1884. 


842  MALARIA. 

Manifestations  on  the  Part  of  the  Skin. — There  is  hardly  any  skin- 
disease  whose  origin  has  not  been  ascribed  to  malaria.  But  no  attempt  at 
proof  has  been  oifered  that  there  exists  any  relation  between  these  affections 
and  malaria.  In  the  chronic  forms  there  is  no  doubt  that  malaria  does 
produce  certain  forms  of  skin-disease,  which  Avill  be  referred  to  hereafter. 
The  only  form  of  skin-disease  which  may  take  the  place  of  an  attack  is 
urticaria.  This  is  comparatively  rare.  Hebra  had  seen  five  hundred  cases 
of  urticaria  in  twenty-five  years,  and  not  one  of  them  malarial.  Zeissl  in 
two  hundred  cases  has  seen  but  one  case  of  intermittent  urticaria.  How- 
ever, this  is  not  to  be  looked  upon  as  an  absolute  criterion,  as  Vienna  is  a 
non-malarial  place.  They  are  very  much  more  common  than  is  represented 
by  these  figures,  as  any  one  who  lives  in  a  malarial  region  can  testify. 
There  is  nothing  characteristic  about  the  attack,  except  that  it  occurs  like 
any  attack  of  intermittens  and  that  the  spleen  is  enlarged.  As  a  rule,  they 
are  very  amenable  to  treatment. 

Organs  of  Special  Seivse. — In  the  ear,  attacks  of  neuralgic  pain  (Volto- 
lini),  furunculosis  of  the  external  meatus  (Weber-Liel),  injection  of  the 
tympanum  ( Voltoliui  and  Hotz),  and  periodic  attacks  of  middle-ear  trouble 
(Hotz)  have  been  observed.  In  a  great  many  of  these  cases  the  only 
evidence  given  of  the  malarial  nature  of  the  disease  is  the  fact  that  quinine 
removed  the  trouble.  It  certainly  must  be  admitted  that  this  evidence  is  not 
conclusive,  especially  when  the  quinine  has  been  given  in  very  small  doses 
(Voltolini  and  Hotz).  Some  of  the  cases,  however,  are  beyond  doubt,  and 
prove  that  the  poison  may  localize  itself  in  the  ear  as  well  as  anywhere  else. 
Concerning  the  effects  of  malaria  upon  the  eye  there  are  many  observations 
which  have  been  published,  but  none  which  show  that  any  manifestations 
taking  the  place  of  a  chill  occur  in  that  organ. 

Remittent  Fever  (including-  continuous  forms  and  the  so-called 
T7pho-Malaria). — We  here  come  to  manifestations  of  malaria  which  are 
exceedingly  difficult  of  diagnosis,  and  for  whose  entity,  as  malarial,  little 
if  any  proof  has  been  offered.  If  we  analyze  the  symptoms,  we  shall  see 
that  not  one  of  those  which  we  have  seen  to  be  characteristic  of  the  affection 
is  present  in  great  constancy.  Even  the  effect  of  quinine  is  recognized  as 
having  lost  its  specificity  in  these  cases.  So  that,  practically,  the  only 
reasons  we  have  for  calling  these  forms  malarial  are  that  they  occur  in 
malarial  regions,  that  they  occur  at  those  times  of  the  year  when  malaria  is 
most  common,  that  they  occur  in  epidemics  for  Avhich  there  seems  to  be  a 
common  cause,  and  that  the  lesions  resemble  those  of  the  intermittent  forms. 
To  illustrate  this  latter  statement:  In  1884,  a  street  in  Cincinnati  which 
had  been  torn  up  late  in  the  preceding  winter  was  again  dug  up  for  sewage 
purposes.  Along  that  street  a  great  number  of  cases  of  remittent  and  con- 
tinuous fever  developed  which  could  n(^t  l)e  called  typhoid,  and  for  whose 
existence  no  cause  could  be  found  except  the  disturbance  in  the  soil  of  the 
street.  These  cases  corresponded  more  or  less  with  the  descriptions  given 
of  malarial  fever,  and  were  therefore  called  such.     Since  the  discovery  of 


MALARIA.  843 

the  Plasmodium  and  its  application  to  practice,  nothing  has  been  published 
to  warrant  us  in  taking  advanced  ground  on  the  position  taken  above.  It 
is  possible  that  the  same  poison  in  different  states  of  development  may  in 
the  one  instance  produce  an  attack  of  intermittent,  and  in  the.  other  a  con- 
tinuous form.  Until  these  questions  are  settled,  however,  it  is  the  duty  of 
the  physician  to  give  his  patients  any  benefits  that  may  arise  from  inability 
to  make  a  positive  diagnosis.  We  refer  here  especially  to  the  difficulty  of 
differentiating  between  typhoid  fever  and  some  of  the  forms  of  malaria. 
Whenever  such  difficulty  arises,  the  patient  must  be  treated  for  typhoid 
fever,  and  not  for  malaria,  for  reasons  that  are  manifest.  In  the  extensive 
epidemic  of  typhoid  fever  that  existed  in  this  country  in  1887—88  many 
physicians  persisted  in  the  opinion  that  they  were  dealing  with  malaria, 
and  would  not  be  convinced  of  the  contrary  until  they  were  shown  the 
characteristic  typhoid  lesions.  To  such  an  extent  has  the  malarial  idea 
gained  foothold,  especially  in  malarial  regions,  that  typhoid  fever  is  not 
recognized  when  it  does  occur.  But  the  weight  of  professional  opinion  is  so 
much  in  favor  of  the  acceptance  of  at  least  two  forms,  the  remittent  and 
the  continuous,  that  a  description  follows  with  the  reservations  mentioned 
before, — that  these  forms  may  be  due  to  a  different  stage  of  the  malarial 
virus,  or  that  we  are  dealing  with  an  entirely  different  poison,  as  no  direct 
evidence  exists  as  to  any  of  the  three  propositions. 

Remittent  fever  usually  comes  on  suddenly,  without  prodromata  of 
any  sort.  The  patient,  who  has  been  feeling  very  well,  is  suddenly  taken 
with  headache,  and  pain  in  the  back  or  limbs ;  he  has  malaise,  anorexia, 
perhaps  feels  slightly  nauseated  or  vomits.  Combined  with  these  there  is 
chilliness,  or  repeated  chills,  slight  in  degree,  especially  in  coming  in  contact 
with  cold  air,  or,  if  he  is  in  bed,  when  uncovered.  He  may  have  a  slight 
dry  cough,  so  that  the  diagnosis  of  a  cold  has  been  made.  The  physician 
upon  examining  the  patient  will  find  him  with  flushed  face,  unusually 
bright  eyes,  more  or  less  restless,  and  complaining  that  he  feels  very  badly. 
Upon  examination  there  are  found  a  rapid  pulse  and  a  comparatively  high 
temperature  (102°-104°  F.).  The  tongue  is  usually  coated,  yellow  at  the 
back,  the  breath  slightly  offensive.  Examination  of  the  chest  reveals  the 
signs  of  slight  bronchial  catarrh.  The  spleen  is  usually  enlarged.  The 
bowels  are  constipated,  but  nothing  abnormal  is  found  about  the  abdomen. 
On  the  second  day  the  temperature  is  lower,  and  the  patient  perhaps  better 
in  every  respect.  This  condition  lasts  for  from  three  to  five  days,  and  re- 
covery takes  place.  Relapses  are  common  after  the  lapse  of  five  to  seven 
days.  The  relapses  are  of  the  same  character  as  the  first  attack,  as  a  rule. 
It  is  rare  to  find  this  form  of  fever  lasting  longer  than  from  five  to  ten  days. 
Such  is  the  clinical  picture  as  we  see  it  in  our  zone.  In  the  tropics  or  sub- 
tropics  this  form  of  fever  may  be  pernicious.  Werner  ^  makes  the  follow- 
ing divisions  :  1,  the  ordinary  form  (which  has  just  been  described,  and 

*  Loc.  cit. 


844  MALAEIA. 

from  which,  as  he  says,  there  are  no  deaths) ;  2,  the  adynamic  form,  a  low 
fever,  with  typhoid  symptoms,  attacking  especially  those  that  have  had  pre- 
vious attacks  of  malaria,  prisoners,  badly-developed  persons,  etc. ;  in  this 
form  the  mortality  is  about  six  per  cent. ;  3,  the  comatose  form,  high  tem- 
perature, 104°  F.,  continued  coma,  death  not  later  than  the  fourth  day; 
mortality,  among  adults,  fifty  per  cent,  j  4,  the  hemorrhagic  form  ;  bleeding 
from  the  nose,  under  the  skin,  from  the  bowels,  etc. ;  death  between  the 
sixth  and  sixteenth  day  ;  mortality,  seventy-one  per  cent.  All  these  forms 
are  characterized  by  enlargement  of  the  spleen,  sometimes  very  great,  and 
frequently  by  the  deposit  of  pigment. 

For  the  description  of  the  continuous  form  we  cannot  do  better  than 
quote  from  an  excellent  article  by  Dr.  Maury,  of  Memphis,  Tennessee :  ^ 
"Its  invasion,  instead  of  being  abrupt,  as  is  the  case  with  remittent,  is 
sometimes  marked  by  prodromes.  In  many  cases  the  patient  has  been  ailing 
for  a  week  before  going  to  bed.  In  other  instances  he  will  have  had  a  repe- 
tition of  the  chills  for  two  or  more  weeks,  at  irregular  intervals,  when  finally 
the  fever  which  follows  the  chill  assumes  a  continued  form,  and  goes  on  rising 
gradually,  day  by  day,  until  on  the  sixth  or  seventh  day,  when  the  tempera- 
ture has  reached  103J°  or  104°.  In  other  cases  there  are  no  premonitory 
symptoms.  The  patient  is  attacked  in  the  midst  of  apparent  health,  with- 
out appreciable  cause,  having  had  no  previous  manifestation  of  malaria. 
The  fever  presents  a  stadium  of  increase  of  about  one  week,  a  stadium  of 
height  of  five  or  six  days,  and  a  stadium  of  decrease  which  terminates 
completely  on  the  twenty-first  day. 

"  Its  thermometric  range  is  decidedly  lower  than  that  of  typhoid.  It 
seldom  goes  above  103|°.  Vomiting  of  bile  is  quite  a  common  symptom 
during  the  first  days  of  the  attack.  Bronchial  catarrh  is  generally  present. 
Constipation  and  a  concave  abdomen  are  marked  features.  Appreciable 
splenic  tenderness  or  enlargement  has  been  so  rare  in  my  observation  that 
from  memory  I  can  recall  but  two  cases  in  fifteen  years.  .  .  .  All  the  essen- 
tial features  of  typhoid  or  enteric  fever  are  absent.  There  is  no  diarrhoea, 
no  ileo-cffical  tenderness  or  gurgling,  no  meteorism,  no  eruption  of  rose- 
colored  spots.  As  a  rule,  there  is  entire  absence  of  abdominal  symptoms. 
In  some  instances,  where  the  patient's  previous  condition  was  bad,  perhaps 
the  system  undermined  by  malaria,  and  where  he  was  unfavorably  situ- 
ated for  treatment  or  had  no  treatment,  I  have  seen  diarrhoea,  dry,  red  and 
shining  tongue,  sordes,  and  low  delirium,  with  picking  at  the  bedclothes, 
and  a  condition  closely  resembling  typhoid. 

"  In  quite  a  large  proportion  of  cases  of  this  fever  a  prominent  feature 
is  neuralgia.  It  will  come  about  mid-day  and  continue  until  after  midnight, 
— in  some  instances  so  severely  as  to  demand  the  hypodermic  use  of  morphia. 
In  one  case  the  pain  will  be  supraorbital  and  extend  to  the  side  of  the  face, 
neck,  and  shoulder ;  in  another  the  neuralgia  attacks  the  intercostal  nerves 


1  Amer.  Jour,  of  Med.  Sci.,  vol.  cl.  p.  395,  1881. 


MALARIA.  845 

of  one  or  both  sides  so  severely  that  there  is  dyspnoea  from  inability  to 
expand  the  chest.  In  a  third  I  have  seen  this  pain  localized  in  the  right 
side,  over  the  region  of  the  ascending  colon,  extending  from  there  upward 
into  the  chest  and  downward  to  the  hip.  In  a  fourth  it  is  in  the  abdomen. 
These  neuralgias  are  periodical,  coming  on  in  the  forenoon." 

It  will  be  seen  from  this  graphic  description  how  absolutely  impossible 
it  would  be  to  diiferentiate  this  form  from  typhoid  fever.  The  points  of 
differentiation  that  are  given  are  certainly  not  sufficient  to  warrant  any  one 
in  excluding  typhoid  fever  absolutely.  Every  clinician  has  seen  cases  of 
typhoid  fever  to  which  the  description  given  by  Dr.  Maury  would  apply 
perfectly.  Now,  if,  in  addition,  cases  present  themselves  with  more  or  less 
abdominal  tenderness,  ivith  diarrhoea,  tvith  enlargement  of  the  spleen,  ivith 
an  eruption,  it  seems  almost  impossible  to  realize  that  it  is  not  typhoid  but 
malarial  manifestations  we  are  dealing  with.  And  yet  every  one  practising 
in  a  malarial  region  has  seen  these  cases  called  typho-malaria.  It  is  not  the 
individual  case  which  ought  to  influence  us,  but  the  general  picture  of  such 
an  epidemic.  From  this  we  shall  be  able  to  judge  whether  it  is  typhoid 
fever  or  continued  malarial  fever  we  are  dealing  with.  One  thing  ought  to 
be  added  to  Dr.  Maury's  description, — that  relapses  do  occur.  I  have  seen 
three  relapses  in  a  child  eleven  years  of  age ;  and  this  could  be  used  as  an 
argument  against  the  typhoid  nature  of  the  fever.  Not  that  relapses  do  not 
occur  in  typhoid  fever,  but  they  are  more  common  in  those  mild  attacks 
which  have  been  called  malarial.  The  whole  subject  must  be  left  for  de- 
cision, however,  to  the  microscopist  and  the  bacteriologist :  it  seems  impossible 
on  clinical  grounds  to  come  to  a  positive  conclusion. 

So  far  as  the  subject  of  typho-malaria  is  concerned,  this  is,  fortunately, 
a  thing  of  the  past.  A  disease  is  either  typhoid  fever  or  malarial  fever,  or 
a  combination  of  both.  Such  a  thing  as  typho-malaria  per  se,  as  an  entity 
or  the  result  of  an  individual  poison,  does  not  exist.  While  the  term  may 
be  a  convenient  one  to  use,  as  expressing  something  more  serious  than 
malaria  and  less  dangerous  than  typhoid  fever,  it  is  one  that  has  done  and. 
is  still  doing  serious  harm  to  the  profession  as  well  as  to  the  layman.  The 
only  raison  d'Mre  it  possesses  is  for  the  latter ;  and  very  little  consolation  it 
is  to  him  to  have  the  patient  die  from  an  intestinal  perforation  or  hemor- 
rhage as  a  result  of  typho-malaria.  We  repeat  that  whenever  a  case  is 
doubtful,  for  the  good  of  the  patient  as  well  as  of  the  physician  it  must  be 
called  typhoid  fever  and  treated  as  such. 

Chronic  Malaria  and  the  Malarial  Cachexia. — ^Malarial  cachexia  is 
the  usual  concomitant  of  chronic  malaria  in  children.  This  is  the  case  in 
the  majority  of  instances ;  although  there  are  mild  forms  of  chronic  malaria 
in  which  the  general  health  does  not  seem  to  suifer  at  all.  On  the  other 
hand,  we  have  the  cachexia  developed  in  patients  who  are  constantly  ex- 
posed to  the  effects  of  the  poison,  without  the  production  of  active  symp- 
toms. Children  having  the  cachexia  present  well-marked  external  evidences. 
They  are  emaciated,  extremely  anaemic,  and  the  pigment  deposited  in  their 


846  MALARIA. 

skins  gives  them  a  peculiar  color.  I  have  seen  all  the  colors  from  a  yellowish 
tint  to  a  brown,  almost  the  same  as  in  Addison's  disease,  well  marked.  The 
children  are  dull,  listless,  have  lost  their  appetites,  usually  suifer  from  some 
gastro-intestinal  derangement,  dyspepsia,  constipation,  or  diarrhoea ;  they 
have  a  little  elevation  of  temperature  every  evening,  and  they  are  very 
weak.  The  spleen  is  enormously  enlarged,  always  painful  upon  pressure ; 
if  the  child  is  old  enough  it  will  complain  of  pain  in  the  region  of  the 
spleen.  The  enlargement  of  the  spleen  arrives  at  its  greatest  development 
in  this  form  of  malaria ;  it  reaches  to  the  umbilicus,  towards  the  right,  and 
sometimes  as  low  as  the  pelvis ;  its  contours  may  be  sharply  defined,  its 
edges  well  rounded,  and  its  resistance  great,  so  that  the  idea  of  amyloid 
degeneration  suggests  itself,  which  is  frequently  proved  upon  post-mortem 
examination.  At  other  times  the  spleen  also  enlarges  upward,  impinging 
upon  the  diaphragm  and  pushing  aside  the  thoracic  organs.  The  liver  is 
also  enlarged,  and  frequently  becomes  amyloid.  Frequently  the  kidneys 
also  become  affected.  At  times  there  is  set  up  an  hydrsemic  condition, 
giving  rise  to  dropsies, — anasarca,  ascites,  or  serous  effusions  into  the  vari- 
ous cavities  of  the  body.  Embolic  or  thrombotic  processes  are  not  uncom- 
mon,— in  the  skin,  producing  petechise,  gangrene ;  in  the  sinuses  of  the 
brain  ;  in  the  lungs  ;  in  the  kidneys.  It  is  remarkable  how,  in  some  cases, 
death  may  be  almost  imminent  and  yet  the  patient  taken  to  a  non-malarial 
climate  may  still  recover.  On  the  other  hand,  a  trifling  illness,  a  follicular 
angina,  a  bronchial  catarrh  of  comparative  unimportance  to  a  healthy  child^ 
may  close  the  chapter  in  a  malarial  cachectic. 

It  would  be  idle  repetition  to  go  over  the  various  forms  under  which 
chronic  malaria  can  manifest  itself.  In  general  terms,  the  manifestations 
are  the  same  as  those  described  under  intermittens.  The  symptoms  become 
continuous  or  prolonged  over  a  great  period  of  time,  and  the  patient  suffers 
until  relief  comes,  until  the  malarial  poison  has  been  eliminated,  or  until 
death  terminates  the  disease.  To  these  there  must  be  added  some  affections 
not  mentioned  before.  In  the  eyes,  Kipp^  has  described  keratitis.  Brill  ^  in- 
traocular hemorrhages,  Landsberg^  hemorrhages  in  the  region  of  the  macula 
lutea,  opacity  of  the  vitreous,  and  iritis,  and  Prucet*  choked  disk  and  pig- 
ment-deposits. Troubles  in  the  mouth  are  common  in  chronic  malaria, 
from  the  simple  stomatitis  to  cancrum  oris, — the  latter  sometimes  ending 
the  life  of  a  cachectic  subject.  Stomatitis  ulcerosa  is  very  common,  and 
unless  the  cause  be  removed  the  disease  itself  will  go  from  bad  to  worse. 
Patients  with  malaria  frequently  have  mouths  which  resemble  those  of 
scorbutic  patients.  Indeed,  the  differential  diagnosis  is  impossible  from  the 
appearance  of  the  mouth  alone.  Oppenheim,  in  Heidelberg,  has  tried  to 
establish  the  existence  of  a  relation  betAveen  rachitis  and  chronic  malaria. 

^  1  Trans.  Amer.  Opth.  Soc,  1880. 

«  New  York  Medical  Record,  xxx.,  1886. 

*  Archiv  f.  Kiiiderheilk.,.xiv.  84. 

*  Ann.  d'Ocul.,  iv.  39,  1878. 


MALARIA.  847 

While  his  arguments  are  very  ingenious,  facts  do  not  seem  to  carry  out  his 
views.  We  cannot  leave  this  subject  without  calling  attention  to  the  great 
difficulty  that  exists  in  recognizing  the  nature  of  chronic  malaria.  Only  he 
will  succeed  who  tries  to  find  the  cause  for  symptoms :  he  who  is  satisfied 
with  treating  symptoms  alone  will  never  recognize  this  form  of  trouble,  and,, 
therefore,  will  never  have  results. 

Prognosis. — The  prognosis  must  be  pitched  for  each  individual  case. 
The  elements  to  be  taken  into  consideration  are  the  age  of  the  patient,  the 
forni  of  the  affection,  and  the  nature  of  the  surroundings.  Pari  passu,  the 
younger  the  child  the  worse  the  prognosis,  the  older  the  better.  Pernicious 
forms  always  mean  a  bad  prognosis ;  and  the  more  rapid  and  violent  the 
onset  the  more  serious  the  case.  Nervous  complications  on  the  part  of  the 
central  organs  always  increase  the  danger.  The  surroundings  must  be 
taken  into  consideration.  A  highly  malarial  district  will  produce  worse 
forms  than  one  in  which  malaria  is  beginning  to  disappear.  The  physician 
himself  comes  in  as  a  prognostic  factor.  The  sooner  the  diagnosis  is  made, 
the  more  energetic  the  treatment,  the  better  the  results.  Sometimes  the 
giving  or  the  withholding  of  a  large  dose  of  quinine  means  life  or  death  to 
a  patient.  For  the  latter's  sake,  it  is  far  better  to  see  malaria  too  often  than 
too  rarely,  provided  the  symptoms  are  of  a  foudroyant  nature.  The  chil- 
dren of  wealthy  parents,  as  in  almost  every  other  form  of  children's  disease, 
will  do  better  than  those  of  poor  ones :  the  former  can  be  removed  to  a 
non-malarial  region,  while  the  latter  have  to  remain,  taking  in  new  poison 
and  going  from  bad  to  worse. 

Treatment. — I.  Prophylaxis. — Much  can  be  done  to  prevent  the  intro- 
duction of  malarial  poison  into  the  system.  In  a  malarial  region  children 
should  be  kept  in  the  house  from  sundown  to  sunrise.  They  must  be  re- 
quired to  live  more  strictly  than  otherwise  according  to  the  physiological 
rules  for  diet,  clothing,  exercise,  etc.  A  great  many  observations  have  been 
made  which  tend  to  show  that  a  person  may  live  for  a  long  time  in  a 
malarial  region  and  escape  infection,  then  be  infected  by  malarial  poison- 
ing after  excess  in  eating  or  drinking,  or  after  some  nervous  effect,  such 
as  fright,  sorrow,  etc.  The  reports  concerning  the  beneficial  prophylactic 
effects  of  the  continued  use  of  small  doses  of  quinine  vary  very  much,, 
some  praising  highly,  others  detracting  just  as  positively.  Some  articles 
of  diet  are  looked  upon  as  liable  to  produce  malaria ;  in  the  South  of  the 
United  States  the  nutmeg  melon  has  been  looked  upon  as  a  bugbear,  notably 
by  the  colored  population.  It  is  not  at  all  probable  that  any  article  of  diet 
will  carry  malaria;  but  indigestible  food  should  be  avoided.  AVhen  any 
digging  of  earth  is  to  be  done,  if  at  all  feasible,  it  should  be  done  when  the 
temperature  averages  below  50°  F., — lower,  if  possible.  Places  in  which 
the  earth  has  been  freshly  dug  up  are  to  be  especially  avoided.  There  is  no 
protection  against  malaria  like  sodding :  the  sod  forms  an  almost  iraperme-' 
able  covering  for  the  earth  and  prevents  the  malaria  from  "  rising."  It  is 
said  that  the  cultivation  of  the  eucalyptus-tree  will  render  a  malarial  region 


848  MALARIA. 

non-malarial.  The  books  are  not  closed  on  this  subject  yet,  and  it  is  too 
early  to  judge  conclusively  thereupon.  In  the  prevention  of  malaria  it 
would  be  very  fortunate  if  the  overflow  of  rivers  aud  creeks  could  be 
prevented.  This,  with  advanced  civilization,  will  undoubtedly  be  accom- 
plished. As  yet  no  other  means,  such  as  chemicals,  have  been  found  to 
destroy  the  malarial  poison  ;  but  sanitary  science  has  done  more  to  change 
the  geography  of  malarial  distribution  than  that  of  almost  any  other  dis- 
ease. Yet  still  more  should  certainly  be  done,  especially  in  cities,  in  which 
the  turning  up  of  the  earth  ought  to  be  controlled  by  public  authority. 
The  physical  discomfort,  to  say  nothing  of  loss  of  life  and  money,  occasioned 
to  individuals  by  the  putting  down  of  a  .series  of  pipes  is  often  but  inade- 
quately counterbalanced  by  the  gain  to  the  community  in  having  these 
pipes.  It  should  be  the  duty  of  every  sanitary  officer  to  superintend  all 
changes  that  are  made  which  imply  turning  up  of  the  earth,  laying  founda- 
tions, etc.,  so  as  to  reduce  to  its  minimum  the  chance  of  infection  by 
malaria.  The  individual  has  a  right  to  demand  this  of  the  communal  gov- 
ernment, and  the  community  will  reap  an  enormous  profit  by  a  little  care 
in  this  direction.  Any  number  of  examples  could  be  mentioned,  in  different 
cities  of  this  country,  in  which  a  local  epidemic  of  malaria  was  started  by 
digging  up  a  street  or  by  laying  the  foundation  for  a  large  building. 

II.  Medicinal  and  Othenvise. — Quinine  is  the  sovereign  remedy  against 
the  manifestations  of  malaria.  A  host  of  remedies  have  been  recommended 
to  take  the  place  of  this  one,  but  we  have  always  come  back  to  it.  The 
administration  of  this  drug  to  children  is  no  easy  matter.  Quinine,  to 
break  up  some  forms  of  malaria,  must  be  given  in  large  doses ;  it  is  exces- 
sively bitter ;  a  great  many  children  cannot  bear  it  upon  their  stomachs.  In 
order  to  overcome  these  difficulties,  the  physician  must  be  thoroughly  well 
acquainted  Avith  all  the  various  modes  in  which  quinine  can  be  given.  First, 
as  to  dose ;  in  order  to  prevent  the  recurrence  of  an  intermittent  attack,  the 
quinine  must  be  given  at  one  dose,  or,  what  practically  amounts  to  one 
dose,  the  whole  quantity  administered  within  half  an  hour.  On  account 
of  the  fact  that  the  drug  manifests  its  maximum  effects  about  four  hours 
after  administration,  it  Avill  have  to  be  given  in  the  majority  of  cases  be- 
tween six  and  half-past  six  a.m.  Many  a  time  have  I  had  the  following 
experience.  An  intermittent,  quotidian  attack  has  been  coming  on  at  fivfc 
o'clock  in  the  evening.  The  next  day  the  patient  is  advised  to  take  his 
quinine  at  one  o'clock  p.m.  The  attack  does  not  present  itself  with  such 
violence,  but  the  patient  complains  of  having  felt  badly,  say,  at  noon ;  so 
that  he  is  ordered  for  the  day  after  to  take  his  medicine  at  eight  o'clock  in 
the  morning.  That  day  he  complains  of  feeling  badly,  but  much  less  so 
than  before.  The  next  day,  perhaps  an  increased  dose  is  administered  at 
the  normal  time,  and  the  attack  is  broken  up.  There  are  exceptions  to  this 
rule,  however :  they  represent  those  mixed-type  cases,  or  some,  very  few, 
cases  in  which  the  attacks  come  on  in  the  evening  or  night.  The  explana- 
tion for  the  apparent  unreliability  of  the  patient's  statements  is  to  be  found 


MALARIA.  849 

iu  the  fact  that  the  maximum  but  not  the  beginning  of  the  attack  presents 
itself  at  the  time  when  the  patient  states  it.  Now,  I  make  it  the  rule,  after 
having  tried  one  large  dose  to  accord  with  the  patient's  observations,  to  give 
the  quinine  at  the  normal  time,  and  usually  I  succeed  in  breaking  up  the 
attack.  Sometimes  the  patient's  observations  are  correct,  and  the  applica- 
tion of  a  sufficiently  large  dose  of  quinine  will  either  prove  or  disprove  his 
statements.  Another  important  matter  is  to  prevent  relapses.  In  the  simple 
forms,  with  the  exception  of  the  quartan,  the  relapse,  if  it  comes,  will 
appear  on  the  seventh,  the  fourteenth,  and  the  twenty-first  day  after  the 
first  chill.  For  the  quartan  form,  which  frequently  changes  its  type,  it  is 
the  eighth,  sixteenth,  and  twenty-fourth  days.  On  these  days,  at  the  normal 
time,  the  full  doses  of  quinine  must  be  given.  The  percentage  of  relapses 
differs  at  diiferent  times  of  the  year  and  in  different  places,  biit  I  never 
allow  a  patient  to  go  without  his  quinine,  after  an  attack  of  intermittens, 
on  the  day  of  his  relapses,  unless  several  examinations  reveal  the  spleen 
reduced  to  its  normal  size.  Even  then,  on  account  of  the  uncertainty  of 
diagnosis  of  enlarged  sjileen,  relapses  will  occur :  so  that  the  safest  plan  is 
to  give  the  patient  his  full  dose  of  quinine  four  times.  In  some  cases,  of 
mixed  type,  it  is  almost  impossible  to  calculate  when  the  day  of  relapse 
will  be ;  and  in  these  cases  it  is  advisable  to  give  the  full  dose  on  two  or 
three  consecutive  days,  in  this  way  positively  precluding  a  relapse.  The 
dose  should  be  sufficiently  large :  it  is  better  to  give  a  little  too  much  than 
too  little. 

Much  has  been  said  about  the  permanent  ill  effects  of  large  doses  of 
quinine.  Where  specialists  are  dealing  with  a  condition  which,  according 
to  their  own  observations,  may  be  produced  by  malaria,  it  is  rather  risky 
for  them  to  assert  that  the  remedy  produces  the  malady,  without  proving 
the  statement  beyond  a  doubt.  The  normal  dose  for  intermittens  that 
I  use  is  as  follows :  below  six  months  of  a^e,  one  to  two  grains :  from 
six  months  to  one  year,  two  to  two  and  a  half  grains ;  from  one  year  to 
two  years,  two  and  a  half  to  three  grains ;  from  two  years  to  five  years, 
three  to  five  grains;  and  from  five  to  twelve  years,  five  to  eight  or  ten 
grains,  depending  upon  the  size,  the  strength  of  the  patient,  and  the  return 
of  the  affection.  Quinine  can  be  administered  by  one  or  all  of  the  methods 
used  in  giving  drugs, — by  the  mouth,  the  rectum,  the  skin.  There  is  no 
method  known  by  which  the  bitter  taste  of  quinine  can  be  effectually  dis- 
guised to  make  it  applicable  to  the  administration  of  sufficiently  large  doses. 
If  the  sulphate  or  muriate  be  used,  liquorice  is  the  best  vehicle,  the  Syrupus 
Liquiritise  (Glycyrrhizse)  Aromaticus  of  the  German  Pharmacopoeia  being 
the  best  preparation.  The  quinine  is  here  given  as  a  -mixture  (never  add 
free  acid,  as  it  produces  a  precipitate),  but  one  drachm  will  not  cover  over 
the  taste  of  more  than  one  grain  of  quinintie  sulphas.  For  the  latter  reason, 
the  applicability  of  this  method  is  very  limited  :  just  where  we  need  it  most, 
in  children  from  three  to  five  years,  it  cannot  be  used,  on  account  of  tlie 
large  quantity  of  vehicle  required.  When  the  patient  can  swallow  pills, 
Vol.  I.— 54 


850  MALARIA. 

this  mode  of  giving  the  remedy  is  to  be  preferred.  To  the  practitioner  using 
very  much  quinine  it  is  not  necessary  to  state  that  he  should  be  careful 
whose  pills  and  what  kind  he  prescribes.  One  is  tempted  to  make  remarks 
about  how  the  dose  of  quinine  has  been  increased  within  the  last  ten  or 
fifteen  years ;  but  the  question  arises,  how  much  the  administration  of  pre- 
pared pills  has  to  do  with  it.  The  tannate  of  quinine  is  a  preparation 
which  is  very  serviceable  in  about  double  the  dose  of  the  sulphate.  This,, 
given  with  pulv.  glycyrrhizee  or  in  the  form  of  the  chocolate  tablets,  can 
be  used  in  older  children  where  no  other  preparation  will  be  taken.  The 
objection  that  applies  to  the  liquorice  mixture  does  not  apply  to  the  tablets, 
for  when  children  take  them  at.  all  they  are  not  particular  as  to  number. 
The  results  are  not  so  satisfactory  as  those  obtained  with  the  sulphate,  but 
the  tannate  is  very  valuable,  especially  in  malarial  intestinal  catarrhs. 
There  are  children  who,  although  good  and  willing,  cannot  take  quinine,  as 
their  stomachs  will  not  retain  it.  These  children  swallow  quinine  without 
resistance,  but  as  soon  as  they  have  it  down  it  is  vomited.  This  is  not  due 
to  any  general  effect,  as  Binz  has  stated,  but  simply  to  local  irritation  of 
the  gastric  mucous  membrane.  Two  methods  are  open  in  such  children, — 
the  administration  of  the  drug  by  other  channels  than  per  os,  or  the  exhibi- 
tion of  one  or  other  of  the  alkaloids  of  Peruvian  bark.  In  one  or  two- 
cases  the  patients  have  been  able  to  bear  cinchonidia  where  quinine  was 
always  regurgitated  :  otherwise  there  is  no  advantage  in  giving  substitutes 
for  quinine,  especially  when  we  take  into  consideration  that  these  substitutes 
have  the  same  bitter  taste  and  must  be  given  in  larger  doses.  The  question 
of  difference  in  cost  is  unimportant. 

In  giving  quinine  by  the  rectum,  in  which  way  it  works  just  as  promptly 
as  per  os,  double  the  dose  must  be  used.  Two  ways  are  open  to  us, — by  in- 
jection and  by  suppository.  It  must  be  confessed  that  the  latter  method  is 
much  more  satisfactory  than  the  first.  The  principal  objection  to  it  is  that 
there  is  great  difficulty  in  causing  the  patient  to  retain  the  remedy ;  more  or 
less  irritation  of  the  rectum  is  bound  to  follow,  and  upon  this  depends  the 
capability  of  the  patient  to  retain  the  quinine.  For  injection  I  suspend  the 
quinine  in  sweet  cream :  any  bland  fluid,  such  as  an  emulsion  of  sweet  oil, 
would  undoubtedly  do  as  well.  The  cream,  if  good,  is  not  coagulated  by 
the  quinine,  and  is  retained  as  well  as  any  other  fluid  I  have  used.  Sup- 
positories cannot  be  made  larger  than  to  contain  five  grains  each  :  although 
this  is  sufficient  for  infants,  for  larger  children  two  or  more  are  necessary. 
Great  care  must  be  exercised  in  making  these  suppositories,  as  the  quinine 
has  the  property  of  crystallizing  on  their  outer  surface,  and  in  this  way 
causes  them  to  irritate  the  intestinal  mucous  membrane.  The  rectal  method, 
when  it  can  be  used,  is  the  most  pleasant  to  the  patient,  especially  to  the 
older  who  cannot  take  pills.  The  use  of  quinine  by  hypodermic  injec- 
tion is  necessary  in  cases  in  which  all  the  other  methods  fail  or  in  which 
it  is  necessary  to  get  (piinine  into  the  system  as  quickly  as  possible, 
as  in  the  pernicious  forms.     The  objection  to  its  use  in  this  way,  that  it 


MALAEIA.  851 

produces  abscesses,  is  sentimental.  It  is  better  for  the  patient  to  have  an 
abscess  than  to  lose  his  life ;  in  addition,  if  proper  antiseptic  precautions  are 
taken,  the  production  of  abscesses  after  the  hypoderniic  use  of  C[uinine  is  by 
no  means  so  certain  as  most  authors  assert.  In  malarial  districts  practi- 
tioners are  in  the  habit  of  using  quinine  by  the  endermic  method.  Al- 
though I  have  never  been  able  to  break  an  attack  in  this  way,  I  have  been 
repeatedly  assured  by  practitioners  that  this  can  be  done.  The  use  of  the 
remedy  as  a  tonic  according  to  this  method  is  certainly  indicated. 

No  substitute  has  been  found  for  quinine ;  but  the  remedy  next  in  im- 
portance is  arsenic.  This  is  most  applicable  to  the  chronic  forms,  and  is  to 
be  administered  between  various  doses  of  quinine  which  are  given  to  pre- 
vent relapses.  It  must  also  be  given  in  full  doses,  although  it  is  entirely 
unnecessary  to  produce  its  toxic  effects.  It  can  be  given  for  months  at  a 
time,  and  ought  to  be  given  until  we  have  reasonable  assurance  that  the 
spleen  has  returned  to  its  natural  size. 

In  the  remittent  and  continuous  forms  quinine  does  not  have  any  other 
effect  than  it  would  have  in  any  other  fever, — i.e.,  that  of  an  antipyretic. 
The  treatment  of  these  forms  is  purely  symptomatic.  Those  who  have 
dealt  most  with  them  prefer  to  begin  the  treatment  with  a  mercurial,  fol- 
lowing this  up  with  quinine  in  small  but  frequently-repeated  doses.  I  am 
not  prepared  to  say  that  this  or  any  other  method  will  have  any  effect  upon 
the  duration  of  the  disease.  Especially  in  the  continuous  form,  the  patient 
should  be  kept  in  bed,  put  upon  diet,  and  watched  very  closely  until  the 
physician  is  positive  that  he  is  not  dealing  with  a  mild  type  of  typhoid. 

For  the  treatment  of  the  chronic  forms  and  the  cachexia,  nothing  suc- 
ceeds so  well  as  removal  to  a  non-malarial  region.  This,  naturally,  is  also 
true  of  the  acute  forms  ;  but  there  it  is  rarely  necessary,  as  attacks  can  be 
controlled  with  quinine.  If  the  removal  is  only  from  one  district  of  a  city 
to  another,  provided  there  be  no  malaria  in  the  quarter  to  which  the  patient 
is  taken,  the  result  will  still  be  good. 

Physicians  should  be  very  careful  where  they  advise  their  patients  to 
move  to.  In  my  own  experience  I  have  seen  several  instances  in  which 
the  patients  were  brought  home  from  places  advertised  as  non-malarial  with 
worse  forms  than  they  had  been  sent  away  with.  Everything  else  being 
equal,  mountain  resorts  are  to  be  preferred  to  the  sea-coast. 

Besides  quinine  and  arsenic,  all  the  tonics  have  been  used, — especially 
iron.  In  anaemic  or  hydrajmic  cases  iron  with  quinine  frequently  produces 
very  good  results.  For  the  affections  of  the  nervous  system  accompanying 
malaria,  strychnine  in  very  small  doses  is  of  value. 

The  enlargement  of  the  spleen  will  be  found  frequently  to  require  special 
treatment.  When  this  organ  is  very  much  enlarged,  the  iodides  are  some- 
times of  value.  When  the  enlargement  is  only  moderate,  faradization  has 
seemed  to  me  frequently  to  give  good  results,  although  recent  reports  do  not 
appear  to  warrant  us  in  using  the  method,  because  of  its  being  absolutely 
unserviceable. 


852  MALARIA. 

In  all  the  various  neuralgic  forms  antipyrin  frequently  acts  like  a 
charm, — not  curative,  but  palliative.  The  remedy  can  be  given  per  os 
or  by  hypodermic  injection.  Acetanilide  seems  to  have  special  control  over 
the  neuralgia  of  the  fifth  pair  of  nerves  due  to  malaria. 

It  is  not  necessary  to  add  that  the  treatment  has  to  be  frequently  modi- 
fied to  suit  the  individual.  There  are  some  patients  who  cannot  take  quinine 
at  all ;  in  some  it  produces  urticaria,  in  others  it  causes  a  series  of  nervous 
symptoms  which,  at  times,  are  worse  than  the  original  malady.  These 
patients  must  be  treated  with  substitutes  or  removed  to  a  non-malarial 
climate. 

Among  the  laity  there  are  many  remedies  which  are  used  for  chills  and 
fever.  Of  these  the  only  one  which  has  given  me  any  results — and  I  have 
been  faithful  in  trying  any  that  are  within  the  boundary  of  common  sense 
— is  lemon-juice.  This  given  in  doses  of  two  drachms  to  a  half-ounce 
twice  or  three  times  daily  has  certainly,  in  some  cases,  produced  good 
results.  In  others,  on  the  other  hand,  the  results  have  been  negative. 
Further  observations  will  be  necessary  to  establish  its  comparative  value. 


YELLOW  FEVER. 

By  JOHN   GUITERAS,  M.D. 


Synonymes. — French,  Fievre  jaune,  Typhus  amaril,  Fievre  matelote; 
Spanish,  Vomito  negro,  El  vomito,  Fiebre  amarilla ;  Portuguese,  Fiebre 
amarela ;  German,  Gelbfieber ;  Italian,  Febbre  gialla. 

The  yellow  fever  of  children  is  described  in  the  tropics  under  the  names 
of  mauvaise  fievre,  fievre  inflammatoire,  fievre  d'acclimatement,  fievre  grave 
des  enfants,  by  the  French ;  fiebres  malas,  vomito  de  los  criollos,  tifo,  fiebre 
de  borras,  in  Spanish ;  pernicious  fever,  ardent  fever,  etc.,  by  the  English. 
These  names  indicate  that  the  disease  in  children  is  not  recognized  as  yellow- 
fever. 

Definition. — Yellow  fever  is  a  contagious  miasmatic  disease,  traceable 
to  populous  centres  in  several  sections  of  the  shores  of  the  tropical  Atlantic, 
whence  it  is  transmitted  by  commercial  and  individual  intercourse.  The 
specific  symptoms  of  the  disease  are  (1)  a  fever  of  from  two  to  seven  days' 
duration,  characterized  by  a  sudden  invasion,  and  a  fastigium  of  from  one 
to  four  days'  duration,  terminating  by  lysis,  the  latter  being  interrupted,  in 
severe  cases,  by  a  secondary  exacerbation ;  (2)  a  steady  fall  of  the  pulse, 
commencing  during  the  fastigium  and  leading  to  a  remarkable  slowing  of 
the  heart-beat ;  (3)  jaundice  ;  (4)  vomiting  ;  (5)  albuminuria ;  (6)  a  tendency 
to  stasis  of  the  circulation,  and  (7)  to  hemorrhages.  The  specific  lesions 
are  parenchymatous  inflammations  of  the  liver,  kidneys,  and  stomach. 

History. — This  is  the  first  time,  I  believe,  that  a  chapter  in  a  treatise 
on  the  diseases  of  children  has  been  devoted  to  the  yellow  fever.  And 
yet  no  disease  is  more  deserving  to  be  so  classed. 

The  history  of  yellow  fever  in  children  reduces  itself  to  occasional 
statements  in  the  descriptions  of  epidemics  occurring  outside  of  the  yellow- 
fever  zone.  Most  of  these  observations  are  directed  to  show  that  there  is  a 
comparative  exemption  from  the  disease  in  early  life.  It  is  a  curious  fact 
that  the  existence  of  the  disease  in  children  of  yellow-fever  countries  has 
been  persistently  denied  by  the  native  physicians.  These  views,  Avhich  were 
founded  on  the  idea  that  the  disease  was  an  acclimating  fever,  still  domi- 
nate general  opinion,  especially  in  those  countries.  The  only  concession 
made  in  this  direction  has  been  to  accept  the  occurrence  of  exceptional  cases ; 

8-53 


854  YELLOW    FEVER. 

and  pitched  battles  have  been  fought  over  these,  as  to  whether  they  were 
or  were  not  cases  of  yellow  fever. 

Blair/  however,  in  his  report  on  the  yellow  fever  of  Guiana,  recog- 
nized the  susceptibility  of  children,  Rufz  de  Lavison^  suspected  that  the 
immunity  of  the  Creoles  from  yellow  fever  was  the  result  of  a  previous 
attack  in  early  life.  Lota,^  in  a  most  interesting  paper,  upholds  the  same 
opinion,  supporting  it  with  clinical  observations.  Reyes,*  of  Cuba,  and 
Bordas,^  of  Key  West,  reported  several  cases,  but  without  making  any  gen- 
eralizations. Chaille,^  of  New  Orleans,  has  given  the  most  convincing 
arguments  in  this  discussion  in  his  analysis  of  the  death-rate  of  that  city. 

My  own  tables  of  the  death-rate  of  Key  West  will  throw,  I  think, 
some  light  on  this  subject.  They  not  only  prove  the  susceptibility  of  white 
children  in  the  tropics,  but  show  also  the  errors  of  diagnosis  that  have  led 
to  the  opposite  opinion. 

The  facts  that  I  have  collected  warrant  the  conclusion  that  the  foci  of 
endemicity  of  yellow  fever  are  essentially  maintained  by  the  Creole  infant 
population, — the  very  population  whose  supposed  immunity  has  been  the 
subject  of  innumerable  theories. 

During  the  epidemic  of  1887  in  Key  West  I  found  that  the  disease 
spread  very  extensively  among  the  children.  I  discovered,  however,  a 
remarkable  immunity  of  the  children  seven  and  eight  years  old.  These 
were  the  children  aged  respectively  one  and  two  years  at  the  time  of  the 
last  preceding  epidemics  of  1880  and  1881.  The  following  table  is  con- 
structed from  data  kindly  furnished  by  the  president  of  the  local  Board  of 
Health,  Dr.  J.  Y.  Porter,  U.S.A. : 

Table  I. — Cases  of  yellow  fever  among  the  natives  of  Key  West  during  the  epidemic  of  1887, 

classified  by  ages. 


Less  than  1  year 2 

1  year 4 

2  years 10 

3  years 13 

4  years 13 

5  years 15 

6  years 3 

7  years 0 

8  years 0 

9  years 6 


10  years 7 

11  years 1 

12  years 4 

13  years 0 

14  years 1 

15-20  years 2 

20-25  years 1 

Total 82 


Many  more  cases  undoubtedly  occurred,  but  were  not  reported,  because 
most  of  the  Cuban  physicians  practising  in  the  city  did  not  believe  that  the 
native  children  could  have  yellow  fever. 

1  Yellow  Fever  in  British  Guiana,  London,  1852  and  1856. 

2  Chronologic  des  Maladies  de  la  Ville  de  Saint-Pierre,  1869. 
^  Archives  de  Medecine  navalc,  1870,  p.  815. 

*  Fiehre  de  Borras  de  los  Ninos,  W.  Keyes. 

5  Fiehre  amarilla  de  los  Ninos,  Cronica  Med.-Quir.  de  la  Hahana,  1881. 

6  Annual  Report  of  the  National  Board  of  Health,  1880. 


YELLO.W-FEVER  YEARS 


NO-FEVER  YEARS 


Tears. 
Quarters. 


CHART 

I. 

1875 

1878 

1880 

1881 

1881 

1881 

1887 

1887      1 

1877 

1877 

1879 

1882 

1883 

1884 

1885 

1886      1 

1rr 

2»i. 

3ri> 

4th 

1st 

2nd 

3.0 

4t» 

1st 

2m 

3rd 

4tm 

Ut 

2md 

3rd 

4tm 

1st 

2hd 

3rd 

4t^ 

1.T 

2»o 

3rd 

4th 

Ibt 

2no 

3»o 

4  th 

Irr 

^m 

3ro 

4TX 

• 

• 
+ 

# 

* 
+ 

+ 

« 

» 

+ 

♦ 

* 

+ 

». 

(f 

+ 

• 

• 
+ 

♦ 

* 

« 
+ 

'• 

7 

6 

5 

4 

t 

s 

3 

'ri 

;'  ', 

2 

f 

t\ 

\ 

A 

^ 

\ 

\ 

A 

J 

/I 

A 

s 

J 

r\ 

A 

f 

\ 

I 

V 

A 

^ 

J 

V 

/ 

\ 

J 

'. 

i 

v 

..\ 

/ 

\ 

1 

I 

,y 

s/ 

v 

■^ 

f 

■*, 

V 

A, 

V 

/ 

\ 

// 

V 

( 

.* 

•■'■ 

! 

i 

■>j 

\ 

/ 

■. 

-«• 

V 

■■»■ 

' 

0 

V 

__ 

_ 

Number  of  deaths  of  white  adults  per  1000  of  living  population. 
CHART   II. 


Tears. 

m 

1878 
1877 

1880 
1879 

1881 
1882 

1881 
1883 

1881 
1884 

lii? 

mi  1 

Quarters. 

Ut 

2hd 

3rd 

4  th 

1st 

2nd 

3m 

4th 

1st 

2nd 

3bd 

4th 

1st 

2no 

3rd 

4th 

Ibt 

2nd 

3rd 

4th 

1st 

2no 

3rd 

4th 

1st 

2nd 

3rd 

*TH 

1st 

2nd 

3rd 

*T>H 

7 

» 

+ 

* 

+ 

* 

+ 

* 

* 

* 
+ 

* 

* 

» 

+ 

w 

# 

+ 

If 

» 
+ 

« 

* 

« 

» 

6 

A 

5 

A 

A 

A 

4 

./ 

A 

1 

\ 

/ 

\ 

3 

1 

\ 

i\ 

'■•j 

r 

\ 

A 

A 

A 

/i 

' 

i 

y 

2 

/ 

i 

J 

\" 

\ 

/ 

\ 

V 

/ 

V 

s/ 

/ 

V 

•./ 

/■ 

V 

V 

\ 

\ 

1 

i 

Si 

V. 

\ 

"^ 

/ 

■\ 

"\ 

,.'•• 

,a' 

'■■••■' 

^ 

■^ 

0 

V 

~v 

"*' 

Number  of  deaths  of  white  children,  ^I'e  years  of  age  and  under,  per  1000  of  living  population. 
CHART   III. 


Number  of  deaths  of  ivhiie  children,  one  year  of  age  and  under,  per  1000  of  living  population. 

John  Guiteras,  M.U. 


YELLOW    FEVER.  855 

I  tabulated  the  death-records  I  found  in  Key  West,  covering  the  period 
from  1875  to  1887.  The  details  of  this  investigation  will  be  found  in  the 
Report  of  the  Surgeon-General  of  the  Marine  Hospital  Service  for  1888. 
The  following  charts — from  I.  to  VI. — show  graphically  the  results.  The 
vertical  spaces  rej)resent  two  series  of  years,  contrasting  a  yellow-fever  year 
with  one  of  absolute  or  perhaps  only  relative  immunity.  The  years  are 
divided  into  quarters,  as  follows :  first  quarter,  December,  January,  and 
February ;  second  quarter,  March,  April,  and  May,  and  so  on.  The  quar- 
ters in  which  deaths  from  yellow  fever  were  reported  are  marked  with  an 
asterisk.  The  one  quarter  in  which  the  greatest  number  of  deaths  from 
that  disease  were  reported  is  further  indicated  by  a  cross.  In  the  hori- 
zontal lines  are  marked  the  death-rates  per  thousand  of  the  living  popula- 
tion for  the  different  quarters.  The  rates  are  represented  by  the  continued 
line  in  yellow-fever  years,  by  the  dotted  line  in  no-fever  years. 

These  charts  leave  no  doubt  of  the  increase  of  the  death-rate  of  children 
in  yellow- fever  years.  The  exception  of  the  year  1878  is  explained  by  the 
prevalence  of  an  epidemic  of  whooping-cough.  This  disease  appeared  also 
in  1884.  The  correspondence  of  the  rise  of  the  infantile  death-rate  with 
the  yellow-fever  quarters,  and  the  accentuation  of  the  rise  during  the 
greater  epidemics  of  1875  and  1887,  are  remarkable  facts. 

In  order  more  conclusively  to  prove  that  this  excess  of  infantile  mor- 
tality was  caused  by  the  yellow  fever,  I  have  contrasted  the  death-records 
of  whites  and  blacks.  Charts  lY.,  V.,  and  VI.  represent  the  curves  for 
the  colored  population.  The  mildness  of  yellow  fever  in  the  black  race  is 
universally  admitted.  We  are  not  surprised,  therefore,  to  find  that  the 
prevalence  of  yellow  fever  has  no  influence  upon  the  death-rate  of  colored 
children. 

Inasmuch  as  this  increase  of  the  number  of  deaths  of  white  children  is 
not  accounted  for  in  the  mortuary  records  under  the  diagnosis  of  yellow 
fever,  it  becomes  of  great  importance  to  discover  under  what  heads  they  are 
to  be  found. 

This  is  shown  in  Table  II.  I  selected  certain  diseases  with  which 
yellow  fever  might  be  confounded,  and  these  were  classified  in  several 
groups, — Group  A,  Group  B,  etc.  The  figures  represent  the  death-rate  for 
the  quarter  of  the  year  in  which  the  greatest  number  of  deaths  from  yellow 
fever  were  reported,  contrasted  with  the  same  quarter  of  a  no-fever  year. 


856 


YELLOW    FEVER. 


t?^    <» 
^  » 


s  "+-> 


"i; 

<s 

Cl 

s' 

■t-J 

c 

o 

?^ 

s 

-to 

^ 

a. 

<S1 

?^ 

S       ==5 


e  § 


>. 


"« 
^ 


1 

t^ 

t^ 

Gi 

Id 

CO 

•* 

i-O 

CD 

•SIBO^  I8Aaj-0M 

CO 

i-H 

CO 

00 

CO 
00 

CO 
CO 

00 

CO 

CO 

1-H 

^ 

, 

o 

00 

'^ 

CO 

t^ 

CD 

la 

=*  a^ 

,— 1 

T-H 

c 

Cl 

CO 

o 

Cl 

00 

8^6 

^_, 

^_, 

o 

o 

o 

c 

o 

d 

CO 

^     top 

5"= 

n 

^ 

t^ 

t^ 

t^ 

^ 

o 

05 

■* 

^ 

■* 

^ 

o 

LO 

C5 

1^1 

o 

o 

o 

o 

o 

o 

o 

'* 

lC 

CO 

o 

^ 

1-H 

^ 

r~ 

J:^ 

■siBa^  jOAOj-Aiona^ 

CO 

I-H 

CO 

CO 
00 

CO 
00 

CO 
00 

00 
00 

CO 

00 

t^ 

l-~ 

^_ 

Ol 

CO 

^ 

i-C 

CD 

•SI'BO.?  J9Aaj-0JsI 

1^ 

CO 

GO 

GO 

00 
CO 

I-H 

00 
CO 

00 
GO 

GO 
GO 

00 

CO 

aJ 

(M 

(M 

,_, 

CO 

^^ 

^ 

-* 

CD 

00 

C  c    . 

1—1 

!M 

o 

Tf 

GO 

1-H 

c^ 

1-H 

•i-2S 

o 

O 

O 

o 

o 

o 

o 

o 

Cl 

CO 

t^ 

o 

00 

00 

GO 

lr~ 

t^ 

CO 

oi 

lO 

lO 

1-H 

T—^ 

CO 

CO 

CD 

o^ 

o 

o 

o 

o 

o 

o 

o 

o 

Cl 

lO 

GO 

o 

^ 

^ 

^ 

t^ 

t^ 

■S1.VBA.  J9A8J-A\.0n8i 

CO 

CO 

I-H 

oo 

00 

00' 
00 

00 
00 

CO 

CO 

CO 

t^ 

Ir~ 

o 

rM 

CO 

Tt* 

lO 

CD 

■SlfSSJi  I0A9J-O>I 

CO 

00 

00 

CO 

CO 

GO 
CO 

GO 
GO 

CO 
CO 

^H 

CO 

t^ 

X' 

^ 

o 

CO 

■     2  Si'O  o  S 

CO 

oo 

o 

Cl 

-* 

-* 

o 

o 

o 

o 

o 

o 

o 

o 

1-H 

o,£  o  ?t2 

CD 

■* 

o 

o 

Oi 

c: 

Cl 

Cl 

T-H 

"•-xJ^^ 

lO 

CO 

o 

o 

o 

1-H 

— 1 

o 

I— 1 

o 

o 

o 

o 

o 

o 

o 

Cl 

lO 

00 

o 

^ 

^ 

^ 

t~ 

t~ 

•SI'BOiC  JOAaj-AiOlpA 

CO 

00 

CO 

00 

00 
CO 

CO 
CO 

CO 
GO 

00 

00 

CO 

1-H 

t^ 

t- 

o 

cq 

CO 

-* 

m 

-'■^ 

•SIB9iC  I9A9J-0^ 

oo 

00 

CO 

CO 

CO 

GO 
CO 

00 
00 

CO 
00 

CO 
CO 

(M 

Cl 

00 

1:^ 

o 

CO 

ir-- 

'2'"   -     d 

I-H 

o 

o 

CO 

1-H 

CO 

l°P^£ 

d 

o 

o 

o 

o 

o 

o 

o 

o 

d    ^S-BS2 

o 

-<*< 

I-H 

00 

CO 

CO 

gcgc^-g 

■* 

CO 

CO 

T-H 

cq 

cq 

o 

^ 

o 

1— 1 

o 

o 

O' 

'-' 

'-' 

CD 

o 

CO 

o 

, , 

^ , 

^ 

t^ 

t~ 

•SJB9j£  jaASJ-AiOlp^l 

1^ 

CO 

CO 

GO 
00 

CO 
GO 

00 
00 

CO 
00 

00 

CO 

Ol 

CA 

CO 

■* 

lO 

CD 

■si'ea.C  J9A9J-0M 

00 

CO 

00 

CO 
CO 

1-H 

00 
00 

00 

CO 

I-H 

GO 
CO 

00 
CO 

I-H 

o 

o 

o 

o 

o 

o 

o 

o 

o 

t- 1.  fl   • 

cq      ^-;  S'S 

o 

Ci 

05 

LC 

uO 

t^ 

g§|-si 

o 

o 

o 

o 
d 

o 
d 

o 
d 

d 

Cl 

d 

d 

uO 

00 

o 

^ 

1-H 

I-H 

lr~ 

lr~ 

•Sl^aX  J9A9J-A\0U9A 

CO 

CO 

00 

00 

00 

CO 

00 

00 

00 

00 

00 

00 

00 
00 

1— 

1— 

C' 

Cl 

CO 

-* 

lO 

CO 

■SiVa.i  J9A9J-0M 

CO 

GO 

00 

00 
00 

00 
CO 

1-H 

00 

00 

GO 
00 

00 
00 

t^ 

(~ 

cc 

CD 

iC 

^ 

<-. 

Cl 

.S  w  ,   o      -• 

CO 

CO 

d 

I-H, 

1—1 

Cl 

-* 

ro 

A. 

lingit 
-ebriti 
rebro 
al  fev 
tc.,  in 
ildrei 

o 

CO 

o 

o 

o 

o 

o 

o 
1^ 

o 

CD 

CD 

t^ 

|S-|"o 

Cl 

d 

d 

d 

CO 

d 

CO 

d 

CO 

d 

d 

d 

CO 
CO 

IC 

CO 

o 

^ 

^ 

^ 

t~- 

t- 

•SJB9./C  J9A9J-M.0n9A 

OO 
I— 1 

00 

I-H 

CO 

CO 

CO 

I-H 

00 

GO 

00 

00 

o 

=s     SS 


YELLOW-FEVER  YEARS 


NO-FEVER  YEARS 


CHAET 

IV. 

Tears, 

1875 
1877 

1878 
1877 

~  l88(J 
1879 

1881 
1882 

1881 
1883 

1881 
1884 

1887 
1885 

1887      1 
1886      1 

daarters. 

Irr 

2>.o 

3ri. 

4t. 

IHT 

2m 

3to 

4n 

Irr 

2«> 

%m 

♦t« 

1>T 

2nD 

3«. 

4t» 

1.T 

2no 

3» 

♦th 

In 

2,, 

9"? 

4th 

In 

2x0 

3>D 

4t». 

In 

2hd 

3x0 

4t>. 

7 

• 

* 
+ 

• 
+ 

» 

+ 

♦ 

*- 

+ 

» 

-» 

* 
+ 

» 

« 

+ 

* 

• 
+ 

» 

« 

* 
+ 

« 

6 

5 

4 

3 

2 

1 

/i 

'-s 

>, 

A 

-% 

r*t 

.\ 

,^ 

IS 

V 

< 

-^ 

0 

-/ 

"^ 

■J' 

'^^ 

\c 

>s 

■y 

'  V 

'v 

^  -- 

^ 

s»< 

S 

V 

\ 

V 

i/ 

"v' 

^^ 

y 

'■• 

Number  of  deaths  of  colored  adults  per  1000  of  living  population. 
CHAET   V. 


Tears. 

1875 
1877 

1878 
1877 

1880 
1879 

1881 
1       1882    . 

1881 
1883 

1881 
1884 

1887             1887 
1885             1886 

Qaarters. 

1st 

P.m 

Isn 

4th 

In 

2r.D 

3bo 

4th 

In 

2nd 

3ro 

4t« 

In 

2nd 

3rd 

4th 

In 

2no 

3iio 

4th 

In 

2nd 

3rd 

4th 

In 

2nd 

3rd 

4th 

In 

2nd 

3rd 

4t. 

7 

* 

» 

* 
+ 

* 

* 
+ 

* 

# 

« 
+ 

♦ 

4t» 

-* 

+ 

-* 

* 

» 
+ 

* 

• 
+ 

* 

* 

+ 

« 

6 

5 

4 

3 

2 

. 

^ 

V- 

^ 

v- 

1 

,)> 

^ 

P 

^ 

,'■ 

A_ 

A 

/-, 

>A 

A, 

/., 

'•v' 

A 

i 

\ 

2 

7 

/ 

'\ 

< 

0 

^ 

i»^ 

^ 

7 

t 

y 

V, 

V 

.J 

v:> 

^ 

-• 

-'' 

V 

^ 

s;^ 

_ 

_ 

Number  of  deaths  of  colored  children,  five  years  of  age  and  under,  per  1000  of  living  population. 

CHAET   VI. 


Quarters. 


1875 
1 ^1877 

1878 
1877 

1880 
1879 

1881 
1882 

1881 
1883 

1881 
1884 

1887 
1885 

1887 
1886 

1st 

?ND 

^Rnl 

4  th 

Ut 

?W1 

3«D 

4t> 

1lT 

?Nn 

3«t. 

4Tf 

In 

2Nn 

3ro 

4th 

In 

2nd 

3rd 

4th 

In 

2nd 

3«o 

4t- 

In 

2nd 

3rd 

4th 

la 

Sl£ 

3rd 

42 

7 

» 

+ 

+ 

» 

+ 

* 

# 

+ 

• 

# 

« 
+ 

* 

# 

* 
+ 

• 

* 
+ 

« 

• 

• 
+ 

• 

R 

■i 

4 

? 

? 

1 

A 

, 

■  \ 

_>1 

/s 

s— 

-r' 

^ 

- 

0 

r: 

»^ 

_ 

^ 

>J 

V 

"n 

c 

>^ 

-% 

y 

A 

c 

=s 

V 

^ 

>j;r' 

A 

s/ 

<^ 

>^ 

_J 

s/ 

^. 

-"**, 

\ 

^ 

T 

S 

^ 

Number  of  deaths  of  culortd  clnldrea,  one  year  «/  u<jc  and  under,  pur  lUOU  of  living  population. 

John  Guit^rai?,  M.D. 


YELLOW    FEVER.  857 

A  glance  at  this  table  shows  that  the  excess  of  deaths  is  to  be  found 
under  the  head  of  acute  cerebral  and  meningeal  affections  and  the  malarial 
fevers.  This  result  I  had  anticipated  in  consideration  of  the  astonishing 
frequency  with  which  the  diagnosis  of  meningitis  or  pernicious  fever  is 
made  for  the  diseases  of  childhood  in  the  tropics.  The  death-rate  from 
meningitis  (so  reported)  in  the  city  of  Havana  is  extraordinarily  high,  as 
shown  by  the  following  terms  of  comparison  : 

Annual  Death-Rate  per  1000  of  Living  Population  from  Meningitis,  etc. 

For  the  United  States,  census  of  1880 0.20 

Louisville,  Ky.  (highest  in  the  Union) 0.50 

Havana,  mean  of  seven  years 1.27 

Key  West  in  yellow-fever  years 1.40 

Key  West  in  no-fever  years 1.27 

In  regard  to  the  malarial  fevers,  I  may  say  that  I  have  elsewhere^ 
furnished  proof  that  Key  West  is  not  a  malarious  locality. 

We  have  reason,  then,  to  believe  that  yellow  fever  in  its  native  haunts 
is  essentially  a  disease  of  childhood,  the  adult  natives  being  protected  by  a 
previous  attack.  The  prevalence  of  the  disease  among  adults — foreigners 
— is  an  accident  consequent  upon  immigration.  The  same  would  happen 
with  measles  in  Northern  cities  if  these  were  subject  to  immigrations  from 
countries  where  that  disease  was  unknown.  And  if  this  foreign  element 
were  to  belong  to  the  colored  race,  it  is  very  probable  that  measles  would 
assume  a  very  grave  form,  and  would  throw  in  the  shade  the  milder  mani- 
festations of  the  disease  in  native  white  children. 

Etiology, — The  early  historians  of  the  Spanish  invasion  of  America 
furnish  grounds  for  the  belief  that  yellow  fever  was  endemic  with  the 
American  aborigines  of  the  littoral  of  the  tropical  Atlantic,  and  that  the 
disease  appeared  with  them  sporadically,  and  in  the  shape  of  periodic  epi- 
demics, in  the  same  manner  that  cholera  exists  in  portions  of  Asia.  Cer- 
tain it  is  that  yellow  fever  manifests  itself  in  this  shape  among  the  present 
indigenes  of  the  yellow-fever  zone.  But  the  increase  of  commercial  inter- 
course and  travel  has  established  two  modalities  of  the  disease :  on  the  one 
hand,  the  yearly  influx  of  foreigners  has  given  rise  to  the  formation  of 
centres,  in  the  yellow-fever  zone,  where  the  disease  is  annually  epidemic ; 
on  the  other  hand,  the  communications  with  the  exterior  have  caused  the 
transportation  of  the  infecting  agent  to  more  or  less  distant  lands,  where 
the  vitality  of  the  germ  does  not  apjiear  to  hold  from  year  to  year. 

I  have  therefore  divided  the  regions  affected  by  the  yellow  fever  into 
three  classes : 

I.  The  regions  of  annual  epidemics  (focal). 

II.  The  regions  of  periodic  epidemics  (perifocal). 

III.  The  regions  of  accidental  epidemics  (occasional). 


'  Annual  Report  of  the  Marine  Hospital  Service  for  1888. 


So8  YELLOW    FEVER. 

The  focal  zone  (I.)  includes  the  ports  of  Havana,  Vera  Cruz,  Matanzas, 
Rio  Janeii^o,  and  other  imjDortant  seaports  of  intertropical  America,  perhaps 
also  a  portion  of  the  African  coast  on  the  Atlantic.  In  these  ports  the  dis- 
ease, never  entirely  absent,  regularly  spreads  every  year  with  the  advent  of 
warm  weather,  and  invades  the  inhabitants  who  are  not  protected  by  a 
previous  attack,  with  few  exceptions.  In  Havana,  for  instance,  we  find 
that  the  lowest  number  of  deaths  from  yellow  fever  in  one  out  of  seven 
consecutive  years  is  five  hundred  and  fifteen,  and  the  highest  sixteen  hun- 
dred and  nineteen,  in  a  population  of  about  tv^o  hundred  thousand.  And 
this  does  not  include  the  deaths  of  native  children. 

In  the  perifocal  zone  (II.),  or  regions  of  periodic  epidemics,  belong  the 
majority  of  the  ports  of  the  tropical  Atlantic  in  America  and  Africa,  and 
a  smaller  number  on  the  Pacific  coast  of  the  American  continent.  Xew 
Orleans,  Charleston,  and  probably  other  American  cities  belonged  once  in 
this  category. 

The  zone  of  accidental  epidemics  (III.)  includes  those  places  of  the 
temperate  zone  or  of  high  altitude  where  the  disease  is  occasionally  im- 
ported and  will  prevail  for  one  season  only.  It  would  be  rash  to  limit 
absolutely  the  boundaries  of  this  area ;  that  is,  the  limits  within  which, 
once  imported,  the  yellow  fever  may  assume  an  epidemic  form.  No  place 
can  claim  an  absolute  immunity,  in  the  countries  bordering  on  the  Atlantic 
Ocean  between  the  parallels  of  45°  north  latitude  and  35°  south  latitude, 
and  below  an  altitude  of  fifteen  thousand  feet  above  sea-level.  It  is  true, 
however,  that  as  we  approach  the  limits  above  specified  the  probabilities  of 
infection  become  almost  nil. 

As  examples  of  this  third  group  we  may  mention  the  epidemics  of  Xew 
York,  Philadelphia,  the  Mississippi  Valley,  Florida,  Spain,  Montevideo, 
Cuzco,  etc.  The  increasing  facilities  of  railroad  communications  in  southern 
countries  are  fast  divesting  the  watercourses  of  their  importance  as  neces- 
sary means  of  transportation  of  the  yellow  fever. 

In  the  regions  of  Classes  I.  and  II.  we  say  that  the  disease  is  endemic 
because  it  occurs  in  succeeding  or  periodic  seasons  without  the  necessity  of 
importation.  The  theory  of  spontaneous  origin  of  infectious  diseases  has 
not  received  any  support  in  bacteriological  researches.  We  say,  therefore, 
that  in  these  localities  the  germs  of  the  disease  are  not  destroyed  during  the 
healthy  season.  This  endemicity  is  by  no  means  permanent,  as  is  shown  by 
the  fact  that  New  Orleans  and  Charleston  have  been  transferred  from  Class 
II.  to  Class  III.  It  is  very  prol^able  tliat  by  efficient  sanitation  the  centres 
of  Classes  I.  and  III.  could  l)e  eliminated, — those  of  Class  I.  by  being 
ti'ansferred  to  Class  II.,  and  those  of  Class  III.  by  securing  an  absolute 
exeinption. 

The  centres  of  Class  IL,  wliich  represent  the  natural  modality  of  the 
disease,  deserve  a  more  extended  consideration.  We  remark  here  the 
periods  of  more  or  less  prolonged  exemption.  This  absence  of  the  disease, 
in  my  opinion,  is  not  real.     The  belief  in  it  is  founded  on  the  opinion  that 


YELLOW   FEVER.  859 

the  disease  does  not  occur  among  native  children.  But  the  facts  advanced 
in  the  historical  part  of  this  article,  proving  the  susceptibility  of  all  chil- 
dren, warrant  the  opinion  that  in  these  localities  the  foci  of  endemicity  are 
maintained  by  the  native  children.  This  is  an  important  factor  in  the  epi- 
demiology of  yellow  fever.  We  must  remember  that  these  periods  of 
latency  follow,  as  a  rule,  after  extensive  epidemics,  during  which  tlie  great 
majority  of  children  have  had  the  disease  and  have  acquired  immunity. 
From  experience  we  know  that  after  these  epidemics  the  number  of  houses 
or  rooms  where  exceptional  conditions,  that  we  know  very  little  about,  will 
keep  up  the  vitality  of  the  germs  are  very  few,  and  few  also  will  be,  in  the 
following  year,  the  number  of  unprotected  children.  In  the  fewer  instances 
still  in  which  these  two  conditions  are  brought  into  mutual  operation,  a  case 
of  yellow  fever  will  present  itself.  These  cases  are  not  recognized,  because 
the  foreigner  is  looked  upon  as  the  only  touchstone  for  the  detection  of  the 
disease.  Now,  in  yellow-fever  countries  the  foreigner  is  not  a  frequenter 
of  the  homes  of  the  Creoles.  Thus  the  disease,  like  cholera  in  some  of  the 
cities  of  India,  may  be  confined  to  the  natives.  Only  occasionally  we  hear, 
during  these  periods  of  supposed  exemption,  of  a  sporadic  case  of  yellow 
fever  in  a  foreigner.  It  can  be  readily  seen  how,  in  this  manner,  epidemics 
have  occurred  where  it  was  impossible  to  trace  the  origin  to  importation, 
thus  giving  rise  to  the  opinion  that  the  germs  of  the  disease  developed 
spontaneously  from  local  causes. 

In  some  epidemics  we  may  be  able  to  trace  the  outbreak  to  both  sources : 
we  will  have,  after  some  years  of  apparent  exemption,  the  disease  assuming 
an  epidemic  form  among  the  native  children  who  have  grown  up  without 
being  protected  by  a  previous  attack ;  and  at  the  same  time  the  disease  may 
break  out  around  some  focus  traceable  to  importation.  This  latter  eruption 
generally  occurs  in  the  business  quarters  of  the  city,  and  among  strangers. 
It  constitutes,  as  a  rule,  the  first  accepted  evidence  of  the  presence  of  the 
disease.  These  facts  account  for  the  statement  frequently  made,  to  the  eifect 
that  epidemics  of  yellow  fever  are  preceded  or  announced  by  the  prevalence 
of  bilious  fevers,  etc.,  especially  among  children. 

This  double  origin  of  an  epidemic  I  discovered  in  Key  West  in  1887. 
Charts  II.  and  III.  of  the  present  article  show  an  increased  mortality  of 
white  children  for  the  first  quarter  of  the  year,  before  the  first  recognized 
cases  of  yellow  fever  occurred  in  the  business  quarters  of  the  city  around  a 
focus  evidently  of  imported  infection.  Even  the  preceding  summer  I  notice 
an  increase  of  the  infantile  mortality. 

This  tendency  to  spread  of  the  domestic  infection,  together  with  the 
facility  with  which  the  imported  infection  takes  hold  during  the  same 
season,  may  be  simply  due  to  the  greater  vulnerability  of  the  population 
resulting  from  the  increase  by  immigration  of  unprotected  strangers,  and  by 
birth  of  natives.  The  fact,  however,  that  this  susceptibility  seems  to  aifcct 
large  extents  of  territory  points  towards  the  existence  of  some  atmospheric, 
telluric,  or  other  conditions,  entirely  unknown,  that  prevail  in  certain  years 


860  YELLOW    FEVER. 

and  favor  the  spread  of  the  disease.  In  this  sense  we  may  speak  of  an 
epidemic  wave  or  territorial  receptivity. 

In  this  connection  it  is  that  the  subjects  of  heat,  moisture,  atmospheric 
pressure,  electricity,  prevalence  of  certain  winds,  etc.,  deserve  consideration. 
But  we  must  confess  that  this  study  has  been  fruitless.  In  regard  to  the 
prevalence  of  certain  winds  I  have  to  call  attention  to  the  fact  that  the 
houses  in  the  tropics  are  constructed  so  as  to  favor  as  much  as  possible  a 
complete  exposure  to  the  prevailing  breezes.  A  season  of  persistent  winds 
from  the  opposite  quarters  reduces  ventilation  to  a  minimum,  as  all  will 
acknowledge  who  have  felt  the  oppressive  influence  of  a  southwesterly  wind 
in  the  city  of  Havana,  where  every  house  seems  to  breathe  from  the  east- 
ward. The  prevalence  of  southwesterly  winds  has  been  considered  in  the 
Antilles  as  an  element  of  great  importance  in  the  causation  of  yellow  fever. 
It  is  very  probable  that  their  action  is  merely  such  as  I  have  indicated 
above. 

I  have  used  the  term  contagious-miasmatic  in  the  definition  of  yellow 
fever,  because  it  is  the  one  generally  employed  for  the  group  of  infectious 
diseases  in  which  yellow  fever  belongs.  But  there  is  not,  as  Prof  William 
H.  Welch  yerj  well  observes,  any  essential  difference  between  these  and  the 
diseases  termed  contagious.  It  is  merely  a  question  of  degree  or  facilitj^  for 
transmission.  All  these  diseases  require  a  medium,  a  vehicle  of  transpor- 
tation from  the  sick  to  the  well.  Those  diseases  in  which  this  medium 
acquires  great  importance,  to  the  extent  that  media  apparently  the  same 
prove  sometimes  destructive,  sometimes  favorable,  to  the  vitahty  of  the 
infecting  agent,  we  term  contagious-miasmatic.  They  might  with  propriety 
be  called  indirectly  or  mediately  transmissible.  Such  a  disease  is  yellow 
fever.  So  great,  in  fact,  is  the  importance  of  the  locality  and  surroundings 
in  this  disease  that  the  term  infectious,  as  formerly  understood,  was  prop- 
erly applied  to  it.  When  we  are  confronted,  however,  with  a  doctrine  of 
pure  miasmatic  origin,  we  have  to  place  yellow  fever  M'ith  the  contagious 
diseases.  For  surely  yellow  fever  belongs  with  those  diseases  in  which  the 
methods  of  modern  research  have  discovered  the  presence  of  a  micro- 
organism in  the  body,  capable,  if  favorable  means  are  provided,  of  convey- 
ing the  disease  to  other  individuals.  The  general  characteristics  possessed 
by  yellow  fever  in  common  with  those  diseases  are :  first,  yellow  fever  is  a 
disease  of  populous  centres ;  secondly,  it  is  a  portable  disease  and  extends 
along  the  lines  of  travel ;  thirdly,  there  is  no  evidence  of  the  disease  ever 
having  developed  where  there  was  no  possibility  of  infection  from  other 
cases ;  fourthly,  one  attack  confers  immunity  against  a  second  invasion. 

I  need  not  mention  cases  illustrating  the  transmission  of  the  disease  by 
fomites.  This  is  admitted,  though  rather  reluctantly,  even  by  the  believers 
in  the  local  origin  of  the  disease.  I  shall  present  examples  only  of  the 
transportation  of  the  disease  by  sick  persons,  and  these  will  be  taken  from 
observations  of  the  Florida  epidemic  of  1888. 

In  the  first  place,  we  must  bring  as  evidence  the  general  course  of  the 


YELLOW    FEVER.  861 

epidemic.  It  was  confined  to  Key  West  during  the  spring  and  summer  of 
1887.  Finally,  towards  the  end  of  summer  it  made  a  landing  on  the  main- 
land, at  Tampa,  the  only  port  of  Florida  that  was  in  constant  communica- 
tion with  Key  West,  thus  leaving  untouched  many  places  that  were  nearer 
to  the  infected  area.  Some  of  these  became  subsequently  infected  through 
communication  with  Tampa.  In  fact,  soon  after  the  outbreak  at  Tampa 
and  the  stampede  that  followed  it  we  find  cases  reported  and  local  outbreaks 
in  the  track  of  refugees.  Now,  the  end  of  summer  and  beginning  of 
autumn  is  not  the  season  for  the  commencement  of  epidemics  in  those  local- 
ities where  the  disease  does  not  require  importation  for  its  development. 
Here  the  disease  o-raduallv  rises  with  the  advent  of  warm  ^veather. 

The  outbreaks  at  Sanford  and  Bartow  occurred  around  refugees  who 
took  sick  soon  after  their  arrival  from  the  seat  of  the  epidemic.  So  con- 
stantly has  this  been  my  experience  that  when  this  link  is  missing  the 
explanation  is  often  to  be  found  in  the  fact  that  the  original  case  was  a 
convalescent,  or  else  the  disease  was  so  mild  as  not  to  be  recognized.  It  is 
very  probable  that  children  and  negroes  import  the  disease  in  this  manner 
unsuspected. 

Another  case  of  importation  by  individuals  is  that  of  the  village  of 
Callahan.  This  town  is  situated  at  the  intersection  of  railroads  from  Fer- 
naudina  and  Jacksonville.  Callahan  is  much  nearer  to  Jacksonville  than  is 
Fernandina,  but  had  established  a  vigorous  quarantine  against  the  former 
place  when  the  fever  was  declared  epidemic  in  July  of  1888.  On  the  occa- 
sion of  a  strike  in  Fernandina,  this  city  being  erroneously  reported  healthy, 
the  town  of  Callahan  contributed  a  contingent  of  guards  for  the  occasion. 
These  guards  went  and  returned  without  any  baggage  whatever.  On  their 
return  they  scattered  at  once  to  their  homes  in  the  country  around  Callahan. 
Only  one  of  these  guards,  Upchurch,  remained  in  the  town.  He  took  sick 
the  day  after  his  arrival  at  his  home,  one  of  the  oldest  houses  in  the  village. 
Five  cases  are  traceable  to  this  one, — a  brother  who  occupied  an  adjoining 
room,  three  white  employees  of  the  railway-station,  and  a  negro  who  nui^sed 
the  Upchurch  brothers.  The  station  is  separated  by  a  narrow  road  from 
the  house.  The  employees  visited  the  first  Upchurch  brother  frequently, 
and  used  the  privy  of  the  house.  All  this  happened  between  the  9th  and 
29th  of  September.  One  of  these  employees  was  treated  in  the  hotel.  The 
two  subsequent  cases  among  the  whites  are  traceable  to  the  hotel, — the  son 
of  the  proprietor  on  the  13th  of  October,  and  a  Mr.  Rawson,  who,  after 
having  refugeed,  returned  to  the  hotel  on  the  23d  of  October  and  took  sick 
on  the  27th.  The  white  population  fled  from  the  city,  and  they  appear  to 
have  carried  no  infection  with  them.  T^\•o  cases  were  discovered  later  in 
the  colored  jiojiulation.  Long  before  this  outbreak  at  Callahan,  the  town 
of  McClenny,  lying  farther  on  the  railnjad  from  Jacksonville  and  Fernan- 
dina, had  been  infected  by  a  refugee,  a  printer  from  Jacksonville. 

I  attach  much  importance  to  the  fallowing  incident.  Here  the  events 
were  predicted  and  carefully  watched  for.     Mr.  Upton  owns  a  saw-mill  at 


862  YELLOW    FEVER. 

Uptonville,  Georgia,  on  the  railroad  between  Jacksonville  and  Savannah, 
seven  miles  from  the  inter-state  line.  He  arrived  in  Uptonville  on  the 
22d  of  October,  after  driving  over  country  roads  forty  miles  from  Baldwin. 
The  previous  history  of  Mr.  Upton  is  very  unsatisfactory.  I  have  found  that 
he  was  at  Callahan  on  September  25,  and  visited  the  second  Upchurch  case. 
At  any  rate,  when  I  saw  him  at  Uptonville  on  the  24th  of  October,  I 
decided,  together  with  Dr.  Posey,  of  New  Orleans,  that  he  was  a  convales- 
cent from  yellow  fever,  notwithstanding  his  protestations  and  denials.  It 
was  not  possible  to  remove  Mr.  Upton  from  the  village  until  the  26th.  I 
suspected  that  other  cases  would  arise  from  this  one,  because  Mr.  Upton's 
room  was  very  filthy.  Furthermore,  it  had  been  constantly  croAvded  by 
villagers.  I  made  a  careful  inspection  of  these  on  the  25th  and  26th. 
On  the  latter  date  a  Mr.  Simmons  was  taken  with  yellow  fever.  He  was 
a  night-watchman,  and  had  spent  the  greater  portion  of  one  night  in  the 
room  with  Mr.  Upton.  On  the  27th  I  removed  the  whole  of  the  Simmons 
family  to  the  United  States  quarantine  camp.  Mr.  Simmons  was  sent  to 
the  hospital,  and  Mrs.  Simmons,  with  three  children,  to  the  camp,  which 
was  free  from  infection.  On  the  28th  Mrs.  Simmons  was  taken  sick  and 
died  of  yellow  fever.  No  other  cases  occurred.  This  town  had  no  com- 
munication with  the  infected  district.  The  infecting  agent  in  this  case  was 
brought  by  a  convalescent.  Yet  this  man  had  been  probably  sick  at  his 
own  home  in  Baldwin  without  conveying  the  disease  to  any  one.  His  house 
here  is  new,  airy,  and  neatly  kept. 

The  most  interesting  experience  of  all,  however,  is  that  of  a  train  of 
refugees  from  Jacksonville  to  the  mountains  of  North  Carolina.  There  is 
evidence  to  prove  that  in  less  than  thirty-six  hours  a  source  of  infection 
was  developed  in  this  train  by  the  refugees  themselves.  For  we  find  that 
out  of  two  hundred  and  eighteen,  ten  were  attacked  in  the  train  or  soon 
after  arrival ;  whilst  out  of  more  than  nine  hundred  unacclimated  refugees 
leaving  Jacksonville  under  more  hygienic  circumstances,  by  a  short  journey 
of  one  hour  and  a  half  to  Camp  Perry,  only  twenty-four  were  affected. 
The  train  to  North  Carolina  was  composed  of  cars  brought  into  Jackson- 
ville from  the  North  an  hour  or  two  before  departure ;  and  no  baggage  was 
allowed  on  the  train.  The  excess  of  cases,  it  appears,  was  due  to  auto- 
infection  of  the  croAA^d  shut  up  in  the  cars  over  thirty-six  hours. 

On  the  other  hand,  the  cases  are  numerous  that  Avould  seem  to  contradict 
the  above  experience, — Mr.  Upton,  for  instance,  who  infected  no  one  at 
Baldwin  ;  more  than  one  thousand  refugees  coming  to  Camp  Perry  without 
producing  a  secondary  focus  of  infection ;  in  the  very  hospital  of  the  camp 
several  unprotected  persons  were  exposed  without  any  one  contracting  the 
disease ;  and  the  same  may  be  said  of  the  larger  hospital  of  the  Sand  Hills, 
near  Jacksonville. 

All  this  illustrates  practically  what  I  have  said  of  the  importance  of  the 
medium.  In  some  localities  there  is  an  obstacle  to  the  spread  of  the  disease. 
But  it  is  evident  that,  when  these  obstacles  are  absent,  a  case  of  yellow  fever 


YELLOW    FEVER.  86S 

is  capable  of  infecting  certain  localities,  and  these  may  be  restricted  to 
very  small  limits.  Many  times,  in  the  presence  of  these  apparently  contra- 
dictory facts,  I  have  looked  for  the  points  of  difference  between  the  infect- 
able  and  non-infectable  places.  I  can  only  say  that  in  the  latter  there  was 
abundance  of  fresh  air,  and  an  absence  of  old  Avood,  of  packed  things,  and 
of  crowded  people.  This  is  unquestionably  one  of  the  most  important  and 
most  obscure  problems  in  the  etiology  of  the  disease. 

The  disease  fails  to  spread  for  one  of  two  reasons :  either  the  locality 
resists  infection,  that  is,  is  unsuitable  for  the  life  of  the  infecting  agent  out- 
side of  the  human  organism,  or  else  the  conditions  of  the  place  create  a 
non-receptivity  on  the  part  of  the  individual.  And  how  insignificant  a 
cause  may  produce  the  latter  effect !  I  had  an  attack  of  yellow  fever,  mild, 
unrecognized,  thirty-four  years  ago,  and  a  barrier  was  raised  forever,  some- 
where in  my  organism,  against  all  encroachments  of  the  disease, — an  event 
insignificant  in  the  distance  of  time,  and  that  has  left  no  other  appreciable 
trace  upon  my  body.  Is  it  not  reasonable  to  suppose  that  modifications  in 
the  surroundings,  the  food,  the  air,  may  also  produce  similar  though  tem- 
porary modifications, — a  slight  change  in  the  acidity  or  alkalinity  of  a  secre- 
tion, the  substitution  in  the  orifices  of  the  body  of  one  form  of  micro- 
organism for  another?  For  instance,  I  found  that  during  my  sojourn  in 
Camp  Perry  the  odor  and  taste  of  putrefaction  disappeared  almost  com- 
pletely in  a  cavity  in  one  of  my  teeth.  We  must  not  lose  sight  of  appar- 
ently unimportant  factors  in  this  complicated  problem,  where  even  chance 
must  play  an  important  part. 

This  temporary  individual  resistance  received  some  support  in  the  fact 
that  a  considerable  number  of  persons  escape  during  an  epidemic  who  come 
into  town  only  during  business  hours.  This  measure,  hoAvever,  is  not  as 
successful  as  is  generally  believed. 

Sex. — It  appears  that  in  infancy  the  male  sex  shows  a  slight  predispo- 
sition to  the  disease.  I  noted  the  sex  in  fifty-six  children  in  Key  West,  and 
thirty-four  were  males. 

The  previous  condition  of  health,  and  the  social  position,  have  no 
influence  as  predisposing  causes  of  the  disease. 

Period  of  Incubation. — The  period  of  incubation,  as  far  as  it  can  be 
determined  in  tlje  absence  of  inoculation  experiments,  may  vary  from  a  few 
hours  to  fourteen  days.  The  cases  in  which  it  extends  beyond  the  seventh 
day  are  exceptional.  Out  of  twenty-seven  persons  who  had  the  disease 
after  removal  from  an  epidemic  centre,  seven  had  i\\G  disease  on  the  first 
day,  one  on  the  second  day,  five  on  the  third,  three  on  the  fourth,  five  on 
the  fifth,  one  on  the  sixth,  two  on  the  seventh,  one  on  the  ninth,  one  on  the 
eleventh,  and  one  on  the  thirteenth  day. 

In  the  last  two  cases  there  is  a  possibility  of  infection  after  removal 
from  the  infected  centre.  Of  nine  hundred  unacclimatcd  individuals  who 
left  Jacksonville,  going  into  healthy  districts,  after  serving  ten  days  of  pro- 
bation at  Camp  Perry,  none  developed  the  disease. 


864  YELLOW    FEVER. 

Morbid  Anatomy. — The  cadaver  presents  always  a  yellow  discolora- 
tion. The  body  is  frequently  mottled,  especially  in  the  dependent  portions. 
The  features  may  be  somewhat  bloated,  and  there  is  often  a  dark  discharge 
from  the  nose  and  mouth.  I  have  noticed  often  in  children  a  purplish  dis- 
coloration about  the  pubis,  which  may  be  limited  to  the  scrotum  or  labia. 
These  latter  structures  may  show  some  evidence  of  infiltration  and  excori- 
ation, amounting  in  very  rare  cases  to  actual  sloughing.  Putrefactive 
changes  and  rigor  mortis  set  in  early. 

I  have  never  dissected  the  body  of  a  child  dead  from  yellow  fever.  As 
the  symptoms  in  the  grave  cases  are  precisely  the  same  as  those  met  in  the 
adult,  there  is  no  reason  to  suppose  that  any  difference  will  be  found  post 
mortem. 

The  muscles  present  a  dark  color  in  contrast  with  the  yellow-stained 
adipose  tissue.  The  contents  of  the  thoracic  cavity  are  generally  normal. 
The  lungs  present  in  rare  cases  small  hemorrhagic  foci,  and  seldom  any 
marked  tendency  to  hypostatic  congestion.  The  left  heart  I  have  always 
found  firmly  contracted.  The  muscular  wall  presents  a  normal  appearance. 
The  cavities  contain  always  some  dark  fluid  blood,  very  rarely  some  small 
coagula.  Neither  the  endocardium  nor  the  pericardium  shoAvs  evidences  of 
inflammation.  Under  the  microscope  I  found  the  muscular  fibres  generally 
healthy.     A  few  are  found  with  some  granulations  about  the  nucleus. 

In  the  abdomen  we  notice  at  once  the  peculiar  color  of  the  liver.  This 
I  have  never  found  absent  in  an  uncomplicated  case  of  yellow  fever.  The 
organ  is  not  enlarged.  It  is  of  a  light  color  in  which  yellow  predominates 
decidedly.  The  comparison  with  boxwood  is  a  good  one.  In  cases  of 
rapidly-fatal  termination  the  discoloration  may  appear  only  in  patches.  The 
consistence  of  the  organ  is  not  impaired.  On  section  we  find  the  blood- 
vessels comparatively  empty.  The  microscopic  evidences  of  fatty  degener- 
ation are  present.  Under  the  microscope  we  find  evidences  of  some  acute 
interstitial  inflammation.  The  interlobular  connective  tissue  is  often  swollen 
and  contains  in  places  accumulations  of  embiyonal  connective-tissue  cells. 
The  liver-cells  are  either  cloudy  or  decidedly  fatty.  Some  of  them  are 
pigmented  more  than  the  normal. 

The  stomach  is  inflamed.  The  blood-vessels  of  the  mucous  membrane 
are  engorged  with  blood.  In  many  ])laces  near  the  surface  I  found  minute 
extravasations  of  blood.  The  abundance  of  leucocytes  or  embryonal  con- 
nective tissue  around  the  gastric  tubules  is  evidence  of  inflammation.  The 
stomach  very  frequently  contains  the  dark  fluid  called  black  vomit,  even 
when  it  has  not  been  ejected  during  life. 

The  kidneys  are  large,  soft,  and  congested.  The  microscope  reveals  the 
existence  of  a  diffiise  nephritis.  The  form  of  nephritis  present  in  these 
cases  needs  further  investigation.  It  must  differ  in  important  particulars 
from  the  disturloanccs  of  tlie  kidney  that  occur  in  other  infectious  diseases. 
It  is  characterized  by  a  prompt  invasion  and  an  equally  rapid  subsidence, 
and  leaves  no  permanent  traces.     It  does  not  produce  any  dropsy. 


Ph 


f^ 


CO 

i-t 

^ 

,    ^ 

cc 

"j^ 

> 

-a  2 

o  o     • 

^ 

i  S  o 

' 

'' 

^^^ 

W 
i-H 

,    , 

.* 

ery.    Eigh 
ery.    Thre 
.    Three  y 

»6 

< 

•I:* 

6 

•' 

•c- 

» 

^ 

•:'- 

-- 

<^ 

> 

Recov 
Reco-v 
Death 

•" 

CO 

fH 

Eh 

.--« 

5  3  o 

.- 

rati 
rati 
rati 

.# 

^ 

'C  13  "C 

•^ 

i. 

f. 

ur  days 
ar  days 
ur  days 

6 

/ 

..  " 

f 

^ 

• 

o  o  o 
fc<  f^  &^ 

o 

o 

00 

o 

eg 
O 

o 

o 
o 

05 
C7> 

00 

05 

05 

1    1    1. 

-*■  o  to 

d  6  d 

o 
to 

o 

o 

CO 

o 

o 

o 
o 

O 

o 

00 

o 

^  ^  ^ 

CO 
CSl 

■^ 

> 

^ 

*~~ 

CO 

1—1 

f''  , 

J 

,• 

"^ 

<; 

>•■'' 

,. 

y 

o 

o 

CO 

o 

CM 

O 

o 

o 
o 

05 
05 

00 
05 

05 

o 

o 

o 

CO 

o 
2 

o 

o 
o 

o 
c:5 

o 

GO 

o 

To 

>> 

tj 

3 

>. 

ta 

GJ 

fl 

o 

oS 

K 

W 

3   S 

■a  -o 


I  I 

c4  CO 

o  g 


C3 

1— 1 

Eh 

-1 

1 

... 

-« 

/ 

. 

K 

O 

o 

CO 

o 

CN 

o 

o 

o 

05 

o> 

00 
05 

t^ 

05 

o 

o 

o 

CO 

o 

CM 

o 

o 
o 

O 

05 

o 

00 

o 

— 

CO 

in 

CO 
C3 

i-i 

Eh 

_...■ 

.'/' 

^ 

^ 

• 

f 

.... 

,--■ 

• 

I 

S' 

— r 

^" 

lO 

o 

si- 
o 

CO 

o 

CM 

O 

O 

o 
o 

05 

cr5 

00 
05 

05 

o 

10 

o 

o 

CO 

O 
CM 

o 

o 

o 

o 

05 

o 

CO 

O 

CO 

■<# 

CO 
CO 

.^ 

' 

>• 

^ 

<^ 

> 

o 

< 

■^ 

^ 

*- 



— - 

' — 

\ 

CO 

<* 

CO 

l-f 

^ 

'/• 

/ 

y 

y 

d 

\ 

^ 

^ 

::::: 

S 

r" 

^ 

■■* 

C 

i 

f 

CO 

tn 

CO 
03 
I-i 

EH 

^ 

J 

^ 

> 

, 

*'•- 

"> 

Ci 

1 

, 

f 

J 
^ 

^ 

;> 

^ 

o 

o 

CO 

o 

CM 

o 

o 

O 
O 

05 
05 

00 
05 

05 

o 

10 

o 

1^ 

o 

CO 

o 

CM 

o 

o 
o 

o 

O 

oo 

O 

-.S  a 
'.  't:  <" 

'        ^ 

•  o    . 
'.  >  .a 


5.2, 

■5    03 


CO 
03 

i-t 

> 

CO 

; 

o 

7 

\^ 

< 

V' 

\ 

in 

CO 
03 

r-t 
EH 

Ph 

y 

J 

•• 

J, 

J' 

t^ 

; 

s. 

"^ 

in 
o 

o 

CO 

o 

o 

o 

o 
o 

05 
05 

00 
05 

05 

o 

10 

o 

o 

CO 

o 
eg 

o 

o 

o 

o 

05 

o 

00 

O 

YELLOW    FEVEE.  86 O 

The  spleen  is  not  altered  in  yellow  fever.  I  have  been  inclined,  with 
others,  to  believe  that  the  semilunar  ganglia  of  the  solar  plexus  were  often 
inflamed  in  yellow  fever.  But  my  observations  were  not  sufficiently 
numerous,  and  we  have  the  high  authority  of  Woodward  against  this 
view.^ 

No  histological  changes  have  been  found  in  the  blood  by  Surgeon  G. 
M.  Sternberg,  U.S.A.^  The  subsequent  studies  of  this  investigator  have 
been  devoted  to  the  discovery  of  the  specific  micro-organism  of  the  disease. 
He  has,  I  believe,  successfully  refuted  the  claims  of  Freire,  Carmona,  and 
Finlay  to  the  discovery  of  such  micro-organisms.  In  brief,  he  has  discov- 
ered no  microbe  peculiar  to  the  disease  in  the  blood  and  tissues.  The  same 
results  were  obtained  by  Dr.  Tamayo  and  his  colleagues  of  the  Bacterio- 
logical Institute  of  Havana.  In  a  personal  communication  Dr.  Sternberg 
informs  me  that  he  has  lately  directed  his  labors  to  the  examination  of  the 
organisms  found  in  the  gastro-intestinal  contents.  The  same  line  of  inves- 
tigation has  been  followed  by  the  French  pathologist  Dr.  Gibier. 

Symptomatolog'y. — Fever  and  Pulse. — The  absence  of  previous  records 
of  the  disease  in  childhood  justifies  the  publication  of  several  temperature- 
charts.  I  have  selected  illustrations  showing  different  periods  of  duration 
of  the  disease,  and  contrasting  the  favorable  with  the  fatal  cases.^ 

Yellow  fever  presents  a  more  characteristic  temperature  and  pulse-curve 
than  any  other  of  the  acute  infectious  diseases.  The  distinctive  features  are 
observed  in  making  a  simultaneous  survey  of  the  temperature-  and  pulse- 
lines,  and  they  are  as  distinct  in  the  child  as  in  the  adult. 

During  the  initial  chilliness  and  first  rise  of  the  temperature,  the  pulse 
will  rise,  as  it  does  in  all  acute  febrile  diseases,  in  proportion  with  the 
increase  of  bodily  heat.  The  invasion  takes  place  generally  during  the 
night,  and  on  the  morning  of  the  first  day  the  pulse  will  be  found,  in 
children,  above  120,  and  frequently  as  high  as  150.  The  temperature  in 
favoral)le  cases  does  not  often  exceed  103°  F.  The  temperature  will 
generally  show  an  evening  exacerbation  on  the  first  day,  but  even  at  this 
early  date  the  pulse-curve  may  start  on  the  line  of  descent  that  is  so  charac- 
teristic of  the  disease.  This  will  certainly  happen  on  the  second  or  tliird 
day  of  the  disease,  even  though  the  fever  may  still  show  a  persistent 
fastigium.  Dr.  J.  C.  Faget,  of  New  Orleans,  was  the  first  to  discern  tlie 
importance  of  this  phenomenon  as  a  diagnostic  sign. 

Of  course  the  pulse  in  children  is  more  subject  to  accidental  variations 


'  Keports  of  .John  Guiteras  and  .T.  .1.  Wtxxlward  in  connection  with  reports  of  the 
Havana  Yellow  Fever  Commission,  Supplements  Nos.  I.  and  IV.  of  the  Bulletin  of  the 
National  Board  of  Health. 

2  Supplement  No.  I.  of  the  Bulletin  of  the  National  Board  of  Health. 

3  Many  valuable  clinical  notes,  and  opportunities  to  study  the  disease  in  children,  I 
owe  to  the  kindness  of  my  friends  Drs.  Bordas,  Porter,  Monteresi,  and  Armona,  of  Key 
West,  Dr.  Faget,  of  New  Orleans,  and  Dr.  Caldwell,  of  Sanford,  Florida.  See  Bordas, 
"  Fiebre  amarilla  de  los  Ninos,"  Cronica  Medico-Quirurgica  de  la  Habana,  1887. 

Vol.  I.— 55 


866  YELLOW   FEVEE. 

produced  by  emotion  or  exertion,  but  it  is  still  governed  by  the  same  law. 
The  very  slow  pulse,  however,  that  characterizes  the  end  of  the  lysis  and 
the  convalescence  of  adults  is  not  generally  marked  in  very  young  children. 
The  gradual  fall  of  the  temperature  is  often  broken  by  one  or  more 
evening  exacerbations,  which  in  severe  cases  constitute  a  secondary  fever. 
This  may  extend  over  several  days,  giving  rise  to  prolonged  cases  of  ten 
and  fifteen  days'  duration.  In  these  cases  we  frequently  observe  well- 
marked  diurnal  remissions  independent  of  all  malarial  complications.  In 
fact,  I  find  that  writers  have  insisted  too  much  on  the  continued  type  of 
this  fever.  This  was  occasioned  by  the  discussions  as  to  whether  yellow 
fever  was  or  was  not  a  malarial  disease.  As  compared  with  these,  yellow 
fever  is  certainly  a  continued  fever ;  but  this  feature  is  not  specific  of  the 
disease.  The  same  may  be  said  of  the  statement,  to  which  much  promi- 
nence has  been  given,  that  yellow  fever  is  a  fever  of  one  paroxysm.  As  a 
matter  of  fact,  there  is  quite  often  a  well-marked  remission  of  the  fever 
between  the  primary  and  secondary  exacerbations.  In  fatal  cases  there  is 
often  a  marked  accentuation  of  this  secondary  fever.  In  fact,  an  early  break 
in  the  lysis  by  a  sharp  rise  of  the  temperature  above  that  of  the  fever  of 
invasion  is  of  very  bad  omen.  In  mild  cases  the  secondary  fever  is  absent 
or  only  slightly  indicated. 

The  Fades. — Jaundice. — The  Skin. — The  appearance  of  the  face  is  often 
sufficiently  characteristic  on  the  first  day  of  the  disease  to  warrant  a  positive 
diagnosis.  Except  the  jaundice,  the  appearance  is  that  of  measles  before 
the  eruption, — the  same  lively  coloration  of  the  skin,  the  slight  puffiness  of 
the  lids  with  red  borders,  the  hypersemia  of  the  conjunctivae,  the  same  lustre 
and  watery  condition  of  the  eye, — the  ferrety  eye  of  typhus,  in  fact,  but 
always,  from  the  very  commencement,  with  a  slight  shade  of  yellow.  In  the 
earlier  stages  of  the  disease,  when  the  injection  and  the  jaundice,  especially 
the  latter,  are  not  well  marked,  it  is  an  important  fact  that  these  phenomena 
are  better  observed  at  a  slight  distance  than  on  close  inspection.  Very  fre- 
quently, and  especially  in  children,  on  approaching  the  bedside  I  have 
noticed  the  turgidity  of  the  lips,  the  suffusion  of  the  eye,  and  the  faint 
icteric  hue  that  are  unmistakable ;  and  yet,  on  separating  the  lids,  on  close 
inspection  absolutely  nothing  abnormal  can  be  detected. 

In  the  mild  cases  of  children  the  above  may  be  the  only  evidence  of 
jaundice.  In  severe  cases,  about  the  third  or  fourth  day  the  skin  assumes 
a  lemon-yellow  color.  Even  before  this  we  may  notice  from  time  to  time 
a  transient  shade  of  yellow  to  pass  over  the  red  mask  of  the  face,  when  the 
movements  of  expression  chase  for  an  instant  the  blood  from  the  distended 
vessels.  General  jaundice  is  neither  as  frequent  nor  as  marked  in  the  child 
as  in  the  adult. 

We  notice  also  in  children  that  a  very  intense  injection  of  the  con- 
junctiva, witli  ecchymotic  spots  there  and  on  the  surface  generally,  are  rare 
manifestations.  We  find  very  frequently  an  erythematous  condition  of  the 
scrotum  and  labia  (as  described  by  French  observers),  Avhicli  may  lead  to 


YELLOW   FEVER.  867 

infiltration  and  excoriations.  Very  rarely  we  may  meet  with  sloughing  of 
these  parts  or  other  regions  of  the  integument.  I  have  noticed  in  some 
cases  herpes  labialis,  in  others  boils,  and  occasionally  a  lichenous  eruption ; 
but  all  these  are  exceptions. 

The  skin  presents  alternations  of  dryness  and  moisture.  It  is  easy  to 
produce  perspiration,  but  this  secretion  is  not  critical.  The  sweat  is  always 
acid. 

A  peculiar  odor  sometimes  emanates  from  the  bodies  of  yellow-fever 
patients.  I  have  never  noticed  it  outside  of  wards  where  the  patients  were 
treated  by  inducing  profuse  perspiration,  and  I  could  never  detect  it  in 
children. 

The  tongue  is  generally  moist  and  presents  a  whitish  coating.  It  is 
more  apt  to  be  pointed  than  flat.  The  gums  are  spongy  in  some  cases,  and 
they  bleed  easily.  A  dry  tongue  with  sordes  is  exceptional  with  children. 
It  may  be  encountered  in  prolonged  cases  of  an  adynamic  type.  The  thirst 
is  intense, — more  so  than  in  the  adult. 

Vomiting. — This  is  not  an  initial  symptom,  nor  is  it  as  striking  a  feature 
as  in  the  adult,  because  of  the  comparative  absence  of  painful  retching.  Xt 
is  frequently  limited  to  the  occasional  and  even  exceptional  rejection  of 
food.  The  matters  vomited  are  generally  light-colored,  of  a  very  faint 
greenish-gray  shade,  and  watery.  Their  reaction  is  acid.  In  severe  cases 
the  gray  color  becomes  darker,  and  black  strige  appear  in  the  fluid.  In 
these  cases  the  vomiting  becomes  more  frequent  and  is  followed  by  exhaus- 
tion. This  earlier  stage  of  the  black  vomit  is  quite  common  in  children  as 
■compared  with  adults,  and  not  rarely  darker  shades  occur  without  fatal 
results.  The  true  black  vomit  is  not  so  frequent  as  in  the  adult,  and,  as  in 
the  case  of  the  latter,  though  possibly  to  a  less  extent,  it  is  a  forerunner  of 
death.  This  fluid  is  uniformly  black  and  somewhat  syrupy  in  consistence. 
These  varieties  are  evidently  diiferent  degrees  dejDending  on  the  amount  of 
blood  exuded  into  the  stomach.  They  all  show,  under  the  microscope,  red 
blood-corpuscles  and  granular  pigment,  besides  other  usual  contents  of  the 
stomach.  I  have  also  found  plates  of  cholesterine.  It  is  very  probable 
that  both  the  biliary  and  blood  pigments  contribute  to  the  formation  of  the 
dark  coloring-matter.  I  have  been  shown  by  Dr.  Gibier  some  cultures  of 
a  chromogenic  micro-organism  found  by  him  in  the  fluids  of  the  stomach. 
The  culture  gave  a  dark-brown  color.  It  is  possible  that  this  discov^cry 
may  change  the  views  at  present  entertained  as  to  the  color  of  these  fluids. 

Vomited  matters  containing  unaltered  biliary  pigment  may  resemble,  it 
is  said,  the  black  vomit  of  yellow  fever.  A  piece  of  white  linen  immersed 
in  the  former  is  stained  of  a  dark-yellowish  color,  while  in  the  latter  case 
the  stain  is  bro\vnish  l^lack. 

The  bowels  are  generally  costive,  tliough  easily  acted  upon  by  catliartics. 
Exceptionally  the  dejecta  are  dark  and  tarry.  Diarrhoea  and  dysentery  are 
encountered  in  some  cases. 

The  Urine. — Together  with  the  course  of  the  pulse  and  temperature, 


868  YELLOW   FEVER. 

and  the  facies,  the  examination  of  the  urine  constitutes  the  basis  of  the  diag- 
nosis of  yellow  fever.  AVe  turn  to  this  more  frequently  than  to  any  other 
one  symptom  as  a  crucial  test  in  cases  of  doubt.  The  evidence  we  obtain 
from  the  urine  consists  in  the  presence  of  albuminuria.  This  is  more  com- 
mon than  is  generally  believed.  If  persistently  looked  for,  it  will  be  found 
in  almost  all  cases,  whether  mild  or  severe.  AllDumen  may  appear  in  the 
urine  on  the  first  day  of  the  disease,  more  frequently  on  the  second,  and 
almost  certainly  on  the  third  day.  I  have  found,  especially  in  children, 
that  albimien  may  be  present  only  in  the  urine  passed  during  the  evenings, 
and,  in  some  mild  cases,  durino-  one  evenino;  alone  throu2;hout  the  attack. 
This  explains  why  the  symptom  is  often  found  wanting.  In  fact,  the 
transitory  character  is  a  remarkable  feature  of  the  albuminuria  and  the 
nephritis  of  this  disease.  It  is  an  early  manifestation,  diifering  from  the 
albuminuria  that  is  encountered  in  profound  adynamic  states.  This 
nephritis  disappears  rapidly,  without  ever  leaving,  so  far  as  I  know,  any 
permanent  traces.  It  never  causes  dropsy  nor  inflammation  of  the  serous 
membranes.  Within  a  few  days  we  may  have  albuminuria  that  may 
amount  to  complete  coagulation  of  the  fluid  on  boiling,  blood  in  the  urine, 
and  an  extraordinary  number  of  epithelial,  granular,  and  blood  casts,  to- 
gether with  more  or  less  prolonged  suppression  of  the  secretion ;  and  all 
these  signs  will  disappear  as  rapidly  as  they  came.  The  albumen  may  be 
present  on  one  night  only,  and  casts  but  two  or  three  days.  The  amount 
of  albumen  varies  from  a  trace  to  the  largest  amounts. 

I  attach  much  importance  to  the  method  of  examination  of  the  urine. 
In  the  press  of  Avork  that  attends  an  epidemic,  many  of  the  tests  for  albu- 
men cannot  be  made  with  sufficient  accuracy.  Many  times  I  have  found 
urine  that  was  pronounced  non-albuminous  after  testing  by  heat  and  nitric 
acid,  to  show  a  distinct  trace  by  the  zone  test.  Frequently  when  the  amount 
of  albumen  is  small  the  cloud  is  verv  faint  and  broad,  extending  some  dis- 
tance  above  the  point  of  contact  with  the  acid,  and  may  be  taken  for  a 
general  turbidity  of  the  fluid  if  a  sufficient  quantity  is  not  added.  The 
best  place  to  hold  the  tube  is  near  a  window-frame  or  the  free  edge  of  a 
door,  having  on  one  side  the  shadow  of  the  room,  behind  the  dark  profile, 
and  on  the  other  side  a  free  illumination.  The  urine  should  be  allowed  to 
mn  from  a  small  filter,  holding  the  tube  at  an  angle,  down  to  the  acid. 
A  small  piece  of  filtering-paper  can  be  folded  in  four  and  a  filter  impro- 
vised in  a  moment :  so  that  there  is  truly  no  simpler  or  readier  method 
than  tliis. 

The  urine  is  always  distinctly  acid.  Its  quantity  is  almost  always 
diminislied,  and  the  solids  are  increased  in  proportion  to  the  bulk.  At  first 
the  urine  is  clear  and  of  normal  color,  but  it  may  subsequently  become 
turbid  from  the  presence  of  blood,  of  urates,  and  of  mucus  and  epithelial 
debris.  At  this  time  it  assumes'also  a  darker  color,  from  the  presence  of 
an  excess  of  coloring-matter,  ^\■hich  is  often  biliar^^  The  diminution  of 
the  quantity  of  urine  and  infrequency  of  micturition  are  very  common  in 


YELLOW   FEVER.  869 

children,  but  the  more  advanced  and  serious  degrees  of  suppression  are  not 
so  frequent  as  in  the  adult.  If  sufficiently  prolonged,  the  suppression  leads 
to  uraemic  poisoning  and  a  fatal  termination. 

Hemorrhages. — The  gastric  hemorrhages  have  been  already  mentioned. 
It  only  remains  to  say  that  in  exceptional  cases  they  may  occur  from  any 
of  the  mucous  membranes  or  surfaces  of  the  body. 

I  find  the  following  cases  of  children  recorded  in  my  notes : 

Cases.  Died. 

Hemorrliage  from  the  stomach  (varieties  of  hlack  vomit)      ....  28  9 

"  from  the  nose 4  1 

"  from  the  mouth -.2  1 

"  from  the  bowels 1  0 

"  into  subcutaneous  tissue — extensive 2  2 

Anticipated  menstruation 3  0 

Nervous  Symptoms. — Under  this  head  we  find  the  greatest  difference  be^ 
tween  the  symptoms  of  childhood  and  those  of  adult  life.  Strange  to  say, 
we  find  that  the  nervous  symptoms  are  perhaps  more  prominent  in  the  adult 
than  in  the  child  ;  and  this  is  not  dependent  solely  upon  the  milder  character 
of  the  disease  in  the  latter.  The  difference  lies  partly  in  the  absence  of  the 
moral  or  emotional  element  in  children.  The  loquacity,  the  short-cut  phrases 
and  precipitate  speech,  the  excitement,  the  show  of  indifference,  with  unmis- 
takable evidences  of  fear,  all  these,  that  are  such  prominent  features  of  the 
disease  in  the  adult,  are  absent  in  the  young.  The  wild  delirium  is  seldom 
present.  The  child  is  generally  listless  and  drowsy.  The  rachialgia  and 
pains  in  the  limbs  are  mostly  wanting,  but  the  headache  is  present  without 
a  doubt,  as  we  may  discover  by  inquiry,  or  by  noting  the  corrugated  brow, 
the  expression  of  suffering,  the  evident  desire  to  be  let  alone,  and  the  turn- 
ing of  the  face  away  from  the  light.  The  sleep  is  generally  restless,  and 
the  child  will  wake  up  delirious  or  calling  for  water.  His  movements  then 
will  be  somewhat  ataxic  or  jerky,  as  if  premonitory  of  a  convulsive  seizure. 
Convulsions,  however,  are  not  so  common  in  the  initial  stage  of  yellow 
fever  as  they  are  in  the  eruptive  fevers ;  nor  are  they  more  common  than  in 
the  adult  as  later  evidences  of  ursemic  toxaemia.  As  in  other  fevers  of 
infancy,  we  must  note  here  the  general  absence  of  chills. 

Very  frequently  in  grave  cases  the  child  becomes  semi-unconscious,  and 
lies  with  the  eyes  closed,  and  constantly  turning  the  head  from  side  to  side. 
The  respiration  then  becomes  more  rapid  and  sighing  at  times,  the  pulse 
increases  in  frequency,  the  temperature  may  or  may  not  take  an  upward 
turn,  and  the  drowsiness  deepens  into  coma.  This  is  tlie  usual  terminatictn 
of  fatal  cases.  Their  duration  does  not  exceed  three  or  four  days.  A  few 
of  these  cases  will  die  on  the  fourth  or  fifth  day,  after  ejecting  a  large 
quantity  of  black  vomit. 

Other  cases  run  a  much  longer  course,  and  present  all  the  symptoms  of 
the  typhoid  state,  Avith  a  jaundiced  and  clammy  skin,  defective  renal  secre- 
tion, albuminuria,  and  a  pulse  that  is  comparatively  slow  at  times.     Many 


870  YELLOW    FEVEE. 

of  these  cases  recover.  It  is  in  this  class  of  cases  that  therapeutics  plays 
its  most  important  part. 

The  cases  of  infantile  eclampsia,  with  high  temperatures,  occurring 
during  epidemics  of  yellow  fever  are  probably  the  result  of  the  specific  in- 
fection. Certainly  cases  of  this  class,  often  terminating  fatally,  are  com- 
paratively common  in  yellow-fever  countries.  I  have  noticed  in  these  cases 
a  yellow  discoloration  of  the  skin  after  death.  This  is,  however,  merely  a 
suggestion,  requiring  further  investigation. 

Complications. — These  are  rare  in  the  course  of  the  disease  in  children. 
Malaria  has  been  discussed  as  a  frequent  complication  of  yellow  fever,  but 
without  sufficient  foundation.  I  have  certainly  seen  the  symptoms  that  are 
pointed  out  as  indicative  of  this  complication  occurring  in  localities  where 
there  was  no  possibility  of  malarial  infection.  Such  symptoms  are  not  rare 
in  the  colored  people.  As  I  have  shown  in  another  part  of  this  paper,  a 
great  deal  of  the  malaria  of  childhood  that  is  supposed  to  exist  in  yellow- 
fever  centres  is  really  yellow  fever.  Indeed,  much  of  the  reputation  of 
these  cities  for  malaria  depends  upon  the  false  interpretation  of  these  facts. 
These  cities  very  often  are  not  so  intensely  malarious  as  they  are  supposed 
to  be.  The  opportunity,  then,  does  not  frequently  oifer  for  a  combination 
of  the  two  poisons  in  the  same  individual ;  and  when  it  does  occur  the 
symptomatology  of  one  disease,  as  a  rule,  entirely  dominates  the  other  for 
the  time  being.  The  mere  exaggeration  of  the  diurnal  range  of  tempera- 
ture cannot  be  considered  sufficient  evidence  of  a  malarial  complication. 
This  complication  has  been,  in  my  experience,  exceptional,  and  it  has  shown 
itself  almost  exclusively  during  the  convalescence. 

A  tendency  to  phlegmonous  inflammations  may  present  itself  in  the 
course  of  yellow  fever.  These  may  give  rise  to  phlebitis  and  lymphangitis 
that  are  not,  as  a  rule,  of  serious  character. 

Hepatitis,  insanity,  and  paralysis  (probably  neuritis)  I  have  seen  as 
sequelse  of  yellow  fever,  but  never  in  children. 

Relapses  are  rare  in  children.  Except  in  cases  that  assume  a  typhoid 
tbrm,  convalescence  is,  as  a  rule,  rapid. 

In  regard  to  second  attacks,  it  is  only  necessary  to  say  that  the  successful 
colonization  of  intertropical  America  by  the  Spaniards  and  Portuguese 
depends  entirely  upon  the  fact  that  one  attaclv  of  yellow  fever  confers  an 
immunity  that  is  practically  certain  and  that  lasts  throughout  life,  even 
though  the  individual  may  remove  his  residence  to  a  colder  climate  for  long 
periods  of  time. 

Very  rare  exceptions  to  the  above  rule  do  occur,  and  they  consist  gen- 
erally of  two  distinct  attacks  during  the  same  epidemic. 

Diagnosis. — I  do  not  know  of  any  disease  with  which  an  ordinary  case 
of  yellow  fever  can  be  confounded  if  subjected  to  observation  for  two  or 
three  days.  Yellow  fever  diffisrs  in  every  particular  from  the  hemorrhagic, 
the  hfEUioglobinuric,  and  the  remittent  malarial  manifestations.  The  differ- 
ences are  so  prominently  brought  out  in  tables  of  differential  diagnosis  in 


YELLOW   FEVER. 


871 


monographs  and  treatises  that  one  wonders  at  the  necessity  for  the  construc- 
tion of  them.  There  are,  however,  mild  cases  in  children  where  the 
diagnosis  from  ephemeral  fever  is  difficult,  at  least  wnth  our  present  limited 
means  of  observation.  Limited,  I  say,  because  in  those  localities  where  the 
opportunity  offers  for  a  continued  investigation  of  these  cases,  they  are 
never  studied  from  the  point  of  view  of  yellow  fever. 

I  cannot  insist  too  much  upon  the  importance  of  recognizing  these  cases. 
The  epidemic  influence  often  shows  itself  first  upon  children.  The  first 
recognized  case  of  an  adult  may  not  deserve  the  importance  that  is  attached 
to  it  as  the  starting-point  of  the  epidemic.  I  can  say  this  much,  that  in  the 
absence  of  cases  of  actual  sickness,  because  of  the  impossibility  of  a  house-to- 
house  inspection  in  a  city,  I  have  been  able  to  detect  the  presence  of  yellow 
fever  by  an  analysis  of  the  infantile  mortality.  A  notable  increase  of  the 
deaths  of  children  from  remittent  and  pernicious  fevers,  from  dentition  and 
meningitis,  may  be  considered  as  warranting  suspicion  at  least  of  the  exist- 
ence of  a  spreading  infection  of  yellow  fever.  The  importance  of  detecting 
the  first  cases  out  of  which  this  mortality  sprung  is  apparent. 

In  warm  countries  the  question  of  diagnosis  is  complicated  by  a  remark- 
able liability  of  children  to  fevers  that  may  be  termed  functional  fevers 
because  they  arise  from  an  excessive  demand  made  upon  any  of  the  impor- 
tant functions  of  the  body.  The  function  of  heat-inhibition  must  be  over- 
taxed in  the  long  summers  of  the  tropics.  This  alone,  I  believe,  is  often 
the  primary  cause  of  fever  in  those  regions.  The  term  thermic  fever  pro- 
posed by  Wood  describes  these  cases  satisfactorily.  Short  cases  of  thermic 
fever  will  be  readily  confounded  with  yellow  fever.  As  a  means  of  diag- 
nosis I  can  only  insist  upon  the  three  cardinal  points  mentioned  in  the 
symptomatology, — namely,  the  relations  of  the  temperature  and  pulse,  the 
facies,  and  the  albuminuria.  Without  a  careful  study  of  these  symptoms 
the  diagnosis  may  be  impossible.  In  practice  it 
may  occur  that  the  facies  is  tlie  only  obtainable 
evidence.  This  should  be  assisted  by  a  careful 
inquiry  as  to  whether  there  is  any  cause  to  which 
the  fever  may  be  ascribed.  The  cases  represented 
in  the  accompanying  cliart  had  a  very  suspicious 
appearance.  At  least  the  face  was  very  much 
injected.  It  was,  however,  more  the  appearance 
of  scarlet  fever,  with  blood-shot  eyes,  but  without 
any  icteric  hue.  Furtliermore,  the  children  had 
been  taken  sick  towards  noon  Avith  a  chill,  after 
several  hours'  exposure  to  the  sun.  A  case  of 
yellow  fever  cf)mmencing  with  the  violence  shown  by  the  first  case  could 
not  have  subsided  so  rapidly,  and  would  have  presented,  in  all  probability, 
albumen  in  the  urine  passed  on  the  second  evening.  The  events  of  the 
second  day  showed  that  tlie  exclusion  of  yellow  fever  was  correct.  These 
were  not  cases  of  malaria.     Xo  quinine  was  given.    The  first  case  was  seen 


Fig. 

1?,. 

P      T 

12     3    4 

1     2| 

160 

106 

i " 

150 

105 

140 

104 

\ 

130 

103 

' 

\ 

120 

102 

\ 

110 

101 

\ 

100 

100 

1 

90 

99 

N 

y 

80 

98 

1 

D 

L 

Thermic  I'uver  ol'  short  dunitioii. 


872  YELLOW   FEVER. 

Avitli  Dr.  Bordas  and  treated  with  jaborandi.  The  second  case  I  treated  by 
sponging  with  cool  water  and  alcohol. 

Prognosis. — Yellow  fever  is  much  milder  in  the  child  than  in  the  adult. 
In  a  series  of  one  hundred  and  sixty-one  adults  attacked  with  yellow  fever, 
forty-eight  died,  or  twenty-nine  per  cent.  A  series  of  one  hundred  and 
twenty-one  children  treated  during  the  same  epidemic  numbered  thirteen 
deaths,  or  ten  per  cent.     The  deaths  of  colored  children  must  be  very  rare. 

Among  the  unfavorable  symptoms  we  should  notice  an  extraordinary 
rise  of  the  temperature  during  the  fastigium,  especially  about  the  time  when 
the  lysis  should  commence,  or  when  the  temperature  has  already  started  on 
the  line  of  descent.  If  the  pulse  rises  rapidly  at  the  same  time,  and  the 
temperature  reaches  a  maximum  above  that  of  the  initial  stage,  the  prog- 
nosis is  almost  necessarily  fatal.  A  slow  pulse,  if  it  steadily  loses  in  volume 
and  resistance,  is  a  grave  sign,  even  though  the  temperature  may  be  follow- 
ing a  favorable  course.  Great  agitation  and  increasing  frequency  of  the 
respiration  are  also  of  very  serious  import.  The  suppression  of  urine  is  a 
grave  symptom,  though  it  is  more  easily  overcome  in  children  than  in 
adults.  It  may  be  said  in  general  that  mild  cases  have  very  little  albumen 
in  the  urine,  and  fatal  cases  have  much ;  but  many  presenting  the  largest 
quantities  of  albumen  and  casts  will  recover.  It  is  the  rapid  increase  of 
the  albumen  in  the  second  or  third  day  that  constitutes  the  most  alarming 
information  derived  from  this  sign.  The  progressive  deepening  of  the  color 
of  the  vomited  matters  is  also  of  very  unfavorable  omen. 

The  favorable  signs  will  be  evident  from  the  above  considerations.  But 
I  wish  to  add  that  a  prolongation  of  the  case  beyond  the  sixth  day  may  be 
taken  as  a  favorable  sign,  though  the  patient  may  present  very  alarming 
symptoms.  These  are  the  typhoidal  cases  of  which  I  have  said  that  they 
generally  recover  after  a  prolonged  struggle. 

Treatment. — The  majority  of  practitioners  in  this  country  who  have 
to  contend  with  yellow  fever  are  of  opinion  that  there  is  something  very 
important  to  be  done  in  the  management  of  this  disease  during  the  initial 
stage.  If  the  case  is  taken  in  hand  early  (this  is  the  favorite  expression), 
no  danger  need  be  apprehended.  One  is  led  almost  to  believe  that  there 
must  be  some  great  specific  which  if  promptly  administered  is  sure  to  exert 
a  decidedly  favorable  action  upon  the  course  of  the  disease.  We  find,  hoAv- 
ever,  that  these  advocates  of  an  active  early  treatment  differ  very  much 
among  themselves ;  and,  furthermore,  we  find  that  each  particular  plan 
has  been  condemned  as  useless  or  injurious  by  some  physician  of  great 
experience.  Now,  I  have  no  reason  to  say  that  these  different  plans  of  treat- 
ment are  in  themselves  injurious,  but  the  belief  in  their  efficacy  has  certainly 
led  to  a  most  unfortunate  state  of  the  public  mind  during  epidemics  of 
yellow  fever.  "What  is  to  be  done?"  "Something  must  be  done,"  is 
the  cry,  and  the  observers  and  the  patient  stand  in  dread,  counting  the 
valuable  moments  that  are  lost  before  the  expert  yellow-fever  doctor  and 
the  yellow-fever  nurse  arrive,  and  before  the  mustard  bath  is  ready  and  the 


YELLOW    FEVER.  873 

blankets  piled  upon  the  patient.  And  woe  betide  the  patient  if  none  of 
these  things  are  within  easy  reach,  or  if  the  doctor  happens  not  to  believe 
in  the  efficacy  of  the  classical  sweating  !  The  frame  of  mind  of  the  patient 
becomes  a  very  unhappy  one,  or  is  made  so  by  the  whispered  accounts  of 
the  numerous  cases  that  have  terminated  fatally  because  of  the  want  of  a 
mustard  bath  or  of  a  dose  of  castor  oil  or  of  calomel.  People  will  dread 
moving  out  of  the  infected  area,  will  avoid  going  to  camps  that  may  be 
provided  for  their  exit,  will  become  panic-stricken,  because  they  niay  not 
have  within  reach  the  above-mentioned  paraphernalia.  Now,  if  all  this  fear 
and  tribulation  could  be  avoided,  the  number  of  lives  saved  would,  in  my 
opinion,  exceed  the  number  that  have  been  saved  by  any  plan  of  treatment. 

The  fact  is  that  popular  prejudice  has  held  the  treatment  of  yellow  fever 
to  the  plan  that  was  followed  many  years  ago  in  the  management  of  acute 
febrile  diseases.  The  authority  of  great  names  and  of  centres  of  medical 
learning  has  been  wanting  in  many  of  these  sections  to  bring  about  the 
changes  that  have  been  elsewhere  generally  accepted.  And  yet  M^e  have 
but  to  open  any  authoritative  treatise  on  the  diseases  of  the  tropics  to  find 
a  strong  condemnation  of  such  plans  of  treatment.  Nor  is  it  difficult  to 
prove  that  more  recoveries  occur  among  patients  that  are  not  so  treated ; 
because  their  number  includes  the  isolated  cases  treated,  in  a  measure,  in 
the  open  air,  and  away  from  the  infected  area;  and  in  this  number  is 
included  also  a  considerable  proportion  of  the  cases  of  negroes,  who  gener- 
ally recover  because  of  the  mild  character  of  the  disease  in  that  race. 

Instead  of  active  interference,  I  must  confess  to  a  feeling  of  helplessness 
in  the  presence  of  the  storm  of  the  invasion  of  yellow  fever.  I  do  not 
know  what  is  the  cause,  and  therefore  do  not  know  what  to  do  to  control 
the  morbid  process. 

In  the  treatment  of  children  it  will  be  found  that  the  following  measures 
may  be  considered  as  safe  for  the  relief  of  more  or  less  dangerous  symp- 
toms. If  the  bowels  are  inactive,  cream  of  tartar  should  be  given.  This 
may  be  taken  during  the  evening  with  a  free  supply  of  water.  Magnesia 
is  preferred  by  some,  to  counteract  the  acidity  of  the  stomach.  In  older 
children,  who  can  take  capsules,  I  use  often  the  compound  jalap  powder  in 
laxative  doses.  If  they  are  easily  swallowed,  these  capsules  are  almost 
always  retained.  They  appear,  in  fact,  to  arrest  vomiting,  and  I  have  con- 
tinued to  administer  them  at  intervals,  in  some  cases,  to  the  exclusion  of 
other  treatment, — only  in  such  doses,  however,  as  will  keep  up  a  moderate 
activity  of  the  intestinal  secretions  without  griping. 

If  the  stomach  is  very  irritable  and  the  food  is  not  retained,  calomel 
should  bo  given  in  preference  to  other  laxatives,  and  in  minute  and  fre- 
quently-repeated doses.  The  admixture  of  lime-water  with  the  milk,  or  the 
administration  of  small  doses  of  carbolic  acid  with  bicarbonate  of  sodium, 
or  the  use  of  ice,  will  often  prove  a  good  substitute  for  the  calomel. 

In  other  cases  our  attention  will  be  directed  to  the  relief  of  headaclie 
and  restlessness.    Cold  applications  to  the  head  may  or  may  not  be  soothing. 


874  YELLOAV   FEVEE. 

A  sinapism  to  tiie  back  of  the  neck  will  be  found  beneficial.  The  most 
decided  relief  of  these  symptoms  I  have  obtained  from  the  use  of  antipyrin 
or  of  Dover's  powder.  Either  of  them  may  be  recommended  during  the 
fastigium  of  the  fever  in  ordinary  cases.  In  grave  cases  of  short  duration 
I  employ  the  acetate  of  ammonium  with  tincture  of  digitalis,  to  keep  up 
the  activity  of  the  circulation ;  but  I  doubt  the  utility  of  any  medication 
in  these  cases.  It  is  certainly  pitiful  to  see  these  little  children  treated  with 
blisters  to  the  arms  and  legs,  and  taking  bromides  and  aconite  for  the  relief 
of  cerebral  symptoms.  Many  of  these  patients  are  treated  Avith  large  doses 
of  quinine,  on  the  ground  that  they  are  cases  of  pernicious  malarial  fever ; 
and  I  have  no  doubt  that  the  alarming  and  fatal  symptoms  may  be  the 
result  of  this  medication.  Such  cases,  I  believe,  were  more  connnon  in  the 
practice  of  physicians  who  denied  the  existence  of  yellow  fever  among  the 
children. 

The  treatment  of  the  suppression  of  urine  is  often  a  hopeless  task.  It 
generally  occurs  in  the  desperate  cases  just  mentioned,  and  there  is  neither 
time  for  nor  profit  in  the  employment  of  special  measures  for  this  purpose. 
The  digitalis  recommended  above  will  fill  this  indication,  if  there  is  any 
possibility  of  filling  it.  In  the  more  protracted  cases,  the  use  of  stimulants 
and  tincture  of  the  chloride  of  iron  may  overcome  the  difficulty.  If  the 
complication  continues,  I  would  advise  calomel  as  the  most  certain  diuretic 
to  be  used.  I  have  seldom  employed  it  in  children,  because  the  suppression 
of  urine  does  not  often  arise  as  a  pressing  indication  for  treatment ;  but  in 
the  adult  the  effect  has  been  very  remarkable.  I  have  given  two  or  three 
grains  every  four  hours,  in  capsules,  either  alone  or  in  combination  with 
small  doses  of  compound  jalap  powder.  The  urinary  secretion  is  started 
often  before  the  third  dose  is  administered.  I  used  calomel  as  a  diuretic  in 
yellow  fever  for  the  first  time  in  the  epidemic  of  1887.  On  the  recommen- 
dation of  Dr.  Sternberg,  the  bichloride  has  been  since  used,  with  the  hope 
of  destroying  pathogenic  microbes  in  the  intestinal  contents.  There  is  no 
proof  that  the  theory  has  been  made  good  by  the  experiment.  But  I  am 
informed  by  those  who  used  the  bichloride  that  it  certainly  had  the  effect 
of  increasing  the  secretion  of  urine  and  diminishing  the  amount  of 
albumen. 

In  regard  to  the  use  of  cold,  which  would  appear  to  be  indicated  in 
the  treatment  of  yellow  fever,  I  may  say  that  I  have  employed  cold  baths 
and  have  abandoned  them  in  the  febrile  diseases  of  children.  C^iildrcn 
under  the  age  of  seven  years  are  very  apt  to  sliow  evidences  of  blood- 
stasis  in  the  cold  bath  before  the  internal  temperature  has  been  materially 
reduced. 

The  influence  of  therapeutics  to  determine  a  flivorable  result  is  shown 
unmistakably  only  in  those  cases  that  are  prolonged  beyond  the  sixth  day, 
— the  typhoidal  cases  previously  described.  In  these  the  black  vomit  will 
appear  by  degrees.  As  soon  as  the  black  strife  begin  to  show  themselves  in 
the  vomited  matters,  or  even  before,  if  the  lysis  is  unusually  slow  and  the 


YELLOW   FEVEE.  875 

asthenia  marked,  we  should  prescribe  the  tincture  of  the  chloride  of  iron  in 
doses  of  five  or  ten  drops  every  three  or  two  hours.  This  treatment  is  often 
followed  by  an  arrest  of  the  hemorrhage  and  diminution  of  the  vomiting. 

In  these  cases  great  importance  attaches  to  the  use  of  alcohol.  Good 
brandy  should  be  given,  diluted  with  milk,  water,  or  carbonic-acid  water. 
In  many  cases  iced  champagne  is  very  well  borne  by  the  stomach. 

I  recommend  under  the  circumstances  that  special  attention  be  paid  to 
the  change  of  clothing  and  the  removal  of  the  clammy  secretion  of  the  skin. 
This  is  best  done  by  light  sponging  with  diluted  chlorine-water,  tepid  or 
cool,  as  the  condition  of  the  patient  may  require. 

In  some  cases  during  this  stage  the  jaundice  may  acquire  unusual  promi- 
nence, and  a  slight  enlargement  of  the  liver  will  be  noticed.  I  recommend 
then  that  the  chloride  of  iron  be  substituted  by  chlorate  of  potassium. 

Upon  the  judicious  use  of  the  iron,  alcohol,  and  chlorate  of  potash,  with 
a  nutritious  diet,  depend,  in  my  opinion,  the  few  triumphs  that  therapeutics 
may  boast  of. 

The  mortality  of  yellow  fever  is  considerably  reduced  when  the  patients 
are  treated  in  tents,  or  in  well-ventilated  provisional  buildings  outside  of 
the  infected  area,  provided  all  crowding  of  people  together  be  avoided. 

The  frequent  administration  of  food  in  small  quantities  during  the  lysis 
is  probably  of  great  importance,  and  the'  preference  should  be  given  to 
milk.  We  may  substitute  for  it,  at  times,  strong  meat  broths,  especially 
when  the  time  allowed  for  resting  has  brought  together  the  hours  for  feed- 
ing and  the  administration  of  the  iron.  Soft-boiled  eggs  are  tolerated  even 
before  convalescence  is  well  established.  Alcoholic  preparations  containing 
extract  of  beef  may  be  used  with  advantage  in  the  protracted  cases.  I  have 
seen  in  the  practice  of  Dr.  Charles  Faget  a  preparation  of  this  kind — the 
elixir  Duclos — employed  successfully. 

The  use  of  cool  acidulated  drinks  is  very  generally  recommended,  espe- 
cially in  the  early  stages.  It  is  stated  with  much  truth  that  the  lemonade 
if  boiled  and  subsequently  cooled  will  be  better  borne  by  the  stomach. 

Prophylaxis. — The  mild  character  of  yellow  fever  in  children  and  in 
the  negro  is  a  serious  obstacle  to  the  prevention  of  the  spread  of  epidemics, 
because  individuals  of  those  classes  may  constitute  unrecognized  sources  of 
infection.  Another  obstacle  is  to  be  found  in  the  unfortunate  tendency  to 
conceal  the  first  manifestations  of  the  epidemic.  Lastly,  the  most  serious 
obstacle  is  to  be  found  in  the  mcagrcncss  of  the  provisions  made  for  quaran- 
tine purposes  through  the  indifi'erence  of  the  public  to  sanitary  matters. 

These  obstacles,  it  must  be  confessed,  have  rendered  comparatively  use- 
less all  attempts  to  enforce  successfully  a  reasonable  quarantine.  I  cannot 
understand,  however,  why  tliis  should  be  considered  proof  against  the  ad- 
visability of  attem]3ting  to  restrict  or  regulate  the  intercourse  with  an  in- 
fected district.  Much  has  been  said  of  the  good  results  obtained  by  the 
English  with  their  methods  of  comparatively  free  intercourse.  The  truth 
is  that  wherever  the  territorial  circumstances  are  similar  to  ours  there  is 


876  YELLOW   FEVER. 

nothing  in  the  success  of  the  English  that  is  worthy  of  admiration  and 
imitation.  To  speak  of  yellow  fever  only,  we  find  that  no  control  has  been 
exerted  in  the  West  Indies  over  the  ravages  of  the  disease  by  any  European 
government.  The  tendency  is  rather  the  reverse,  for  we  find  that  centres 
of  periodic  epidemics  (Class  II,)  are  assuming  the  character  of  centres  of 
annual  epidemic.  This  has  been  especially  well  shown  in  the  island  of 
Cuba  since  1761.  In  the  United  States,  on  the  other  hand,  it  appears  that 
important  centres  of  the  second  class  have  been  converted  into  centres  of  the 
third  class,  or  of  accidental  epidemics.  And  let  not  those  tropical  countries 
comfort  themselves  with  the  feeling  of  safety  that  rests  upon  the  belief  in 
the  immunity  of  the  native  population.  They  see  their  commerce  prosper, 
and  they  wonder  at  the  dread  of  the  disease  that  is  shown  in  other  quarters. 
But  their  sense  of  security  is  a  fallacious  dream.  Let  them  reckon  by  the 
infantile  mortality  the  price  they  have  to  pay  for  their  immunity. 

The  United  States  government,  after  gradually  improving  its  system  of 
maritime  quarantine,  has  very  recently  undertaken  to  carry  out  measures 
for  the  restriction  of  epidemics  of  yellow  fever  by  land-quarantine.  Un- 
fortunately, the  means  to  carry  out  these  measures,  and  the  authority  to 
enforce  them,  were  very  limited.  But  the  national  health  authorities  have, 
I  believe,  shown  what  might  be  done  if  these  limitations  were  removed. 
The  object  in  view  was  the  depopulation  of  infected  districts  without  danger 
to  other  sections.  For  this  purpose  a  probation  camp  was  established  at 
Camp  Perry,  where  persons  coming  from  an  infected  district  were  detained 
for  a  period  of  ten  days.  This  experiment  was  made  on  a  somewhat  limited 
scale,  and  some  of  its  features  evinced  a  hasty  preparation.  It  was  shown, 
however,  that  this  camp  could  be  kept  uninfected,  and  that  more  than  one 
thousand  people  who  passed  through  the  establishment  could  have  been 
received  with  perfect  safety  by  any  community.  Unfortunately,  the  local 
quarantine  authorities,  over  which  the  government  could  have  no  control, 
chose  to  disregard  these  facts.  They  were  influenced  by  popular  prejudice, 
and  were  obliged  to  treat  Camp  Perry  as  though  it  had  been  an  infected 
place.  Of  course  this  became  an  obstacle  to  the  usefulness  of  the  camp 
as  a  means  of  depopulating  the  infected  district. 

What  appears  to  be  wanting  to  carry  out  these  measures  eifectually  is  a 
permanent  organization  in  the  shape  of  permanent  quarantine  posts  and 
d^p6ts,  and  a  standing  army,  after  the  fashion  of  the  military  organization 
of  the  nation.  This  is  the  only  way  of  preventing  the  fatal  stampede  of 
the  first  days  of  an  epidemic.  Instead  of  this,  what  do  we  find  ?  A  vast 
disproportion  between  the  appropriations  of  money  made  for  the  War 
Department  and  those  made  for  sanitary  purposes  :  in  the  former  case  many 
millions  of  dollars  annually  supplied  to  keep  up  the  defences ;  in  the  latter, 
a  few  hundred  thousand  dollars,  most  of  which  arc  made  available  only 
after  the  epidemic  invasion  is  well  established.  And  yet  there  is  no  doubt 
that  our  imported  epidemics  have  been  vastly  more  destructive  to  life  and 
capital  than  our  foreign  wars. 


YELLOW    FEVEPw.  877 

Another  desideratum  is  the  education  of  the  j^eople  to  a  proper  under- 
standing of  the  prominent  facts  of  epidemics.  They  should  know  that 
epidemics  commence,  as  a  rule,  about  concealed  cases,  that  the  danger  lies 
in  the  unknown,  but  that  there  is  very  little  risk  even  in  handling  cases 
that  are  properly  labelled  yellow  fever.  These  are  isolated,  and  removed 
from  crowded  places,  and  a  proper  disinfection  of  their  eifects  should  be 
made  by  boiling.  People  should  be  taught  also  to  travel  in  times  of  epi- 
demic with  little  baggage  and  such  as  can  be  easily  and  effectually  disin- 
fected. It  certainly  does  not  seem  unreasonable  to  ask  them  to  give  up  for 
the  nonce  their  silks  and  trappings. 


DENGUE. 

By  EUDOLPH  MATAS,  M.D. 


Definition. — A  febrile  epidemic  disease  which  is  contagious  or  transmis- 
sible and  characterized  by  a  polymorphous  and  often  dichronous  cutaneous 
eruption,  by  very  intense  muscular  and  articular  pains  of  a  rheumatoid  char- 
acter, and  by  a  cyclical  evolution  in  four  periods,  the  last  being  that  of  con- 
valescence, which  is  prolonged  and  difficult.  This  purely  symptomatic 
definition,  which  we  have  adopted  from  Mah§,'  is  properly  completed  by 
the  addition  of  the  following  distinctive  features  which  are  peculiar  to  the 
history  of  dengue, — viz.,  that  it  is  an  epidemic  disease  of  intertropical  or 
warm  climates  (it  has  exceptionally  crossed  the  thirtieth  parallel  of  north 
or  the  twenty-fifth  of  south  latitude) ;  in  addition,  that  it  was  but  very 
indistinctly  recognized  and  never  completely  described  before  the  com- 
mencement of  the  nineteenth  century ;  and,  lastly,  that  it  is,  as  a  rule,  a 
non-fatal  malady. 

Synonymes. — Unknown  or  unfamiliar  epidemic  diseases,  which  over- 
run wide  and  different  territorial  areas  at  considerable  intervals  of  time  and 
afflict  numerous  and  varied  races  of  people  speaking  diiferent  languages, 
usually  receive  a  new  name  in  each  particular  country  which  they  visit,  and 
the  polyglot  and  word-laden  synonymy  which  results  therefrom  constitutes 
only  the  first  difficulty  encountered  by  the  investigator.  This  knowledge, 
however,  is  indispensable  in  order  to  assimilate  all  those  affections  described 
under  different  names  into  one  common  species.  Owing  to  the  intense 
stiffening  and  distorting  pains  which  so  pre-eminently  distinguish  the  dis- 
ease, the  following  names  have  been  given  to  it :  Eruptive  Rheumatic  Fever; 
Eruptive  Articular  Fever ;  Exanthematic  Articular  Fever  ;  Articular  Fever 
of  Warm  Climates  (Thaly,  Senegal) ;  Eheumatismal  Fever  with  gastric  irri- 
tation (Furlong,  United  States) ;  Rheumatic  Scarlatina ;  Arthrodynia  (Cock, 
United  States) ;  Trancazo  [club-blow],  (Santa  Cruz  de  Teneriffe) ;  Panto- 
mima  (Cadiz) ;  Stiffneck  ;  Giraffe ;  Broken-wing  ;  Break-bone  Fever,  a 
favorite  designation  in  the  United  States ;  Polka  Fever  (in  Brazil)  and 
Dandy  Fever,  first  used  by  the  negroes  of  St.  Thomas,  West  Indies,  in 

1  Mahe,  Diet,  encyclop.  des  Sciences   medicales,  art.   "  Dengue,"  Prem.  Serie,  tome 
sxvi.,  Paris,  Masson-Asselin,  1880. 
878 


DENGUE.  879 

1827,  because  of  the  stiifness  witli  which  convalescents  from  the  disease  are 
often  compelled  to  walk. 

The  following  may  be  attributed  to  the  eruptions  :  Exanthesis  Arthro- 
sia,  Rosalia,  Colorada  (Spanish  colonies) ;  Calentura  Roja  (Poggio,  in  Cadiz 
and  Teueriffe) ;  Simple  Red  or  Exotic  Fever  (Senegal,  Cayenne,  Reunion). 

Owing  to  its  intense  epidemic  character  and  some  of  its  geographical 
peculiarities,  dengue  has  also  been  called  Spinal  Epidemic  Fever ;  Anoma- 
lous Fever ;  Calcutta  Fever  (Mellis) ;  Epidemic  Eruptive  Fever  of  India 
and  Toohutia;  Malta,  Mauritius,  Chinese,  and  Mediterranean  Fever. 
Then  a  host  of  other  appellations,  some  rational,  others  merely  curious  and 
bizarre  :  thus,  Date  Fever  in  Arabia,  Port  Said,  because  it  usually  appears 
about  the  date-season ;  Inflammatory  Fever ;  Three-Days'  Fever  (India) ; 
La  Piadosa,  "  the  kind,  the  charitable  fever"  (Cadiz) ;  Fiebre  Rusa,  Gadi- 
tana.  Influenza  Plantaria ;  Biliary  Fever ;  Bou-Hou  or  Wailing  Fever, 
Sandwich  Islands ;  N'Dagamonte,  N'Dongomonte,  N'rogni  (indigenous 
Senegalese) ;  Knee-disease  (Arabia) ;  Abou-dabous  (Tripolitan  Arabs) ;  Kid- 
niga  Pepo  (Zanzibar) ;  Dunga,  Dengue,  equivalent  to  "  coquettish,"  "  fop- 
pish," in  Spanish,  from  which  the  word  denguero  or  dandy  (more  modern 
dude)  is  derived.  Campbell  ^  and  others  suggest,  contrary  to  the  previous 
explanation  of  the  origin  of  the  word,  which  is  that  of  Hirsch  and  Charles, 
that  it  is  a  mere  corruption  or  phonetic  English  adaptation  of  the  Spanish 
word  dengue  (dangy,  dandy,  dengue).  Anyway,  whatever  may  be  the 
origin  of  the  word  or  the  reasons  which  may  have  led  to  its  adoption,  it  is 
a  fact  that  the  word  dengue  has  persisted  and  dominated  more  than  all 
others  in  the  literature  of  the  subject  and  has  become  somewhat  official 
since  it  was  adopted  by  the  Committee  of  the  College  of  Physicians  and 
Surgeons  of  London  in  1869  in  their  System  of  Nosological  Classification, 
and  has  since  been  universally  adopted  to  designate  it  by  all  writers,  irre- 
spective of  nationality. 

History. — Though  vaguely  described,  it  is  pretty  certain  that  dengue 
prevailed  epidemically  and  quite  extensively  during  the  latter  part  of  the 
last  century.  Beyond  this,  the  early  history  of  the  disease  is  lost.  If  we 
were  to  hold  strictly  to  the  dates  indicated,  it  would  appear  according  to  the 
chronicler  Gaberti,  quoted  by  Pruner,  that  in  1779  a  disease  corresponding 
in  its  description  to  dengue  prevailed  extensively  on  the  Arabian  coast  and 
in  Cairo,  Egypt.  Almost  at  the  same  time  a  similar  disease  prevailed  on 
the  Coromandel  coast,  if  we  are  to  acce])t  the  evidence  of  a  French  mission- 
ary, Pcrsin.  In  1779,  David  Brylon  described  the  disease  as  it  prevailed 
in  Java  under  the  name  of  articular  fever.  In  1780,  Benjamin  Rush 
appears  to  have  observed  it  in  Philadel})hia  under  the  name  of  bilious 
remittent  fever  (Wood).     Pezet  also  recognized  it  in  Lima,  Peru,  in  1818. 

These  citations  would  tend  to  prove  that  dengue  had  become  dissemi- 
nated over  a  very  larc-e  area  before  the  advent  of  this  century,  since  it  had 


*■  Language  of  Medicine,  1888,  Appleton,  New  York. 


880  DENGUE. 

been  recognized  in  at  least  three  very  distinct  points  represented  by  the 
three  continents  Asia,  Africa,  and  America.  It  might  even  be  added  that 
it  had  also  prevailed  in  Europe,  if  it  had  been  observed,  as  is  pretended 
with  good  reasons,  in  Cadiz  and  Seville  in  1785  by  Nineto  de  Pinta. 

It  was  certainly  in  India,  however,  that  dengue  was  first  well  described 
from  1824  to  1826,  when  such  men  as  Mellis,  Twining,  Cawel,  and  Mouat 
contributed  to  its  literature.  A  little  later,  from  1826  to  1828,  the  great 
Antillean  epidemic  which  so  extensively  prevailed  in  the  Southern  United 
States  was  observed  and  described,  with  all  the  care  and  attention  possible 
at  that  time,  by  a  host  of  most  competent  observers,  American,  English, 
Spanish,  and  French.  Since  that  time,  as  our  knowledge  of  the  disease 
has  increased,  its  clinical  differentiation  been  perfected,  and  our  means  of 
communication,  both  by  steam  and  by  electricity,  so  largely  and  increasingly 
facilitated,  the  prevalence  of  the  disease  has  been  much  more  frequently 
noted,  though  its  epidemic  itinerary  has  rarely  transgressed  the  boundaries 
of  tropical  and  temperate  latitudes.  Limiting  ourselves  to  the  Western 
Hemisphere  alone,  we  will  notice  that  in  1826  it  prevailed  in  Savannah, 
Georgia;  in  1827  to  1828,  in  St.  Thomas,  Santa  Cruz,  and  other  Antilles, 
Colombia,  Bogota,  Carthagena,  Hayti,  Jamaica,  Charleston,  Mobile,  and 
sporadically  Boston,  New  York,  and  Philadelphia  (Stedmau,  Cock,  Fur- 
long, etc.) ;  in  1839  to  1844,  in  Iberville,  Louisiana,  and  Mobile,  Alabama ; 
in  1846  to  1848,  in  Brazil,  where  almost  all  the  inhabitants  were  attacked 
with  the  disease  (polka  fever);  in  1848-50,  in  New  Orleans,  and  along 
all  the  Gulf  and  South  Atlantic  States, — a  most  extensive  epidemic  (Dick- 
son) ;  in  1850  to  1852,  in  Peru;  in  1854,  in  Havana;  in  1855  to  1856, 
in  Martinique  (Ballot);  in  1861,  reappearance  of  dengue  in  Texas  and 
the  Southern  United  States;  in  1866,  reappearance  of  dengue  in  the 
Southern  United  States;  in  1874  to  1875,  epidemic  in  Martinique, — im- 
ported, it  is  said,  by  immigrants;  in  1880,  in  Charleston,  Savannah,  New 
Orleans,  and  other  cities  of  the  Southern  States ;  in  1885,  a  most  extensive 
and  violent  epidemic,  exclusively  limited  to  the  State  of  Texas. 

The  sum  of  evidence  furnished  by  the  history  and  geography  of  dengue 
would  indicate  that  this  disease  was  originally  an  Asiatic  tropical  infection, 
starting  perhaps  in  India,  which  was  subsequently  cliifused  to  its  present 
wide  geographical  area  of  distribution  by  new  discoveries,  increased  com- 
mercial relations,  etc.  Furthermore,  that,  though  the  disease  cannot  be 
said  to  possess  perennial  endemic  foci  of  prevalence,  still  it  is  known  to 
prevail  sporadically  and  Avith  great  frequency  in  Northern  Egypt,  India, 
and  perhaps  our  own  United  States ;  Europe,  with  the  solitary  exception  of 
the  warmer  provinces  of  Spain,  having  thus  far  enjoyed  almost  complete 
immunity. 

We  will  not  dwell  further  on  this  aspect  of  our  subject,  as  it  is  not  our 
particular  province  to  do  so,  especially  in  so  narrowly  limited  an  article  as 
this.  Any  one  further  interested  in  this  field  of  research  will  find  a  more 
ample  consideration  of  it  in  Hirsch's  "Handbuch  der  liistorisch-geogra- 


DENGUE.  881 

phischeu  Patliologie,"  Creitjhton's  English  translation,  Sydenham  Library, 
1887,  or  in  Mahe's  learned  article,  he.  cit.,  from  Avhich  the  major  portion  of 
the  preceding  data  has  been  condensed. 

Etiolog-y. — Dengue  is  essentially  an  epidemic  disease,  though  it  some- 
times occurs  sporadically  in  the  countries  in  which  it  more  habitually  pre- 
vails. Age,  sex,  social  condition,  race,  and  nationality  appear  to  have  no 
influence  on  the  production  of  dengue.  Infants  at  the  breast,  only  a  few 
weeks  after  birth,  are  stricken  side  by  side  with  septuagenarians.  The 
infirm  valetudinarian  and  the  most  healthy  and  vigorous  youth  are  alike 
exposed  to  its  influence.  There  are  few  diseases  which  are  such  great  level- 
lers as  this.  Climatic  conditions,  insomuch  as  they  are  related  to  thermic 
influence,  are  of  importance.  It  has  been  justly  observed  that  it  is  particu- 
larly in  the  summer  months  that  dengue  breaks  out  in  the  regions  situated 
just  outside  of  the  tropics.  There  are  some  exceptions  to  this,  especially  in 
North  America.  Geographical  distribution  of  the  disease  shows  plainly 
(see  map)  that  its  prevalence  is  influenced  in  a  great  measure  by  the  dis- 
tribution of  heat  on  the  surface  of  the  globe.  In  the  Northern  Hemisphere 
it  has  rarely  crossed,  at  least  as  an  epidemic,  the  thirty-second  parallel  in 
America  and  the  thirty-sixth  in  Europe ;  in  the  Southern  Hemisphere  it 
has  never  gone  below  the  twenty-first;  but  within  these  extreme  limits 
there  are  few  diseases  which  have  spread  so  thoroughly  over  a  large  surface. 
The  extent  of  its  itinerary,  the  rapidity  of  its  march,  the  multitudes  of 
victims^  which  it  strikes  at  once,  its  benign  character  which  contrasts  so 
markedly  with  the  apparent  gravity  of  its  symptoms,  are  all  peculiarities 
which  tend  to  brino-  it  in  relief  and  throw  it  in  strono;  contrast  with  most 
other  pandemic  maladies,  with  perhaps  only  one  exception, — influenza, — 
with  which  it  has  great  epidemiological  affinities. 

After  a  careful  study  of  the  disease  it  becomes  evident  that  the  great 
thoroughfares,  the  public  ways  of  the  world's  travel,  are  the  routes  also  fol- 
lowed by  dengue  in  its  migrations,  and  that,  consequently,  the  more  numer- 
ous and  frequent  the  transit  of  human  beings  along  these  routes,  the  greater 
the  rapidity  of  the  spread  and  the  greater  the  frequency  of  its  visitations. 

A  great  deal  has  been  said  in  regard  to  the  atmospheric,  telluric,  and 
cli^natic  conditions  whicli  are  favorable  and  unfavorable  to  the  spread  of 
dengue,  but  almost  all  this  class  of  information  is  of  a  very  misty  and  un- 
stable sort,  so  that,  outside  of  what  has  been  said  in  regard  to  the  favorable 
influence  of  heat,  little  more  can  be  positively  affirmed.  It  has  been  as- 
serted that  altitude  has  a  decided  effect  in  unfayorably  influencing  the  infec- 
tion, but  this  influence,  the  most  competent  observers  (Catholeudy,  Mah6, 

^  It  is  by  millions  that  we  must  count  tho  victims  of  the  disease  in  the  Indian  epidemic 
of  1872.  At  Reunion,  dengue  swept  over  tin-  whole  island  in  three  months;  there,  at  St.- 
Denis,  out  of  a  population  of  thirty  thousand,  twenty  thousand  were  stricken  with  the 
disease.  In  the  recent  epidemic  of  1885  which  prevailed  with  so  much  violence  in  Texas, 
McLaughlin  estimates  that  in  the  city  of  Austin  alone,  out  of  a  population  of  twenty-two 
thousand,  sixteen  thousand  persons  were  attacked  in  the  course  of  a  few  months. 
Yoh.  I.— at; 


882  DENGUE. 

and  others)  inform  us,  is  due  merely  to  the  difference  in  temperature,  and 
not  of  altitude  alone.  In  Eeunion,  the  high  table-lands  of  Salazie  and  of 
Cafres  (nearly  two  thousand  metres  above  the  sea),  and  even  the  much 
lower  level  of  St.-Denis  in  the  same  island  (seven  hundred  to  eight  hundred 
feet),  Avere  never  troubled  with  the  disease,  while,  on  the  contrary,  the  lower 
country  below  these  points  was  completely  swept  by  it.  Like  other  great 
epidemic  diseases,  it  prefers  large  populated  centres,  not,  of  course,  because 
of  an  inherent  preference,  but  on  account  of  the  greater  pabulam.  Though 
a  warm  climate  appears  to  be  almost  an  indispensable  requisite  for  its 
proper  propagation,  it  is  a  notable  fact  that  cold  does  not  markedly 
diminish  the  spread  of  dengue  epidemics.  (  Vide  Thomas,  loc.  cit,  epidemic 
of  Savannah,  Georgia,  most  intense  in  the  exceptionally  cold  winter  months 
of  1880  to  1881.)  Again,  as  will  be  noticed  farther  on,  one  attack  of  the 
disease  is  not  protective  from  further  attacks,  though  on  this  point  there  is 
some  division  of  opinion. 

From  these  remarks  it  will  be  gleaned  that  little,  if  anything,  is  actually 
known  of  the  auxiliary  agencies  or  factors  which  influence  the  development 
of  the  dengue  poison,  whether  in  a  favorable  or  an  unfavorable  direction. 
As  to  the  vera  causa,  the  essential  ferment  or  contagium,  which  is  the  sine 
qua  non  in  the  etiology  of  the  disease,  our  knowledge  was  still  more 
deplorably  scanty  until  the  advances  of  modern  bacteriological  research  gave 
strength  to  the  numerous  suggestions  that  had  been  offered  by  almost  every 
writer  on  the  disease  since  the  earlier  glimmering  of  the  panspermist  doc- 
trine. All  ideas  in  this  direction  were  entirely  conjectural  and  hypothetical 
until  1885,  when  the  unusually  fertile  and  rich  field  offered  by  the  great 
epidemic  AA^iich  prevailed  in  the  State  of  Texas  was  utilized  by  Dr.  J.  W. 
McLaughlin,  of  Austin,  and  the  first  step  taken  to  examine  the  etiological 
problem  with  all  the  lights  that  modern  science  could  lend  to  the  inquiry. 

McLaughlin's  investigations^  were  not  completed,  but  the  facts  obtained 
by  him  are  sufficiently  striking  and  valuable,  if  confirmed  by  further 
investigators,  to  support  the  most  sanguine  expectations  that  may  be  enter- 
tained as  to  the  early  and  positive  discovery  of  the  essential  etiological 
factor. 

As  a  prominent  and  active  practitioner  in  Austin,  Dr.  INIcLaughlin 
enjoyed  exceptional  advantages  for  obtaining  material  and  assuring  the 
genuineness  of  the  cases  investigated.  These  investigations  covered  the 
space  of  six  months.  The  work  actually  performed  during  this  time  is 
embraced  in  the  following  paragraphs  : 

1.  Blood  which  was  obtained  from  living  subjects  during  the  various 
stages  of  dengue  was  microscopically  examined  (a)  directly,  that  is,  without 
the  addition  of  any  chemical  reagents  ;  (b)  after  it  had  been  subjected  to 
the  action  of  certain  chemical  reagents, — viz.,  glacial  acetic  acid  with  and 

1  Kesearches  into  the  Etioloo;y  of  Dengue.  By  .J.  W.  McLaus;hlin  (President  Texas. 
Microscopical  Society,  Austin,  Texas),  Jour.  Amer.  Med.  Assoc,  .June  19,  1886. 


DENGUE.  883 

without  dilution,  caustic  potash  in  sohition,  both  weak  aud  strong,  chloro- 
form, and  ether. 

2.  This  blood  was  carefully  dried  upon  sterilized  cover-glasses,  by  pass- 
ing them  through  the  flame  of  a  spirit-lamp,  and  then  subjected  to  the 
action  of  various  staining  reagents. 

3.  Dengue  blood,  obtained  from  living  subjects,  was  introduced  upon 
the  points  of  a  platinum  wire  into  test-tubes  containing  sterilized  culture- 
jelly  prepared  for  this  purpose.  These  tubes  were  closed  with  plugs  of 
sterilized  cotton,  then  placed  in  an  incubator,  where  the  temperature  was 
kept  at  100°  F.  for  the  growth  of  such  organisms  as  were  contained  in  the 
blood. 

4.  Blood  was  drawn  directly  from  the  veins  of  a  living  subject  into  a 
series  of  sterilized  glass  bulbs  which  were  united  by  a  capillary  tube.  This 
was  performed  in  such  a  manner  that  it  seems  impossible  for  germs  from 
the  air  or  by  other  accidental  means  to  have  gained  an  entrance  into  these 
bulbs.     These  were  also  kept  in  an  incubator  at  a  temperature  of  100°  F. 

5.  The  matter  vomited  and  urine  passed  by  dengue  subjects  were  sub- 
jected to  microscopic  examination. 

Dr.  McLaughlin  summarizes  the  results  obtained  from  the  preceding 
methods  of  examination  as  follows :  "  In  the  blood  examined  directly  or 
after  its  treatment  with  the  chemical  reagents  already  referred  to,  stained  or 
unstained,  I  invariably  found,  often  in  great  numbers,  in  the  cell  elements 
as  well  as  in  the  plasma,  micrococci  about  2V  ^^  To  ^^^^  diameter  of  the  red 
cells,  spherical  in  shape  and  red  or  purplish  in 
color.  When  these  were  seen  in  great  numbers, 
one  layer  was  superimposed  upon  another ; 
frequently  seen  in  the  cultures  they  appeared 
of  a  black  or  brownish  color,  but  when  seen 
singly  or  in  thin  layers  in  the  blood  or  in 
cultures  the  red  color  is  always  distinct  and 
characteristic. 

"  During  the  development  of  this  organism, 
at  some  period  in  its  life-history,  from  causes 
which  I  do  not  understand,  it  becomes  sur- 
rounded   with    a   gelatinous    envelope  :     this    I  Blood  of  dengue  fever,  from  cul- 

have  frequently  observed  in  the  blood  and  in     t.are-buib,  showing  micrococci  in  the 

T-  ''  red  cells  and  m  the  plasma.    In  the 

the  culture  alike."  ^  latter  they  are  found  singly  and  in 

TIT  T  1,1  •         1  11*  •  zooglcea  masses.     (From  McLaugh- 

McLiaughlin  always  succeeded  in  growing     un-s paper) 
in    culture-tubes    upon    the   surface   of  jelly 

micrococci,  and  no  other  form  of  bacteria,  which  in  color,  size,  and  be- 
havior are  identical  with  those  seen  in  dengue  blood.     The  blood  cou- 

1  It  is  worth  notine;  that  in  the  examination  of  dent^ue  blood  made  in  Calcutta  in  1872 
by  Cunningham  and  Charles  some  curious  observations  were  recorded  which  appear  to  con- 
firm the  observation  of  McLautjlilin,  notwithstanding  the  technical  imperfections  of  the 
then  existing  methods :  "  The  moment  the  blood  was  collected  from  the  veins  it  was  treated 


884  DENGUE. 

tained  in  a  series  of  glass  bulbs  was  examined,  some  after  the  lapse  of  six 
weeks,  some  at  three  mouths :  in  both  instances  it  was  found  that  the 
blood  contained  a  pure  culture  of  micrococci  which  in  all  respects  were  the 
same  as  those  previously  seen  in  fresh  blood.  The  blood  for  examination 
was  obtained  from  about  forty  typical  cases  of  dengue  at  various  times  and 
places  and  during  the  various  stages  of  the  disease.  The  results  obtained 
from  examinations  of  these  diiferent  specimens  were  entirely  uniform.  By 
systematic  attempts  at  staining  with  Bismarck  brown,  vesuvin,  gentian- 
violet,  methyl-violet,  fuchsin,  methyl-blue,  aniline-green,  picro-carmine,  and 
eosin,  Dr.  McLaughlin  came  also  to  the  conclusions,  first,  "  that  the  dengue 
micrococci  do  not  stain  with  aniline  as  readily  as  do  other  forms  of  bacteria;" 
second,  "  methyl-aniline  blue  in  a  weak  solution  of  caustic  potash  furnishes 
a  staining-fluid  for  which  the  cocci  of  dengue  manifest  an  especial  affinity. 
With  all  the  other  dyes  named  the  results  were  negative ;  i.e.,  all  parts  of 
the  picture  were  stained  alike, — cells  and  organisms, — and  they  were  all 
decolorized  with  equal  facility  Avhen  washed  in  one-per-cent.  solution  of 
acetic  acid  and  then  in  absolute  alcohol.  With  the  methyl-blue  potash 
solution,  however,  a  very  diiferent  result  was  obtained:  this  dye,  in  the 
solution  referred  to,  manifested  such  an  affinity  or  elective  action  for  the 
organisms  of  dengue  that  these  would  retain  the  blue  color  after  this  had 
been  extracted  from  the  blood-cells  by  the  decolorizing  agents  named. 

"  The  manner  of  preparing  this  solution  and  the  method  of  staining 
with  it  which  were  adopted  are  as  follows:  Concentrated  alcoholic  solution 
of  methyl-blue,  30  c.cm. ;  solution  of  caustic  potash  1  :  10000,  100  c.cm. 
In  a  dish  filled  with  this  fluid  the  cover-glasses  were  floated  with  the  blood- 
side  downward.  The  dish  was  then  covered,  to  exclude  dust,  and  the  cover- 
glasses  were  kept  in  this  condition  from  twelve  to  twenty-four  hours. 
Better  results  M^ere  obtained  by  keeping  the  staining-fluid  during  this  time 
at  the  temperature  of  100°  F.  The  cover-glasses  are  then  removed  from 
the  staining-solution  and  washed  in  the  one-per-cent.  solution  of  acetic  acid, 
then  in  absolute  alcohol,  until  the  color  is  entirely  or  sufficiently  removed. 

"  I  think  a  better  picture  is  obtained,  and  the  relative  position  of  the 
organisms  to  the  cells  shown,  if  the  process  of  extraction  is  arrested  before 
the  cells  are  entirely  decolorized  :  they  should  then  be  mounted  in  Canada 


with  a  solution  of  osmic  acid,  and  submitted  afterwards  to  the  action  of  an  almost  saturated 
solution  of  potassium  acetate,  with  the  view  of  fixing  the  white  blood-corpuscles,  in  order 
to  examine  the  specimens  subsequently  and  more  leisurely."  It  was  found  that  a  consid- 
erable increase  in  the  number  of  Hayem's  hsemoplasts  (Bizzozero's  blood-plates)  had  taken 
place.  These  little  corpuscles  were  abundant,  sometimes  isolated  and  free,  at  other  times 
agcjregated  in  small  masses  and  held  together  by  a  granular  and  somewhat  gelatinous  material. 
This  condition  of  the  blood  persisted  for  a  few  days,  and  then  the  blood  rapidly  returned 
to  its  normal  appearance  and  condition.  These  modifications  were  very  appreciable  from  the 
third  day,  and  would  last  as  late  as  the  sixth.  These  signs  were  wanting,  however,  in  sev- 
eral cases  of  fever  which  had  been  diagiiosticated  as  cases  of  dengue  fever.  {Vide  E. 
Charles,  Clinical  Lectures  on  Dengue,  Calcutta,  The  Lancet,  1871,  1872,  1873;  quoted  also 
by  Mahe,  loc.  cit.). 


'"••    ••«    .-  / 


Photomicrograph  of  McLauohlin',-  Lu:n(,.l]:  .Mh. imh  uccrs  Culture:  taken  with  2.0 
mm.  hom.  imm.,  1.40°  apert.  apochromatic  objective,  Zeiss,  and  No.  6  Zeiss  apochromatic 
projection  eye-piece.  Magnified  1250  diameters.  (By  W.  M.  Gray,  M.D.,  U.  S.  Army  Mu.seum, 
Washington.) 


DEXGUE.  885 

balsam  and  examined  with  a  high  power  (^  H  1  objective  Grimow's 
N.  Y.,  a  histological  stand,  and  Abbe's  illuminating  apparatus  were  used  in 
these  researches)  and  with  a  large  diaphragm  and  open  condenser.  The 
blood-cells  should  show  a  faint  blue  color,  whilst  the  micrococci,  which  are 
to  be  seen  in  the  blood-cells  and  plasma,  will  be  stained  an  intense  blue. 
The  inability  of  these  organisms  to  hold  the  other  aniline  dyes,  acid  or  basic, 
to  which  they  were  exposed,  their  uniform  size,  their  presence  in  the  blood- 
cells,  their  ability  to  resist  the  destructive  action  of  acids,  alkalies,  ether, 
etc.,  it  would  seem,  are  sufficiently  distinctive  to  differentiate  them  from 
protoplasmic  granules  or  the  products  of  cell-disintegration.  An  additional 
reason  for  regarding  them  as  micro-organisms  exists  in  the  fact  that  they 
can  be  and  have  been  grown  upon  culture-media  outside  of  the  body." 

We  have  thus  far  almost  literally  quoted  Dr.  McLaughlin's  account  of 
his  method  of  distinguishing  the  peculiar  micrococcus  which  he  has  dis- 
covered in  the  blood.  We  will  not  continue  with  him  in  his  detailed 
description  of  the  methods  adopted  for  the  cultivation  of  the  micro- 
organism out  of  the  body,  which  he  succeeded  in  growing  very  successfully. 
To  go  further  into  other  technical  details  would  be  entirely  unpractical  and 
out  of  place  in  this  contribution  :  in  fact,  the  stress  which  we  have  laid 
upon  the  technical  directions  recommended  by  McLaughlin  for  the  recogni- 
tion of  his  micro-organism  would  be  certainly  out  of  place  were  it  not  for 
the  consideration  that  by  thus  quoting  them  m  extenso  we  are  not  only 
illustrating  the  pains-taking  method  adopted  by  McLaughlin  in  his  careful 
research,  but  are  also  laying  before  the  reader  a  method  which  is  so  simple 
that,  if  the  practitioner  be  a  simple  clinical  microscopist,  he  will  find  no 
difficulty  in  repeating  it  quickly  and  correctly.  He  will,  therefore,  be 
materially  assisted  in  carrying  out  a  test-investigation  which,  if  corrobora- 
tive of  McLaughlin's  observations,  will  certainly  prove  of  immense  value 
in  the  sometimes  difficult  and  quite  perplexing  differential  diagnosis  of  this 
remarkable  disease.  If  in  this  respect  alone  McLaughlin's  discoveries  are 
proved  true  and  correct,  then  he  will  have  rendered  a  service  which  should 
make  science  grateful  to  him. 

Now,  as  regards  the  etiological  value  of  McLaughlin's  observations, 
little  can  yet  be  said  :  the  observations  thus  far  are  limited  to  the  discoveiy 
of  a  micro-organism  and  its  cultivation  out  of  the  body  in  blood  and  other 
culture-media ;  the  other  conditions  to  prqve  the  essential  etiological  value 
of  a  micro-organism,  laid  down  by  Koch  and  other  writers,  are  wanting, 
notably  the  experimental  reproduction  of  the  disease  in  the  lower  animals 
and  man  by  the  inoculation  of  the  cultured  colonies.  The  very  careful 
precautions,  the  uniform  results,  and  the  generally  conscientious  methods  of 
researcli  followed  by  Dr.  IVIcLaughlin  would  load  us  to  believe  that  there 
can  hardly  be  any  doubt  as  to  tlic  clos?  causal  relationslii])  of  the  micrococ- 
cus that  he  has  discovered  witli  the  disease,  though  \\'c  must  wait  patiently 
for  another  opportunity  to  jirescnt  itself  before  tlie  full  evidence  needed  to 
establish  the  absolute  imncjrtauce  of  this  micrococcus  in  the  causation  of  this 


886  DENGUE. 

disease  can  be  indisjjutably  asserted.  In  the  mean  time  we  sincerely  hope 
that  the  means  of  recognizing  the  micro-organism,  so  much  insisted  upon 
in  these  pages,  will  be  borne  in  mind  and  will  be  utilized  at  each  and  every 
opportunity.^ 

Clinical  History  and  Symptomatolog'y. —  Varieties. — That  dengue 
fever  is  a  disease  which  presents  a  variety  of  types  is  a  statement  that  will 
be  borne  out  by  any  one  who  has  had  an  opportunity  of  personally  observing 
this  aifection.  In  this  respect  it  resembles  most  of  the  epidemic  diseases 
which  prevail  in  widely  different  territorial  areas  and  among  a  great  variety 
of  races.  It  is  strikingly  like  yellow  fever  in  this  respect,  and  the  distinc- 
tion made  by  Charles,  of  Calcutta,  of  denguis  latens,  denguis  niitis,  and 
denguis  maligna  is  true  in  so  far  as  these  terms  represent  the  various 
degrees  of  intensity  with  which  the  dengue  poison  may  affect  the  organism. 
It  would  be  strange  indeed  if  in  this  respect  dengue  should  differ  from 
the  other  infections  with  which  we  are  more  constantly  brought  in  contact. 
It  is  owing  to  these  differences  in  the  degree  of  intoxication  that  clinical 
confusion  is  liable  to  be  created  in  the  differential  diagnosis  whether  of  the 
milder  or  the  graver  extremes,  which  are  at  times  rendered  especially  ob- 
scure in  tropical  countries,  owing  to  the  wealth  of  these  countries,  as  a  rule, 
in  all  the  varieties  of  allied  forms  of  epidemic  pyrexiae.  The  extremely 
severe  or  mild  types  and,  consequently,  more  perplexing  varieties  of  this 
disease,  which  may  be  regarded,  fortunately,  as  its  exceptional  manifesta- 
tions, because  diverging  from  the  ruling  type,  will  be  considered  subse- 
quently. At  present,  in  order  more  clearly  to  grasp  the  physiognomy  of 
this  disease,  it  is  preferable  to  describe  that  group  of  symptoms  which  when 
present  must  be  considered  peculiarly  distinctive  and  characteristic,  and, 
when  regarded  in  their  ensemble,  pathognomonic  of  dengue.  There  are 
certain  symptoms  which  are  common  to  the  vast  majority  of  the  cases, — 
those  which  have  given  to  dengue  its  independent  position  in  the  nosology, 
and  the  absence  of  any  of  which  is  always  sure  to  lead  to  doubts  and  per- 
plexity when  clinically  dealing  with  the  malady. 

With  Mah^  and  other  competent  observers,  we  will  premise  by  recog- 
nizing in  the  clinical  evolution  of  the  more  typical  cases  of  this  disease  four 
leading  phases,  which  are — 

1.  The  onset  with  fever  and,  ordinarily,  a  transitory  eruption, — the 
initial  rash. 

2.  A  remission,  more  or  less  long,  more  or  less  pronounced. 

1  In  connection  with  the  etiology  of  dengue  it  is  of  interest  to  mention  the  statements 
that  have  heen  made  as  to  the  transmissibility  and  epizootic  prevalence  of  the  disease  among 
the  lower  animals.  Cristobal  Cubillas,  as  early  as  1784,  stated  that  in  the  epidemic  of 
Cadiz  a  great  number  of  animals  were  affected  with  the  disease.  According  to  the  Bombay 
daily  papers,  a  great  many  beasts  in  the  Baroda  di. strict  were  afflicled  with  dengue,  horses 
and  cattle  being  especially  liable  (Martialis).  In  1871,  in  the  Baroda  di.strict  during  the 
prevalence  of  dengue  a  great  many  domestic  animals  were  stricken  as  if  paralyzed  in  the 
extremities,  but  rapidly  recovered  in  three  to  four  days.  The-^^e  interesting  observations 
should  certainly  be  confirmed  and  investigated.     (Mahe. ) 


DENGUE.  887 

3.  A  second  eruption,  more  pronounced  than  the  first,  the  terminal  rash 
with  or  without  fever. 

4.  Desquamation  and  convalescence. 

Period  of  Incubation. — This  appears  to  be  from  a  few  minutes'  duration 
(Bordier,  Mahe,  Rochard,  and  others)  to  five  or  six  days  (Fa}a'er),  and 
to  average  four  days  (Catholendy). 

It  is  almost  universally  admitted  that  a  simple  case  of  dengue  has 
usually  but  few,  if  any,  prodromata  (Hirsch,  Thomas,  Holliday,  Wise, 
Dunckley,  Martialis,  Charles,  Fayrer,  and  others).  These  do  exist  some- 
times, however ;  and  Poggio,  who  is  one  of  the  most  experienced  writers  on 
this  disease,  states  as  a  result  of  his  study  of  eight  hundred  cases  in  the 
Cadiz  epidemics  of  1865  and  1866  that  the  fever  was  constantly  preceded 
by  a  prodromic  period  of  variable  duration,  lasting  from  twelve  to  twenty- 
four  hours,  and  characterized  by  signs  of  malaise,  depression,  lassitude,  fre- 
quent yawning,  repugnance  to  exertion,  cephalalgia,  and  a  sense  of  heaviness 
about  the  supra-orbital  region.  In  our  experience  during  the  epidemic 
which  prevailed  in  New  Orleans  in  1880  we  were  impressed,  along  with 
other  observers,  with  the  belief  that  the  disease  usually  gives  little,  if  any, 
warning  of  its  approach. 

In  infants  and  younger  children,  as  Thomas  and  other  observers  have 
remarked,  the  disease  often  begins  with  a  convulsion,  a  child  being  waked 
up  at  niglit  with  a  spasm.  If  the  child  is  old  enough  to  speak,  it  will  com- 
plain more  often  of  feeling  cold  or  chilly  along  the  back,  and  shortly  after 
of  cephalalgia,  rachialgia,  and  arthralgic  pains.  This  symptomatic  tripod 
— cephalalgia,  rachialgia,  and  arthralgia — should  at  once  awaken  the  sus- 
picions of  the  practitioner  during  an  epidemic  of  the  disease.  The  behavior 
of  smaller  children,  of  infants  especially,  will  depend  almost  entirely  upoi*^^ 
the  intensity  of  the  attack ;  if  the  infection  is  slight  or  moderate,  the  little 
patients  will  give  expression  to  their  suffering  by  their  great  and  sudden 
restlessness,  agitation,  and  manifest  discomfort,  by  constantly  crying  or 
moaning,  and  not  infrequently  by  the  repeated  vomiting,  especially  of 
the  breast-milk  in  nurslings.  More  serious  are  those  cases  in  which  the 
infant  or  child,  after  having  had  a  convulsion,  remains  listless,  apathetic,  or 
in  a  stupor.  In  these  cases  the  gastro-intestinal  disturbance  is  more  pro- 
nounced, vomiting  being  quite  frequent,  the  vomit  usually  consisting  of 
ingesta,  mucus,  gastric  secretions,  and  bile.  These  cases  are  almost  always 
associated  with  a  high  temperature,  and  will  need  very  careful  watching. 
All  these  phenomena  may  be  entirely  wanting,  and  the  disease  may  abruptly 
present  itself  with  fever  and  the  characteristic  pains.  Stedman,  INIartialis, 
and  Charles  cite  curious  illustrations  of  the  occasional  lightning-like  sudden- 
ness of  the  invasion  :  in  more  than  one  instance  persons  have  been  attacked 
in  the  act  of  imitating  the  painful  distortions  produced  by  the  disease,  and 
have  been  forced  to  continue  a  bona  fide  mimicry  in  spite  of  themselves. 

No  matter  how  the  attack  begins,  an  indefinable  prostration  seizes  the 
patient,  and  fever  begins ;  in  adolescents  and  adults  the  pulse  becomes  hard 


888  DENGUE. 

and  rapid,  oscillating  between  100  and  120  and  even  140  (Twining)  to  the 
minute.  In  younger  children  the  pulse  is  often  so  frequent  that  it  is  impos- 
sible to  count  it.  The  respiration  in  children  is  apt  to  be  particularly  hurried, 
though  usually  in  proportion  with  the  fever.  The  temperature  begins  to 
rise  at  once,  and  attains  its  maximum  usually  in  from  twelve  to  twenty-four 
hours,  rarely  after  three  days,  and  very  rarely  after  five  or  seven  days.  The 
fastigium  is  generally  very  short,  and  the  defervescence  is  rapid  and  charac- 
terized by  a  succession  of  remissions  and  exacerbations,  which  continue 
until  the  temperature  has  fallen  one  or  one  and  a  half  degrees  lower  than 
the  natural  heat  of  the  body.^  During  the  next  few  days,  if  the  tem- 
perature is  closely  watched  with  a  thermometer,  it  will  be  found  that  it 
fluctuates  from  a  degree  below  to  one  or  two  degrees  above  the  normal  heat. 
As  will  be  again  stated  below,  by  the  end  of  the  sixth  or  seventh  day  there 
is  a  very  slight  rise  again,  being  a  secondary  fever,  but,  as  a  rule,  this  heat 
soon  subsides,  and  the  temperature  remains  normal  unless  there  is  relapse, 
which  is  not  uncommon  even  in  the  mildest  forms  of  the  disease  after  com- 
plete defervescence.  The  pulse  often  becomes  slower  than  natural,  and 
occasionally  runs  down  in  adults  to  sixty  or  sixty-five  beats  per  minute 
(Thomas),  though  this  marked  retardation  in  the  pulse-beat  is  not  to  be 
compared  in  its  constancy  and  significance  with  that  ^vhich  is  so  notable  a 
feature  of  the  later  stages  of  yellow  fever. 

It  is  during  the  first,  pyretic  stadium  that  the  initial  eruption  is  ob- 
served. In  India  this  first  rash  has  been  observed  in  one-half  of  the  cases, 
according  to  Martialis, — in  two-thirds  of  them  according  to  Charles.  This 
eruption  is  usually  very  transitory  and  lasts  only  as  long  as  the  first  or 
febrile  period  of  the  disease :  it  varies  in  intensity  from  a  slight  blush  to 
a  well-marked  scarlatiniform  erythema.  It  causes  no  desquamation  and 
leaves  no  trace  behind  it. 

During  this  period  of  invasion,  or  pyretic  period,  representing  the  first 


1  Dr.  D'Aquin,  of  New  Orleans,  asserted  that  there  was  a  continuous  and  steady  rise  in 
temperature  uatil  the  highest  point  was  reached  on  the  first,  second,  or  third  day  of  the 
attack  ;  then  a  short  stadium  of  a  few  hours  ;  then  a  remission,  soon  to  he  followed  by  an- 
other fever,  with  rise  in  temperature,  hut  never  reaching  the  point  of  first  maximum  tem- 
perature. Holliday,  also  of  ISTew  Orleans,  and  an  equally  competent  and  experienced 
observer,  in  commenting  upon  the  above  says  ("  Dengue  or  Dandy  Fever,"  Trans.  Amer. 
Pub.  Health  Assoc,  vol.  vi.,  1881,  p.  168),  "  These  views  are  not  corroborated  by  the  reports 
received  by  me,  which  establish  a  distinct  daily  remission,  with  a  ftill  in  thermometer  of 
from  one  to  three  degrees,  with,  of  course,  a  corresponding  rise." 

The  observations  of  D'Aquin  have  been  confirmed  by  Vauvray,  who  observed  the  dis- 
ease in  Egypt,  and  quite  recently  by  De  Brun,  who  observed  the  epidemic  which  prevailed 
in  1888-89  in  Beyrout,  Syria  {Semaine  Medicale,  March  6,  1889) ;  while,  on  the  other  hand, 
Thomas,  of  Savannah,  and  Martialis,  in  India,  and  numerous  other  observers,  speak  of  the 
remission  as  given  in  the  text,  and  agree  with  Holliday.  The  truth  of  the  matter  is  that, 
outside  of  the  fact  that  there  is,  first,  a  paroxysm  of  fever,  secondly,  a  remission,  and  then 
(usually),  thirdly,  a  milder  secondary  thermic  paroxysm,  there  is  no  fixed  and  diagnoffic 
fever-chart  of  dengue.  There  is  no  doubt  that  there  are  cases  presenting  the  D'Aquin  and 
Vauvray  tracings,  but  there  is  no  doubt  also  that  the. type  observed  by  Martialis,  Holliday, 
and  Thomas  is  equally,  if  not  more,  common,  at  least  in  our  Southern  epidemics. 


DENGUE.  889 

phase  of  the  disease,  one  of  the  most  constant  and  truly  reliable  and  earliest 
symptoms  is  the  cephalalgia,  with  the  severe  pain,  which  has  already  been 
mentioned,  in  some  joints,  usually  one  of  the  interphalangeal  of  the  upper 
extremities,  which  rapidly  extends  to  all  the  other  joints  and  bones,  this 
pain  during  the  progress  of  the  disease  passing  from  one  joint  to  another, 
as  in  metastasis.  The  severe  pain  in  the  head  is  very  distressing,  and,  from 
the  results  that  now  and  then  follow,  must  be  due  to  a  slight  hyperemia  of 
the  brain  or  its  meninges.  "  The  heavy  aching  and  throbbing  of  the  tem- 
ples and  balls  of  the  eyes,  with  dilated  pupils,  are  marked  and  significant 
symptoms"  (Thomas). 

To  these  febrile  and  painful  phenomena  symptoms  of  gastric  disturbance 
are  often  added.  The  tongue  becomes  coated  with  a  thick  dirty-white  fur 
in  the  centre,  which  contrasts  with  the  red  edges  (J.  Rochard,  Fayrer,  Mahe, 
and  others) ;  it  is  more  often  noticed  in  the  experience  of  other  observers 
(Holliday  and  others)  that  the  tongue  is  uniformly  coated  with  thick  fur,  as 
in  most  fevers,  and  is  not  notably  red  at  the  edges,  diifering  markedly  in 
this  respect  from  the  tongue  usually  seen  in  yellow  fever.  There  is  nausea, 
sometimes  mucous  or  bilious  vomiting,  constipation,  more  rarely  diarrhoea. 

The  urine  is  usually  dark,  scant,  sedimentary,  and,  as  a  rule,  non- 
albuminous} 

Pari  passu  with  the  subsidence  of  the  fever,  which  takes  place  usually 
after  the  first  forty-eight  hours  (Fayrer),  often  after  three  days,  and  more 
rarely  after  five,  seven,  or  eight  days  (Mahe),  the  characteristic  pains 
diminish  and  "  critical"  phenomena  are  liable  to  take  place,  such  as  profuse 
sweating,  diarrhoea,  and  not  rarely  epistaxis,  as  in  typhus.  During  this 
period  of  remission  the  patient  is  left  exceedingly  prostrated,  stiff,  and 
without  appetite,  if  the  attack  has  been  at  all  severe  :  the  prostration  is 
particularly  noticeable  in  children,  in  whom  it  is  accompanied  by  extreme 
restlessness,  not  infrequently  by  delirium  and  insomnia  (Holliday).  Some- 
times, on  the  contrary,  the  sick  believe  themselves  entirely  well,  and  Mill 
insist  on  getting  out  of  bed.  This  apyretic  period  or  intermission,  though 
it  is  usually  only  a  simple  remission,  may  last  one  or  two  days  (Wilde), 
three  or  four  days  (Fayrer),  two  to  three  days,  or  may  be  absent  (Ballot). 
During  the  remission  the  third  phase  of  dengue  presents  itself,  and  is 

1  The  condition  of  the  urine  in  tropical  pyrexiae  is  always  a  matter  of  great  importance, 
both  from  the  diagnostic  and  from  the  prognostic  stand-point.  The  earliest  observers  of 
dengue  satisfy  themselves  with  noting  simply  the  color,  quantity,  and  reaction,  and  these 
are,  as  usual,  most  diversely  described.  Other  observers,  however,  are  much  more  satisfac- 
tory. Thus,  Morgan  noticed  a  specific  gravity  of  1004  to  1040,  acid,  non-albumbiojiH ; 
Chipperfit'ld,  acid,  specific  gravity  av.  1010,  non-albuminous.  Goodeve  detected  an  occa- 
sional trace  of  albumen  in  four  cases  in  the  Indian  epidemic  of  1853  ;  while  Charles  and 
Martialis  neve?-  detected  it  in  the  epidemic  of  1872.  In  China,  at  Amoy,  Muller  and  ]\Ian- 
son  failed  to  find  albumen.  Albuminuria  was  detected  only  once  by  Ballot  in  the  epidemic 
of  Martinique  in  1800,  and  twice  in  Cochin  China  by  French  observers  in  1873  (Mahe). 
Albumen  was  observed  but  e.xceptionally  by  Holliday  and  his  colaborers  {loc.  cit.)  in  Louisi- 
ana. Enough  has  been  said  to  prove  that.albuminous  urine  is  an  exceptional  occurrence  in 
dengue,  which  differentiates  it  markedly  in  this  respect  from  yellow  fever. 


:890  DENGUE. 

recognized  in  the  peculiar  eruption  or  series  of  eruptions  which  give  to 
■dengue  the  characteristics  of  an  exanthem.  This  eruption  is  polymor- 
phous in  character,  sometimes  erythematous  like  scarlatina,  and  at  other 
times  like  miliaria,  urticaria,  and  herpes.  This  terminal  rash  is  more 
frequent  in  dengue  than  the  initial  eruption.  It  indicates  the  lyds  of  the 
disease,  unless  there  be  one  or  more  relapses, — an  occurrence  which  is  far 
from  rare.  The  eruption  is  usually  accompanied  by  a  very  moderate  rise 
of  temperature ;  it  sometimes  appears  in  successive  crops ;  it  is  also  rare 
for  the  pains  to  return  in  this  period.  This  secondary  febinle  movement 
and  eruption  lasts  about  two  or  three  days,  and  then  the  fourth  phase  of 
the  disease,  or  desquamation  and  convalescence,  is  inaugurated. 

With  the  disappearance  of  the  terminal  eruption  there  is  a  general 
subsidence  in  all  the  acute  phenomena,  and  convalescence  may  be  fairly 
regarded  as  begun.  The  desquamation  of  the  skin  is  more  or  less  marked 
according  to  the  intensity  of  the  eruption.  This  process  is  frequently  asso- 
ciated with  intense  itching  :  usually,  however,  the  process  is  quickly  effected, 
and  convalescence,  properly  speaking,  started ;  at  other  times,  especially  in 
weak,  infirm,  strumous,  rachitic,  or  ill-fed  children,  and  in  aged  persons,  it  is 
very  slow  in  taking  place  and  convalescence  is  equally  retarded. 

The  preceding  synopsis  of  the  clinical  history  and  symptomatology  of 
dengue  will  cover  with  great  probability  the  majority  of  cases.  In  the  midst 
of  large  epidemics,  however,  there  are  all  gradations  of  dengue-infection, 
some  cases  being  so  exceedingly  mild  as  to  be  only  perceptible,  and  others 
so  violent  that  the  identity  of  the  disease  is  lost  and  the  liability  to  con- 
fusion with  others,  commonly  malignant  and  destructive  fevers,  enormously 
increased.  In  the  mild  forms  of  the  disease  the  patients  are  scarcely  ill,  and, 
where  it  is  not  easy  to  decide  as  to  their  exact  nature,  "  a  trifling  malaise, 
a  white  tongue,  bitter  taste  in  the  mouth,  headache,  prickly  sensation  in  the 
eyes,  very  slight  pain  in  the  limbs  without  fever,  may  only  lead  to  a  sus- 
picion of  the  real  nature  of  the  case,  until  a  symptom  (the  terminal  rash) 
appears  which  shows  you  what  you  have  had  to  deal  with ;  and  even  this 
last  symptom  may  be  missing."  Of  the  malignant  form  Charles  says, 
^'  Drowsiness  may  have  passed  into  coma ;  the  temperature  verges  on  the 
hyperpyretic  [one  case,  109|°  F.,  fotal,  quoted  by  Holliday,  of  New  Or- 
leans] ;  the  heart  fails,  and  the  lungs  are  oedematous,  while  the  whole  sur- 
face is  highly  cyanotic."  Tliese  cases  have  been  popularly  termed  '^^  black 
fever,"  and  are  very  justly  dreaded.     Happily,  such  cases  are  rare. 

Complications  and  Sequelae. — Numerous  complications  have  been 
mentioned  in  connection  with  this  disease,  but  it  is  doubtful  if  any,  outside 
of  those  related  to  the  extreme  prostration  of  the  nervous  system,  can  with 
any  propriety  be  regarded  as  proper  complications  of  dcnL;;ue.  Malaria  is 
one  of  the  poisons  that  is  most  likely  to  mark  the  course  of  the  disease  by 
giving  to  it  its  peculiar  seal. 

A  typhoid  condition  was  noticed  by  Poggio  in  the  epidemic  of  Teneriffe 
in  three  cases. 


DENGUE,  891 

In  the  pyretic  stage,  symptoms  of  cerebral  hypersemia,  culmiuating  iu 
convulsions,  coma,  and  even  meningitis,  have  been  noticed,  but  these  are 
usually  phenomena  which  result  from  hyperpyrexia.  The  eruption  is  likely, 
when  very  intense,  to  give  rise  to  inflammatory  oedema  of  the  face  simu- 
lating erysipelas,  especially  when  in  the  neighborhood  of  the  eyes,  nose,  or 
ears.  Coryza,  bronchitis,  gastric  and  intestinal  catarrh,  dysentery,  and 
catarrhal  jaundice  are  occasional  though  not  constant  complications  aifecting 
the  primee  viae.  Endocarditis,  pericarditis,  pleurisy,  and  arthritis  (Zuelzer, 
Mooden  Sheriff,  Dunckley,  Thomas)  have  been  cited  in  support  of  the  rheu- 
matic character  of  the  poison ;  but  these  complications  are  so  very  rare  as 
barely  to  deserve  notice,  and  are  utterly  unworthy  of  being  regarded  as  evi- 
dence in  favor  of  the  nature  of  a  causal  agent.  Glaucoma  (Thomas),  amauro- 
sis, dementia,  and  transitory  paralyses,  neurasthenia  and  neuralgias,  myalgias, 
and  other  evidences  of  the  profound  impression  of  the  poison  on  the  nerv^ous 
system,  are  more  deserving  of  attention.  Epistaxis  and  hsematemesis,  in 
younger  children  especially,  are  not  very  rare,  and  may  lead  to  serious  con- 
fusion in  discriminating  from  yellow  fever,  Ptyalism  (Martialis,  Morgan), 
orchitis  and  orchialgia  (Mellis,  Aitken,  Martialis),  cervical  glandular  en- 
largement, and  other  lymphadenopathies  have  been  noticed  (Christie,  epi- 
demic of  Zanzibar,  1871,  Martialis,  Fouque,  Catholendy).  The  kidneys 
are  rarely  implicated. 

Course,  Duration,  Complications. — Enough  has  been  said  in  the 
section  devoted  to  the  clinical  history  and  symptomatology  to  indicate  ap- 
proximately the  course  of  the  disease.  The  duration  of  dengue  is  exceed- 
ingly variable,  or  at  least  differently  estimated  whenever  writers  have 
attempted  to  calculate  it.  Thus,  we  find  it  four  to  six  days  (Ballot  in  Mar- 
tinique, Morice  in  Cochin  China)  ;  three  to  eight  days  (Thomas) ;  from  five 
to  six  days  (Catholendy  at  Reunion) ;  four  to  five  days  (Poggio  and  Vau- 
vray) ;  eight  days  (Fayrer)  ;  but  it  must  be  borne  in  mind  that  these  figures 
are  very  far  from  giving  a  true  idea  of  a  fever  which  can  be  completely 
evolved  within  extremes  of  two  or  three  days'  minimum  and  persist,  or 
leave  its  distinct  impress  on  the  patient,  for  weeks  and  even  months  (j\Iahe). 

The  convalescence  is  still  more  indefinite  in  its  duration.  Occasionally 
it  is  rapid  and  satisfactory,  in  robust  children  especially,  as  iu  the  epidemic 
of  Reunion  or  in  that  of  1860  in  Martinique  (Mahe).  At  Port  Said,  Vau- 
vray  tells  us,  the  patients  were  up  and  about  in  thirty-six  or  forty-eight 
hours  after  the  fever.  Per  contra,  in  other  epidemics — and  in  tliis  respect 
Ave  may  safely  say  tliat  the  majority  of  epidemics  of  dcugue  resemble  one 
another — tlie  convalescence  is  not  completely  eifected  in  weeks,  especially, 
as  already  stated,  among  the  weak  and  infirm. 

Among  the  sequeliB  or  relics  of  the  disease,  Manson  and  others  have 
noticed  crops  of  furuncles  and  abscesses  and  a  general  tendency  to  pus- 
formation  in  various  parts  of  the  body,  which  are  also  noticeable  in  other 
prostrating  fevers,  and  which  in  the  liglit  of  modern  bacteriological  research 
would  properly  be  classed  under  the  head  of  secondary  mixed  infections,  the 


892  DENGUE. 

various  staphylococci  and  streptococci  of  suppuration  giving  rise  to  the 
abscesses,  the  special  micro-organism  of  dengue  being  supposed  to  be  non- 
pyogenic. 

Relapses. — The  frequency  of  relapses  is  universally  admitted  as  being 
one  of  the  distinctive  features  of  the  clinical  career  of  dengue.  Poggio 
calls  attention  to  this  in  his  observations,  and  is  astonished  that  one  attack 
should  protect  so  little  from  another.  The  frequency  of  these  relapses  was 
estimated  at  fifteen  per  cent,  at  Reunion  in  1869  (Baret,  Mahe).  A  dis- 
tinction must  be  made  in  regard  to  the  term  ''  relapse"  in  connection  with 
dengue.  A  relapse,  properly  speaking,  is  the  repetition  of  an  attack  of  the 
disease  after  complete  recovery  therefrom,  and  must  not  be  mistaken  for  the 
exacerbations  which  follow  frequently  after  the  primitive  remission  and 
before  convalescence  is  completed  (Rochard).  Relapses,  even  in  this  sense, 
are  very  common  while  epidemics  are  in  progress  :  in  fact,  Thomas  con- 
siders that  once  having  had  the  disease  makes  a  person  more  liable  to  it 
than  before,  at  least  during  an  epidemic.  The  same  author  cites  instances 
of  patients  whom  he  treated  for  dengue  in  Savannah  in  1880  who  had  had 
the  disease  in  previous  epidemics. 

Prognosis. — Dengue  almost  invariably  ends  in  recovery.  In  four 
epidemics  out  of  eleven,  notwithstanding  the  thousands  of  victims,  not  one 
person  was  recorded  as  having  succumbed  to  the  disease  ;  in  the  other  seven, 
but  few  deaths  were  noticed, — at  ftirthest  a  total  of  five  in  the  severest 
epidemics.  In  Goree,  Senegal,  Thaly  lost  one  case  only  out  of  one  thou- 
sand patients ;  Mooden  Sheriff  states  that  in  Madras  dengue  was  sometimes 
fatal  in  adults  from  pericarditis  and  in  children  from  convulsions ;  out  of 
three  thousand  six  hundred  and  forty-seven  cases  in  India  collected  by  this 
observer,  twenty  died,  and  the  mortality  was  distributed  as  follows  :  adult 
males,  seven,  female,  one,  children,  twelve, — showing  the  greater  danger  to 
the  latter  class  of  sufferers.  This  experience  with  very  young  children  is  sup- 
ported by  the  observations  of  epidemics  in  TsTew  Orleans  and  in  the  South 
generally,  confirming  in  this  respect  the  general  law  that  the  extremes  of 
age  are  always  more  seriously  exposed  to  the  risks  of  disease.  The  proper 
prognostic  elements  which  belong  to  this  disease  have  not  been  yet  suffi- 
ciently defined.  Rey,  quoted  by  Mah6  and  Rochard,  states  that  the  more 
precocious  and  confluent  the  eruption  the  more  readily  are  the  symptoms 
subdued  and  the  career  of  the  disease  abbreviated.  If,  on  the  contrary,  the 
eruption  is  discrete,  disseminated,  rare  about  the  extremities  and  more 
abundant  in  the  face,  cheeks,  and  neck,  the  fever  will  be  accompanied  by 
greater  malaise,  anxiety,  and  cephalalgia. 

Differential  Diagnosis. — The  positive  or  absolute  diagnosis  of  dengue 
is  exceedingly  difficult  to  establish  in  the  beginning  of  an  epidemic,  just  as, 
on  the  other  hand,  it  impresses  itself  at  once  on  the  profession  and  the  laity, 
once  the  epidemic  has  been  recognized  and  admitted.  The  sporadic  cases 
which  occasionally  occur  in  places  where  dengue  may  be  considered  endemic 
offer  particular  difficulties  if  the  special  group  of  symjitoms  characterizing 


DENGUE.  893 

the  disease  are  not  well  pronounced.  Once,  however,  the  attention  of  the 
attendant  has  been  awakened,  it  is  difficult  to  confound  this  aifection 
with  any  other :  how  mistake  the  acute,  sudden  stiffening  "  break-bone"" 
neuralgic  pains  for  the  inflammatory  rheumatic  pain,  the  fever  so  rapidly 
lighted,  its  eruption  simple  and  double,  the  remission,  the  relapses,  the  non- 
albuminous  urine,  and  finally  the  rapid  spread  and  lack  of  fatality  which 
always  characterize  it?  Still,  the  differential  diagnosis  is  difficult  and 
at  times  impossible,  especially  when  dealing,  as  already  stated,  first,  with 
single,  very  mild,  atypical  cases ;  secondly,  with  very  malignant  and  rare 
hemorrhagic  cases  in  children ;  thirdly,  when  other  allied  infections,  like 
yellow  fever  and  malarial  fever,  are  prevailing  extensively  and  simulta- 
neously with  dengue.  The  differentiation  between  dengue  and  the  two  last- 
mentioned  diseases  is  a  matter  of  very  great  importance  to  Southern  practi- 
tioners and  all  those  who,  living  within  the  areas  which  are  exposed  to  the 
visitations  of  the  three  poisons,  especially  at  the  commencement  of  epidemics, 
are  made  to  appreciate  the  disastrous  consequences  of  an  error  in  diagnosis. 

Differentiation  between  Yellow  Fever  and  Dengue, — It  must  be 
admitted  that  dengue  is  a  most  frequent  companion  of  yellow  fever  in  its 
epidemic  eruptions.  There  is  great  truth  in  the  language  of  Porcher  when 
he  says,^  "It  is  a  significant  fact  that  we  have  never  been  able  to  distinguish 
accurately  between  the  two,  to  say  of  every  case  and  at  every  stage  of  these 
two  diseases,  '  This  is  yellow  fever,  this  only  break-bone  ;'  yet  the  extreme, 
well-marked  examples  of  undeniable  yellow  fever  were  as  different  in  every 
material  respect  from  the  lighter  form  of  break-bone  coexisting  with  it, 
as  black  is  from  white.  .  .  .  The  one  is  a  disease  characterized  at  its  in- 
ception always  by  high  temperature,  by  the  supervention  of  albuminuria, 
hemorrhages,  black  vomit,  convulsions,  bronzing  of  the  skin,  fatty  degener- 
ation of  the  liver,  and  often  by  death ;  the  other  light,  fugitive,  often 
almost  ephemeral,  only  producing  weakness  and  prostration,  and  never 
fatal.  And  yet  they  often  shaded  insensibly  into  each  other  and  no  distinct 
lines  of  demarcation  could  be  drawn  by  any  one.  No  one  could  give  us  a 
single  diagnostic  point.  It  was  a  mere  question  of  plus  and  minus,  the  de- 
cision never  being  positive  or  based  upon  established  scientific  reasons.  .  .  . 
The  milder  cases  were  called  break-bone,  and  the  severe  yellow  fever ;  yet 
we  were  in  constant  dread  lest  a  case  thought  to  be  break-bone  should  prove 
to  be  yellow  fever  by  an  aggravation  of  its  symptoms.  Those  who  Avere 
what  may  be  called  very  sick,  who  had  high  fever  or  some  violent  symp- 
toms of  some  days'  duration,  who  got  well  '  by  the  skin  of  their  teeth,'  or 
who  died,  enjoyed  the  uncertain,  and,  with  regard  to  the  latter,  posthumous, 
credit  of  having  had  the  real  disease." 

It  cannot  be  said  that  Dr.  Porcher  has  greatly  exaggerated  the  situation 
in  presenting  the  case  as  he  has  done,  for  when  it  comes  to  an  absolute,  posi- 

1  "  On-  Dengue  in  South  Carolina  in  1880,"  Trans.  A.mer.  Public  Health  Assoc, 
art.  xxxviii. 


894  DENGUE. 

tive,  and  unfailing  test  we  have  none.  For  this  reason  we  have  insisted  so 
much  upon  the  examination  of  the  blood  in  all  suspicious  cases,  in  order 
that  McLaughlin's  promising  microscopic  test  may  be  confirmed  and  made 
available. 

Pending  the  confirmation  of  these  observations,  we  must  depend  upon 
the  clinical  manifestations,  which,  when  brought  in  contact  with  those  of 
yellow  fever,  as  has  been  so  ably  done  by  Holliday,  will  no  doubt  prove 
of  great  assistance. 

Yellow  Fever.  Dengue. 

Single  paroxysms.  Single  paroxysms  quite  often.     Two  parox- 

ysms with  a  remission  between  them. 
Temperature  rising  regularly.  Temperature  rising  irregularly. 

Duration,  seventy-two  hours.  Duration,  three  to  five  days. 

Tongue,  white  centre,   red  edges,  pointed ;      Tongue   broad,  white,  deeply  indented  by 

conjunctivae  very  much  congested.  teeth,  edges  rarely  very  red. 

Stomach  irritable.  Nausea  complained  of. 

Vomiting  frequent.  .  Vomiting  rare. 

Violent  pains  in  back  and  head  ;  great  jacti-      Pains  occurring  early,  much  more  severe  ;  a 

tation  ;  hebetude  great ;  eruption  rare.  general  early  appearance  of  eruption. 

Jaundice    appearing    early ;    symptoms   of      Conjunctivae    rarely   very   red ;    praecordial 
nervous  exhaustion  evident  and  alarming.  tenderness  on  pressure  rarely  well  marked ; 

nervous  exhaustion  profound,  though  rarely- 
alarming  ;  jaundice  never  observed. 
Secretions  all  suffering;  urine  scanty,  often      Secretions   natural;    urine   usually  normal, 
albuminous  ;  suppression  frequent.  sometimes  and  exceptionally  tv&CQ&oi  aVow- 

men. 
Hemorrhages   frequent   and   alarming,  and      Hemorrhage  slight,  insignificant;   if   at  all 

black  vomit  an  urgent  symptom.  present,  black  vomit  very  rare. 

Recovery  exceptional.  Recovery  the  rule. 

This  comparison  (slightly  modified)  was  based  not  only  upon  a  large 
personal  experience,  but  also  upon  a  careful  analytical  study  of  the  opinions 
of  over  sixty  physicians  who  had  a  long  experience  with  both  diseases  in 
New  Orleans  and  other  parts  of  Louisiana. 

Malaria  and  Dengue. — Dengue  has  been  frequently  mistaken  for 
malarial  remittent  fever,  especially  in  the  earlier,  more  perplexing  periods 
of  dengue  epidemics,  before  the  type  of  the  disease  is  fully  recognized.  Still, 
though  there  may  with  more  or  less  frequency  be  remissions,  relapses,  and 
perhaps  intermissions  and  occasional  so-called  critical  (profuse)  sweatings 
(not  preceded  by  violent  or  regular  chills),  the  pains,  the  absence  of  regu- 
larity in  the  accesses  and  of  paroxysms,  the  absence  of  gastric,  hepatic,  and 
splenic  complications,  of  glandular  enlargements,  of  the  malarial  cachexia, 
sufficiently  mark  the  distinction  between  break-bone  fever  and  the  malarial 
infections  (Porcher).  Finally,  two  other  tests  in  cases  of  great  doubt  offer 
themselves  to  the  physician  :  first,  the  examination  of  the  blood,  which  can 
be  readily  applied  at  the  bedside,  and  which,  by  revealing  the  presence  or 
absence  of  the  plasmodium  malarise  of  Marchiafava  and  Celli  (distinctly 
confirmed  and  admitted  by  Sternberg,  Osier,  Councilman,  and  others),  will 


DENGUE.  895 

decide  whether  the  case  is  malarial  or  not ;  and,  second,  the  therapeutic  or 
quinine  test :  quinine  has  no  influence  whatever  upon  the  career  of  pure 
dengue, — unless  this  be  complicated  with  malaria,  when  quinine  will  clear 
the  case  of  the  malarial  infection, — while  it  will  certainly  modify  the  clini- 
cal career  of  a  pure  malarial  case. 

Again,  the  arthralgia  and  myalgic  pains  of  dengue  have  led  to  confusion 
of  this  disease  with  rheumatism,  and  even  with  gout  (Morice),  especially 
when  there  is  some  swelling  and  redness  over  the  joints,  as  in  the  cases 
observed  by  Martialis,  Sheriff,  and  various  other  observers.  In  our  ex- 
perience true  evidences  of  arthritis,  such  as  redness  and  swelling,  are  excep- 
tional rather  than  usual  phenomena  in  this  disease.  The  eruption  of  dengue 
and  the  whole  complexus  of  symptoms  usually  allow  of  a  ready  diiferen- 
tiation  between  the  two  diseases. 

Finally,  the  eruption  with  fever  has  not  infrequently  caused  dengue  to 
be  mistaken  for  scarlet  fever,  measles,  or  the  early  stage  of  small-pox ;  but 
the  pains,  the  peculiarities  of  the  dengue  fever-chart,  and  the  absence  of 
sequelse,  as  well  as  the  subsequent  career  of  the  cases,  will  promptly  dispel 
any  doubts  that  may  exist  as  to  diagnosis. 

The  eruption  of  dengue  has  also  led  to  confusion  in  the  first  days  of  the 
disease  with  simple  erythema,  febrile  urticaria,  erythema  nodosum,  and 
erysipelas ;  but  it  will  usually  suffice  for  the  practitioner  simply  to  bear  in 
mind  the  characteristics  of  dengue  and  of  these  diseases  to  avoid  any  possi- 
bility of  confusion. 

Pathological  Anatomy  and  Patholog-y.- — It  is  self-evident  that  a 
disease  so  rarely  fatal  as  dengue  nmst  of  necessity  possess  a  very  scant  store 
of  anatomical  data.  Only  three  necropsies  of  pure  cases  (?)  of  dengue  have 
been  recorded  (A.  Hirsch),  and  in  these  the  observations  made  were  limited 
almost  exclusively  to  the  morbid  appearances  of  the  knee-joints,  which 
were  found  hypersemic.  These  observations  are  hardly  worth  mentioning. 
The  few  deaths  that  occur  from  this  disease  are  usually  traceable  to  com- 
plications, hyperpyrexia,  and  exhaustion.  The  pathological  anatomy  of 
dengue  is,  in  reality,  yet  to  be  written. 

The  pathology  of  the  disease  is  entirely  speculative.  Nothing  definite 
is  known,  and  what  has  been  said  in  connection  with  the  clinical  history 
and  in  the  way  of  interpreting  the  insignificance  of  the  clinical  phenomena 
is  all  that  could  be  added  here.  That  there  is  an  infection  that  is  admitted 
in  the  blood  cannot  be  doubted  ;  how  or  by  what  route  it  gains  entrance 
into  the  economy  is  yet  unknown.  It  is  presumable  that  the  poison  afler 
admission  to  the  circulation  acts  primarily  upon  the  nervous  system,  as  the 
intense  cephalalgia  and  neurotic  manifestations  would  lead  us  to  suppose. 
That  the  poison  acts  on  the  joints  and  muscles  like  that  of  rheumatism  we 
doubt,  because  of  the  simple  neuralgic  and  usually  non-inflammatory  char- 
acter of  the  articular  affection.  The  exceptions  to  this  are  too  few  to  allow 
us  to  admit  the  analogy  with  the  rheumatic  poison.  Still,  the  stiflPness  of 
the  muscles  remains,  and  this  favors  the  rheumatic  theory.     The  eruption. 


896  DENGUE. 

with  the  inflammation  and  swelling  of  the  lymphatic  glands  we  are  inclined 
to  associate,  with  Schmidt/  with  the  final  elimination  of  the  infectious 
poison  from  the  organism. 

Treatment. — A  self-limited  disease,  almost  always  ending  in  recovery, 
must  needs  rarely  call  for  active  therapeutic  interference. 

Though  our  acquaintance  with  dengue  is  comparatively  recent,  yet  its 
treatment,  like  that  of  other  great  epidemic  diseases,  has  gone  through 
various  phases  of  doctrinal  therapeutics,  all  of  which  have  left  their  imprint 
behind  them.  In  the  great  Indian  epidemic  of  1824-26  (Twining,  INIouat, 
Cawel,  and  others),  and  in  the  Cadiz  epidemic  of  1784  (C.  Cubillas),  the 
antiphlogistic  method  was  given  an  ample  opportunity  to  test  its  claims 
(large  venous  depletion,  active  and  profuse  emeto-catharsis).  It  is  stated, 
however,  that  even  at  this  early  period  British  practitioners  reserved  the 
sanguineous  depletions  for  special  and  well-marked  indications. 

One  century  afterwards,  in  the  TenerifFe  and  Cadiz  epidemics  of  1867 
and  1868,  Poggio  denounced  venesection  as  pernicious  in  the  treatment  of 
dengue.     He  adopted  the  expectant  method,  much  as  it  is  practised  to-day. 

In  the  Indian  epidemic  of  1872  the  British  practice  consisted  largely 
in  the  administration  of  diaphoretics  (acetate  of  ammonia),  tincture  of  bella- 
donna for  the  pains,  iced  drinks,  cold  sponging  of  the  body,  especially  in 
hyperthermic  cases,  and  stimulants.  Quinine,  in  large  doses,  had  gradually 
become  fashionable,  and  a  host  of  other  more  recent  remedies  were  added  to 
meet  the  symptoms. 

It  is  a  notable  fact  that,  notwithstanding  the  frequent  and  almost  radical 
changes  in  the  methods  of  treatment,  the  mortality  of  dengue  has  remained 
unaffected ;  it  has  always  been  the  same, — practically  nil.  In  this  respect 
it  has  been  most  benignly  different  from  yellow  fever,  which  has  proved 
its  contempt  of  therapeutics  by  its  persistent  malignity  in  spite  of  the 
"systems"  and  "doctrines"  that  have  been  brought  to  bear  against  it. 

Notwithstanding  our  evident  inability  to  jugulate  or  even  seriously 
check  the  progress  of  the  disease,  there  is  unquestionably  much  that  the 
physician  can  do  to  mitigate  the  sufferings  of  the  patient  and  to  comfort 
him  generally  in  his  transit  through  this  most  cruel  ordeal.  In  fact,  a 
careful  observer  like  Mouat  noticed  in  his  earlier  practice  in  India  (1827) 
that  the  disease  did  appear  to  last  longer  and  to  present  more  serious  features 
when  left  to  follow  its  course  undisturbed. 

In  the  majority  of  tropical  diseases  an  evacuant  medication  at  the  onset 
seems  generally  to  be  followed  by  good  results,  and  experience  has  attested 
the  fact  that  dengue  is  no  exception  to  this  general  rule,,  all  observers  appear- 
ing to  agree  on  this  point.  For  this  reason,  it  will  be  proper  to  begin  the 
treatment  of  the  first  stage  by  administering  an  emetic  of  ipecac  syrup,  fol- 
lowed after  the  emesis  by  a  laxative.  In  infants  at  the  breast,  aromatic  syrup 
of  rhubarb  is  a  very  generally  administered  and  popular  laxative ;  several 

1  Article  "  Dengue,"  Pepper's  System  of  Medicine,  vol.  i. 


DENGUE.  897 

large  spoonfuls  of  prune  tea  sweetened  with  syrup  of  manna  will  also  act 
efficiently  in  the  same  direction,  and  may  be  given  to  advantage  to  older 
children  where  the  tea  is  combined  with  a  few  leaves  of  senna.  Calomel 
has  always  been,  of  course,  a  most  popular  laxative  with  English-speaking 
practitioners,  but  it  is  very  doubtful  if  it  has  any  special  advantages ;  if 
used  at  all,  the  more  elegant  and  efficient  modern  triturates  with  sodium  bicar- 
bonate should  be  prescribed.  Husband's  and  Henry's  magnesia,  cream  of 
tartar  in  lemonade  flavored  with  some  pleasant  and  tart  syrup  (raspberry, 
strawberry,  currant,  etc.),  will  be  found  palatable,  if  iced,  even  by  the  most 
fastidious  and  difficult  children.  Iced  citrate-of-magnesia  lemonade  is  usu- 
ally well  taken  by  older  children.  After  the  laxative,  a  hot  mustard  foot- 
bath will  prove  most  grateful  to  the  patient,  as  it  tends  markedly  to  relieve 
the  intense  cephalalgia  of  the  invasion.  In  infants  and  little  children,  the 
convulsive  phenomena  which  occasionally  characterize  the  invasion  will 
tend  to  be  shortened  by  a  general  mustard  warm  bath  prepared  according 
to  Trousseau's  recommendations,  by  simply  immersing  a  small  bagful  of 
mustard-meal  in.  a  tub  of  hot  water  and  pressing  the  bag  in  the  water  with- 
out mixing  the  meal  with  the  water.  Furthermore,  potassium  bromide  is 
especially  effective  in  diminishing  the  reflex  excitability  of  children,  and  will 
prove  more  than  usually  effective  in  this  condition.  In  cases  of  marked 
cerebral  hypersemia,  and  in  adults  or  adolescents  especially,  one  or  two  leeches 
to  the  mastoid  process  or  a  few  small  wet  cups  to  the  nape  of  the  neck  will 
greatly  lighten  and  relieve  the  head-symptoms.  Good  judgment  is  neces- 
sary in  the  exhibition  of  this  depletory  treatment,  which  should  always  be 
reserved  for  sthenic  and  plethoric  children  and  adults,  who  usually  constitute 
the  small  minority  of  the  population  of  warm  climates.  Cold  applications 
to  the  head,  iced  in  summer,  with  camphorated  sedative  water,  bay  rum, 
cologne,  or  any  other  pleasant  evaporating  preparation,  will  always  be  grate- 
ful, if  not  indispensable,  to  the  patient.  This  wetting  of  the  head  should 
always  be  done  in  a  thorough  and  efficient  manner,  parents  and  friends,  in 
tropical  countries  particularly,  being  afraid,  for  some  mysterious  reason,  of 
cold  water  in  fever.  For  this  reason,  this  method  of  cooling  the  head 
should  be  demonstrated  to  them  by  the  physician  himself:  the  little  patient 
should  be  laid  across  the  bed  with  the  head  projecting  beyond  the  edge, 
allowing  it  to  rest  in  a  basin  or  bowl  of  water  mixed  with  the  evaporating 
lotion,  ice  being  also  added  if  the  initial  cephalalgia  is  intense ;  the  head 
should  be  then  gently  but  freely  douched  with  the  water  ;  a  little  shampooing 
of  the  head  aided  by  fanning  will  complete  the  process,  and  the  patient  will 
be  made  thereby  infinitely  more  comfortable,  no  matter  what  his  age.  By 
this  means  alone  the  convulsive  manifestations  and  agitation  of  many  chil- 
dren will  be  lulled  and  averted. 

After  these  preliminaries,  which  are  especially  indicated  in  the  earlier 
period  of  the  invasion, — though  the  cooling  of  the  head  as  above  described 
will  always  be  in  order  during  the  ]">yretic  period, — the  practitioner  must 

prepare  to  combat  more  permanently  the  tendency  to  continued  elevation  of 
Vol.  I.— 57 


898  DEXGUE. 

temperature  and  hyperthermiaj  as  also  the  myalgic  and  especially  arthritic 
pains  which  characterize  the  further  course  of  the  disease.  In  the  first 
highly  painful  stage  of  the  disease,  I  am  satisfied  that  the  remedies  usually 
trusted  in  the  more  common  pyrexiae  of  children  are  not  to  be  relied  upon  : 
aconite,  ^Yith  liquor  ammonii  acetatis  and  mistura  potassii  citratis,  quinine, 
etc.,  all  of  which  have  been  faithfully  tried  in  this  aifection,  are  mere  placebos, 
and  amount  to  nothing  in  the  way  of  securing  positive  relief  to  the  sufferer. 
Here  the  improved  antipyretic  therapeutics  of  the  present  day  finds  an 
admirable  field  of  application.  Thomas  {loc.  cit.)  says  that  in  cases  exhibit- 
ing the  rheumatic  type,  particularly  when  the  temperature  runs  high,  sodium 
salicylate  will  be  found  to  be  veiy  efiicient,  safe,  and  pleasant.  This  expe- 
rience I  can,  with  the  majority  of  observers,  personally  confirm.  But  it 
cannot  be  doubted  that  even  in  this  type  of  the  disease  sodium  salicylate  is 
inferior  in  both  its  antithermic  and  its  analgesic  properties  to  several  of 
the  synthetically  prepared  alkaloids  of  the  aromatic  series  of  the  carbon 
compounds,  of  which  kairin,  thallin,  antipyrin,  and  antifebrin  are  most 
prominent  members.  Of  these  there  is  no  question,  at  present,  as  to  the 
superiority,  reliability,  and  safety  of  antipyrin  and  antifebrin,  the  former 
of  which  has  been  tried  by  De  Bruu  in  the  epidemic  of  dengue  at  Bey- 
rout,  Syria,  already  referred  to.  Observations  on  the  action  of  these  anti- 
thermics  in  dengue  are  still  insufficient  and  lacking  to  complete  our  thorough 
understanding  of  their  comj^arative  merits  in  this  disease.  But  it  appears 
to  the  writer  that  no  matter  which  one  of  these  two  agents  is  employed,  it 
will  be  found  reliable  and  superior  to  the  older  febrifuges.  Antip^Tin  and 
antifebrin  act  well  with  children,  can  be  made  palatable,  especially  the 
latter,  and,  Avhen  properly  exhibited,  seldom  give  rise  to  objectionable  after- 
effects. Argutiusky  recommends  the  folloAving  minimal  doses  of  antipyrin  : 
for  children  under  one  year  of  age  three  grains  thrice  daily,  at  intervals  of 
three  hours ;  for  those  of  from  one  to  three  years,  five  grains  ;  for  children 
between  this  age  and  five  years,  from  five  to  six  grains  three  times,  at  inter- 
vals of  two  hours ;  for  children  of  from  six  to  eight  years,  from  eight  to 
ten  grains  daily,  at  intervals  of  two  hours ;  and  for  children  of  from  ten 
to  twelve  years,  from  ten  to  twenty  grains  thrice  daily,  at  intervals  of  one 
hour.  The  dose  of  thallin  is  about  one-fourth  of  that  of  antipyrin,  but  it 
is  a  dangerous  remedy  and  is  rapidly  being  forgotten.  Antifebrin  affords 
advantages  in  the  opinion  of  most  observers  (Beaumetz,  Huchard,  See,  etc.) 
over  any  of  these  agents.  The  dose  is  one-half  that  of  antipyrin,  though 
its  full  action  is  produced  more  slowly.  The  writer  prefers  to  use  a  weak 
emulsion  of  antifebrin  in  syrup  of  acacia  (gr.  i-5i)  when  dealing  with 
small  children,  and  administering  the  remedy  at  frequent  intervals  .(half 
an  hour),  carefully  watching  the  effect  with  the  thermometer  :  this  is  cer- 
tainly the  safest  and  most  effective  plan  when  dealing  with  children  of  un- 
known idiosyncrasies.  It  should  be  remembered  that  these  agents  are  also 
active  when  administered  by  enema. 

Notwithstanding  the  worthlessness  of  quinine  in  combating  the  pure 


DEN'GUE,  899 

dengue  poison  it  will  be  prudent  to  administer  it  as  a  rule  in  malarious 
localities,  where  the  marsh-poison  is  constantly  seeking  opportunities  to 
manifest  itself.  If  antifebrin  and  antipyrin  fail  in  their  analgesic  effect, 
chloral  will  be  found  to  be  a  valuable  agent  to  soothe  the  pain  and  to  pro- 
cure rest.  Brun  has  obtained  better  results  with  it  than  with  opium  or 
morphine  :  still,  in  some  cases  the  latter  preparations  M'ill  have  to  be  appealed 
to,  especially  in  grown  children,  to  relieve  the  pain,  as  under  other  circum- 
stances opium  and  its  preparations  should  be  administered  cautiously  to 
children.  In  grown  children  or  in  adults  some  benefit  may  be  obtained 
in  relieving  the  insomnia  and  agitation  by  administering  at  night  the  new 
hypnotics  sulphonal  (adult  dose,  gr.  x-xxx)  or  paraldehyde  (adult  dose, 
5ss-3i). 

Liniments  are  prescribed  often,  but  they  do  not  appear  to  add  to  the 
comfort  of  the  patient,  or,  if  of  benefit,  are  so  only  by  impressing  the  mind  : 
camphorated  soap  liniment,  chloroform  liniment,  aconite,  etc.,  will  be  found 
sufficient.  Digitalis  is  expressly  indicated  in  very  depressed  conditions  and 
in  those  in  which  the  heart  appears  to  suffer.  In  very  tedious  cases  the 
proper  nutrition  of  the  patient  is  a  matter  of  great  importance,  especially  in 
children  and  old  subjects. 

The  eruptions  call  for  little  interference  :  when  pruritus  becomes  exces- 
sive during  the  period  of  desquamation,  German  green  soap,  corrosive 
sublimate  soap  (Bergmann's  formula),  carbolic  acid  solution,  one  or  two  per 
cent.,  or  a  salve  of  vaseline  and  hydronaphthol,  may  be  tried  with  expecta- 
tion of  relief.  Aitken  advised  the  application  of  an  emulsion  of  sweet 
almonds  containing  ammonium  hydrochlorate.  A  salve  containing  cocaine 
hydrochlorate,  three  or  four  per  cent.,  will  be  found  available,  if  recently- 
reuorted  experience  with  it  in  this  field  is  to  be  trusted. 

Convalescence  requires  the  greatest  care.  A  reconstructive  and  analeptic 
treatment,  and  generous  diet,  are  here  called  for.  The  preparations  of  iron 
and  cinchona  are  here  as  well  indicated  as  in  most  of  the  prostrating  dis- 
eases of  tropical  climates.  The  persistent  anorexia  is  a  feature  peculiar  to 
the  convalescence  of  dengue,  and  it  may  prove  very  difficult  to  overcome  it. 
Tincture  of  gentian,  bitter  infusions,  or  small  fragments  of  rhubarb-root, 
immediately  before  meals,  appear  to  give  the  best  results  (Rochard).  H. 
Rey  has  found  arsenic  especially  valuable.  Nax  vomica,  in  the  form  of 
tincture,  in  progressively  increasing  doses,  according  to  the  plan  recom- 
mended by  Musser,  of  Philadelphia,  would  find  here  an  excellent  field  of 
application.  Cod-liver  oil  in  strumous  children,  and  massage  in  all  ages, 
will  prove  especially  useful.  Finally,  we  would  advise,  with  H.  Key  and 
Rochard,  Fayrer,  and  other  experienced  tropical  practitioners,  the  use  of 
cold  baths  or  douches  as  among  the  best  means  to  return  to  the  economy  its 
wonted  energy.  If  all  means  fail  to  return  health  to  a  prostrated  dengue 
patient,  the  last  resort  of  tropical  therapeutics  must  be  appealed  to, — i.e.,  a 
change  of  air,  sea-voyage,  and  change  of  residence  to  a  more  temperate  or 
cold  climate. 


CHOLERA  INFECTIOSA. 

By  E.  O.  SHAKESPBAEE,  M.D. 


Definition. — Cholera  Infectiosa  or  Asiatica  is  an  infectious  disease  of  a 
specific  character,  due  to  a  specific  agent  which  primarily  attacks  the  intes- 
tinal canal.  This  agent  is  transportable  from  place  to  place,  and  is  endowed 
with  the  power  of  rapid  multiplication,  both  within  and  without  the  human 
organism,  under  favorable  circumstances. 

This  agent  is  in  all  probability  a  vegetable  parasite, — namely,  the 
comma  bacillus  of  Koch.  In  the  process  of  development  and  growth  of 
this  parasite,  both  within  and  without  the  human  body,  a  specific  poison  or 
ptomaine — a  chemical  alkaloid  possessing  specific  chemical  and  physical 
properties — is  produced  ;  the  primary  action  in  the  human  system  is  upon 
the  mucous  membrane  of  the  intestinal  canal,  chiefly  the  small  intestine, 
and  the  ultimate  result  is  the  desquamation  and  destruction  of  the  epithelial 
elements. 

This  poison  elaborated  in  the  intestines  is  absorbed,  produces  an  inflam- 
matory irritation  of  the  tissues  immediately  underlying  the  epithelia,  and 
finally  enters  the  blood-circulation.  In  the  blood  it  attacks  the  red  cor- 
puscles, causing  destruction  of  some  and  alteration  of  the  function  of  many, 
and  it  causes  great  disturbances  of  the  nervous  system,  the  gravity  of  its 
efiects  falling  principally  upon  the  vaso-motor  and  respiratory  centres. 

The  infecting  agent  exists  in  the  intestinal  contents  of  those  suffering 
from  the  disease,  and  is  discharged  with  the  alvine  evacuations,  and  some- 
times also  with  the  ejections  from  the  stomach.  Both  dejecta  and  ejecta, 
hence,  contain  the  infectious  principle,  and  under  favorable  circumstances 
are  capable  of  conveying  the  disease,  either  directly  or  indirectly,  from  the 
sick  to  the  healthy.  Cholera  Asiatica  is,  therefore,  an  infectious  disease,  and 
is  capable  of  being  conveyed  from  person  to  person  and  from  place  to  place, 
and  under  favorable  circumstances  of  becoming  ejndemic.  It  should,  con- 
sequently, be  properly  named  cholera  infectiosa. 

Means  and  Manner  of  Infection. — Since  the  infectious  agent  exists 
in  the  evacuations  both  from  the  stomach  and  from  the  anus,  various  mate- 
rials become  capable  of  conveying  the  infection  of  this  disease :  such  as 
clothing  soiled  with  this  matter ;  hands  fouled  with  it ;  articles  of  food  and 
drink  which  have  been  contaminated  with  it.  It  is  by  means  of  soiled 
900 


CHOLERA    INFECTIOSA.  901 

clothing  and  personal  effects  upon  which  this  agent  is  preserved  in  a  more 
or  less  moist  condition  that  the  infectious  principle  is  conveyed  long  dis- 
tances both  by  land  and  by  sea.  The  contamination  of  watercourses  and 
small  streams  by  vomit  or  dejecta  is  perhaps  the  most  frequent  and  cer- 
tainly the  most  rapid  means  of  producing  a  sudden  and  widely-extended 
outbreak  of  cholera  infectiosa.  The  watercourses  are  not  infrequently  also 
contaminated  by  washing  therein  the  personal  effects  of  cholera  patients. 

Eeo-ardino;  the  comma  bacillus  of  Koch  as  the  infectious  agent,  it  has 
been  established  by  numerous  and  exact  experiments  that  this  microbe  is 
not  only  able  to  live  for  a  considerable  length  of  time  in  Avater,  but  is  even 
capable  of  enormous  multiplication  therein,  especially  if  the  water  contain 
a  certain  amount  of  organic  or  vegetable  material.  The  use  of  such  con- 
taminated water  for  drinking,  bathing,  and  culinary  purposes  is  perhaps  the 
most  frequent  mode  of  introduction  into  the  human  organism  of  the  conta- 
gious principle  of  cholera  infectiosa. 

The  universal  practice  of  the  watering  of  milk  also  renders  this  article 
exceedingly  and  especially  dangerous  to  children  during  periods  of  the  prev- 
alence of  cholera ;  and,  where  extensive  and  sudden  local  outbreaks  of  the 
disease  cannot  be  attributed  directly  to  the  use  of  contaminated  water,  it  is 
generally  the  milk  which  conveys  the  cause  of  infection.  Other  articles  of 
food  are  in  a  far  less  degree  liable  to  contamination,  but  there  are  numerous 
examples  of  infection  occasioned  by  thoughtless  or  accidental  contamination 
of  vegetables,  fruits,  and  other  nutritive  material.  Experience  has  abun- 
dantly proved  two  laws  which  have  an  important  bearing  upon  the  spread 
of  cholera.  The  tendency  to  infection  varies  exceedingly  among  individuals, 
and  is  with  the  vast  majority  exceedingly  small.  Disturbed  conditions  of 
the  digestive  apparatus  greatly  increase  the  susceptibility  of  an  individual 
and  render  him  far  more  liable  to  an  attack  after  exposure  to  the  infection. 
It  is  exceedingly  improbable  that  the  infectious  principle  is  ever  conveyed 
to  the  healthy  by  the  medium  of  the  air :  it  is  certainly  never  transported 
to  any  considerable  distance  in  this  manner.  It  is  very  doubtful,  if  even 
possible,  that  infection  may  take  place  through  the  lungs.  It  is  certain  that 
it  cannot  be  effected  by  cutaneous  absorption.  The  disease,  therefore,  cannot 
be  properly  termed  truly  contagious  in  the  common  use  of  that  Avord.  It 
is  extremely  doubtful  if  there  be  a  single  well- authenticated  case  upon  record 
where  the  disease  has  been  conveyed  in  any  other  manner  than  by  the  intro- 
duction of  the  infectious  principle  into  the  stomach. 

Still,  regarding  the  comma  bacillus  of  Kocli  as  the  infecting  agent,  it 
has  been  abundautly  proved  that  the  normal  acid  juices  of  the  stomach 
are  capable  of  destroying  it.  It  is,  therefore,  not  surprising  tliat  the  cx- 
ampk'S  are  multiplied  wlierc  water  and  other  iugesta  known  to  be  infected 
have  been  swallowed,  intentionally  or  accidentally,  by  healthy  persons, 
without  harm.  If,  however,  this  living  infectious  principle,  the  comma 
bacilli  of  Koch,  escape  beyond  the  pylorus  and  pass  into  the  small  intestine, 
the  contents  of  which  liavc  an  alkaline  reaction,  multiplication  with  enor- 


902  CHOLERA   INFECTIOSA. 

mous  rapidity  therein,  elaboration  in  considerable  quantity  of  the  poisonous 
ptomaine,  and  the  establishment  of  the  disease  which  we  recognize  as  cholera 
infectiosa,  become  possible. 

Prophylaxis. — The  considerations  already  advanced  suggest  more  or 
less  reliable  prophylactic  measures.  If  the  stomach  be  properly  guarded 
against  the  introduction  of  the  living  infecting  principle,  the  individual 
will  be  necessarily  protected  against  the  danger  of  an  attack.  Protective 
measures  may  be  considered  from  two  stand-points :  first,  with  regard  to 
the  person  suffering  from  an  attack  of  the  disease ;  second,  with  regard  to 
the  healthy  individual  exposed  to  infection. 

A.  With  regard  to  the  person  suffering  from  an  attack  of  the  disease : 
The  evacuations  from  the  stomach  and  the  bowels  should  be  immediately 
disinfected ;  where  this  is  thoroughly  accomplished,  it  is  impossible  for  the 
infection  to  spread  beyond  the  attacked.  The  dejecta  and  the  vomited 
matter  should  be  passed  into  a  vessel  containing  a  quart  or  more  of  a 
strong  solution  of  carbolic  acid,  one  part  to  twenty  of  water ;  and  immedi- 
ately after  the  evacuation  a  sufficient  amount  of  the  disinfectant  should  be 
added  to  make  the  whole  quantity  equal  to  the  bulk  of  the  evacuated  mate- 
rial ;  the  whole  should  then  be  gently  stirred,  and  afterwards  allowed  to 
stand  for  fifteen  to  twenty  minutes,  when  it  should  be  removed  and  emptied 
into  a  pit  containing  unslacked  lime,  and  be  immediately  covered  by  a 
quantity  of  the  same  material.  If  circumstances  render  it  impossible  thus 
to  dispose  of  the  disinfected  evacuations,  they  should  be  emptied  into  a 
large  earthen  vessel  containing  a  quantity  equal  to  their  bulk  of  a  solution 
of  bichloride  of  mercury,  one  part  to  a  thousand,  and  stirred  thoroughly 
therein  ;  after  remaining  there  for  an  hour  or  more,  they  may  be  emptied 
into  a  drain  which  leads  to  the  sewer.  The  clothing  of  the  patient,  as  well 
as  the  soiled  bed-linen,  immediately  after  removal  should  be  disinfected  by 
thoroughly  soaking  for  an  hour  or  more  in  a  large  quantity,  more  than 
sufficient  to  cover  them,  of  a  strong  solution  of  carbolic  acid,  one  part  to 
twenty ;  or  they  should  be  immediately  subjected  to  the  prolonged  action 
of  boiling  water  or  steam.  The  anus,  hands,  and  mouth  of  the  patient 
should  also,  immediately  after  an  evacuation,  be  washed  with  a  disinfectant, 
— in  this  case,  however,  weaker  than  above  indicated,  say  one  part  to  ten 
thousand  of  bichloride  of  mercury  and  water,  for  the  anus  and  hands,  and 
for  the  mouth  water  slightly  acidulated  with  sulphuric  acid.  The  hands  of 
the  attendants,  also,  should  be  washed  with  the  same  weak  solution  of  bi- 
chloride of  mercury  after  handling  the  patient.  Under  no  circumstances 
should  the  attendant,  or  any  one  else,  eat  in  the  same  room  with  the  sick  ; 
and,  as  an  invariable  rule  which  should  be  scrupulously  observed,  no  person 
who  has  been  in  direct  contact  with  the  sick  or  with  any  of  his  personal 
effects  should  eat  without  first  thoroughly  cleansing  and  disinfecting  the 
hands. 

B.  AVith  regard  to  the  healthy  person  exposed  to  the  infectious  principle 
of  the  disease :  Remembering  what  has  already  been  remarked  concerning 


CHOLERA    IXFECTIOSA.  903 

an  increased  snseeptibility  to  infection  by  reason  of  disturbance  of  the 
digestive  apparatus,  it  is  strenuously  insisted  upon  that  all  causes,  of  what- 
ever nature,  of  disturbance  of  the  functions  of  the  stomach  and  intestines, 
should  be  studiously  avoided :  such  as  intemperance  of  all  kinds,  either  in 
drinking  or  in  eating ;  all  irregularities  of  personal  habits,  either  as  to  time 
of  meals,  occupation,  exercise,  or  hours  of  sleep ;  all  emotional  excitements 
should  be  removed  ;  in  short,  every  circumstance  which  experience  has  shown 
may  exercise  a  disturbing  influence  upon  these  important  functions  should 
be  carefully  o-uarded  ao;ainst ;  the  use  of  articles  of  food  which  are  liable  to 
occasion  indigestion,  or  to  cause  an  unusual  or  unhealthy  activity  of  the 
digestive  apparatus,  should  be  interdicted  ;  the  child  should  be  carefully 
prevented  from  indulging  in  exhausting  sport  or  exercise,  and  should  be 
carefully  shielded  against  intemperate  weather ;  it  is  all-important  that  the 
functions  of  the  skin  should  be  kept  regular  and  active  by  a  sufficient 
amount  of  seasonable  clothing  by  day  and  by  night ;  particular  care  should 
be  taken  that  revulsions  of  blood,  produced  by  chills,  from  the  cutaneous 
surface  to  the  internal  organs,  especially  the  abdominal,  may  not  occur, 
and  in  this  connection  it  is  strongly  recommended  that  the  abdomen  be 
enveloped  at  night  by  a  broad  baud  of  flannel,  in  order  that  during  the 
restlessness  of  the  little  one  in  sleep  the  skin  of  the  abdomen  may  not  be 
exposed  to  the  direct  action  of  the  air ;  cold  baths  should  be  avoided ;  the 
surface  of  the  body  should  be  Avashed  at  not  too  frequent  intervals,  by 
sponging  with  tepid  water,  and  afterwards  dried  thoroughly  by  vigorous 
rubbing  with  a  rough  towel ;  meanwhile,  the  body  should  be  protected  from 
draughts.  Irregularity  and  intemperance  in  eating  and  drinking  have  already 
been  alluded  to.  It  is  important  that  the  little  one  be  prevented  from  imbi- 
bition of  large  quantities  of  water  or  other  fluids  at  intervals  between  meals, 
for,  if  there  were  no  other  reason,  it  is  a  w^ll-known  physiological  fact  that 
in  the  intervals  of  digestion  the  reaction  of  the  gastric  juices  is  neutral  and 
sometimes  even  slightly  alkaline.  If  contaminated  water  or  milk  should 
be  swallowed  in  large  quantity  during  this  interval,  it  is  clear  that  the 
probability  of  the  living  infecting  agent  passing  through  the  pylorus  into 
the  small  intestine  is  greatly  increased,  and  the  possibility  of  an  attack 
much  enhanced.  In  a  house  where  a  cholera  patient  is  suflxsring,  the  chil- 
dren should  be  kept  out  of  the  sick-room.  But  if,  as  often  occurs  among 
the  class  of  people  who  are  mostly  the  sufferers  from  cholera, — ^the  poor 
and  the  squalid, — there  be  only  one  common  room  for  the  use  of  the  family, 
the  child  should  on  no  account  be  permitted  to  occupy  the  same  bed  as  the 
sick,  and  should  during  the  day,  as  also  during  the  night,  be  kept  as  much 
as  possible  from  contact  with  the  sick-bed. 

Attention  to  the  preparation  of  food  is  a  matter  of  extreme  importance 
to  all  persons  exposed  to  the  infection  of  cholera,  and  especially  to  chil- 
dren. It  goes  without  saying,  that  the  materials  consumed  should  be  per- 
fectly fresh  and  sound  in  every  respect,  and  that  the  water  and  milk  em- 
ployed should  be  absolutely  free  from  the  living  infecting  principle,  as  well 


904  CHOLERA    INFECTIOSA. 

as  pure  and  healthy.  As  a  guarantee  against  the  possibility  of  infection  by 
means  of  the  water  or  milk,  both  should  be  thoroughly  boiled  before  use, 
and,  as  it  is  possible  for  the  cholera-microbe  to  multiply  rapidly  both  in 
water  and  in  milk,  these  articles  should  not  be  used  except  after  very  recent 
boiling.  Coffee  and  tea  should  be  recently  made  and  served  hot.  All  food 
should  be  thoroughly  and  recently  cooked.  No  raw  food  of  any  description, 
except  possibly  a  moderate  quantity  of  perfectly  fresh,  ripe,  and  absolutely 
clean  fruit,  should  be  eaten.  Salads  and  other  such  articles  should  be  inter- 
dicted. Bread,  as  well  as  butter,  should  be  carefully  protected  against  the 
possibility  of  contamination.  The  culinary  utensils  and  table-ware  should 
be  scrupulously  cleaned  with  boiling  water. 

The  hygienic  condition  of  the  dwelling  and  its  surroundings  should  be 
made  as  perfect  as  possible.  All  decaying  animal  or  vegetable  matter 
should  be  removed.  The  house-drains  should  be  free  and  clean  and  jflushed 
with  a  sufficient  amount  of  water  at  intervals,  followed  by  the  emptying 
therein  of  a  liberal  quantity  of  strong  solution  of  copperas  in  water,  or  of 
a  five-per-cent.  solution  of  carbolic  acid.  The  cess-pits  and  the  privies 
should  be  kept  clean  and  free  from  odor  by  the  use  of  unslacked  lime, 
large  quantities  of  copperas,  or  other  similar  inexpensive  materials.  The 
supply  for  drinJdng-water  should  be  scrupulously  guarded  from  possible 
contamination  of  any  kind. 

Among  the  precautions  to  be  enforced  against  a  threatened  attack  of 
cholera  infectiosa  in  any  one,  but  especially  in  the  young,  one  of  exceeding 
importance  is  watchfulness  over  the  condition  of  the  alimentary  canal.  In 
a  large  number,  perhaps  the  majority,  of  instances,  an  attack  of  cholera  is 
preceded  some  hours  or  days  by  derangements  of  the  digestive  apparatus, 
such  as  distress  or  a  sense  of  fulness  or  heaviness  in  the  stomach,  of  gas- 
tralgia  or  nausea,  or  of  occasional  vomiting  ;  or  the  disorders  may  be  limited 
to  the  intestines  only,  and  be  manifested  by  vague  general  abdominal  uneasi- 
ness, or  slight  fleeting  pains,  or  active  peristaltic  movements  which  can  be 
seen  or  felt  through  the  abdominal  walls ;  and  all  or  any  of  these  may  be 
associated  or  end  with  diarrhoea,  and  sometimes  with  tendency  to  dispropor- 
tionate prostration ;  or,  again,  the  disorders  of  the  stomach  and  intestines 
may  be  combined. 

If  these  disturbances  of  the  alimentary  tract  are  promptly  discovered 
and  remedied,  many  an  attack  of  cholera  will  be  thereby  avoided.  In  such 
cases,  absolute  rest  in  bed,  and,  if  possible,  also  total  abstinence  for  a  day 
or  two  from  food,  should  be  enjoined ;  if  there  be  reason  to  infer  the  pres- 
ence in  the  stomach  of  undigested  food,  a  single  emetic  dose  of  ipecac 
should  be  administered ;  or  if  there  be  visible  peristaltic  movements  of  the 
intestines,  or  diarrhoea,  these  should  be  controlled  respectively  by  small 
doses  of  opium  in  a  convenient  form,  and  of  such  drugs  as  salol,  napli- 
thalin,  salicylate  of  bismuth,  or  analogous  compounds. 

What  has  been  thus  far  said  applies  especially  to  individuals ;  but, 
unfortunately,  in  this  disease  public  interests  and  relations  must  also  be 


CHOLERA    INFECTIOSA.  905 

regarded,  and  from  this  stand-point,  so  long  as  there  are  in  the  locality  only 
a  few  scattered  cases  of  the  disease,  the  utmost  efforts  should  be  made  to 
prevent  the  estabhshmeut  of  an  epidemic. 

The  presence  of  the  comma  bacilli  of  Koch  in  the  alvine  evacuations  or 
in  the  vomited  material  from  a  suspicious  case  once  determined,  the  duty  of 
the  attending  physician  and  of  the  health  officer  becomes  plain.  The  safety 
of  the  other  inmates  of  the  dwelling,  and,  what  is  of  infinitely  greater  im- 
portance, that  of  the  general  community  as  regards  public  health  and  com- 
mercial interests,  demand  that  the  most  skilful  and  intelligent  physicians 
and  nurses  be  procured  for  the  sick  and  Jcejjt  in  constant  attendance.  If 
the  dwelling  be  a  hovel  of  the  poor,  as  is  usually  the  case,  the  inmates 
should  be  removed  without  delay  to  clean,  healthful,  and  commodious 
quarters ;  if  the  attacked  is  already  in  a  desperate  condition,  where  every 
prolonged  disturbance  increases  the  probability  of  a  fatal  termination,  he 
should  not  be  moved. 

Inasmuch  as  the  safety  not  only  of  the  health  and  trade  of  the  popula- 
tion of  the  locality  involved  and  its  immediate  surroundings,  but  also  of 
those  of  great  states  and  sometimes  nations  in  communication  with  it,  is 
seriously  threatened  by  the  escape  and  spread  of  the  infectious  principle 
elaborated  in  and  discharged  from  the  intestines  of  the  person  suffering 
an  attack  of  cholera  infectiosa,  skilful  and  constant  attendance  is  impera- 
tively called  for,  and  should  be  provided  at  the  public  expense.  Further- 
more, that  same  public  has  a  paramount  interest  and  absolute  right  to  be 
assured  that  every  rational  precaution  against  the  spread  and  dissemination 
of  the  infectious  agent  is  scrupulously  and  conscientiously  enforced.  This 
is  tantamount  to  saying  that  the  care  of  the  attacked  and  of  the  dwell- 
ing, as  well  as  the  custody  or  close  surveillance  of  all  persons  associated 
or  in  communication  with  him  or  it,  should  be  under  the  strict  control  and 
direction  of  the  jeopardized  public  through  its  own  intelligent  and  respon- 
sible agents.  The  prevention  of  the  spread  of  infection — of  such  enormous 
importance  to  the  public — should  under  no  circumstances  whatever  be 
trusted  in  any  degree  to  the  ignorance  or  carelessness  or  conflicting  interests 
of  the  inmates  of  the  infected  dwelling ;  neither  should  it  be  left  to  tlie 
chance  of  uncertainty  through  the  incompetence  or  neglect  or  whimsical 
notions  or  personal  interests  or  lack  of  authority  of  the  private  physician. 
Of  course  this  means  temporary  invasion  of  the  private  rights  and  restriction 
of  the  personal  liberty  of  a  few  individuals,  whose  own  security  is  thereby 
enhanced.  But  the  public  safety  demands  a  temporary  sacrifice  of  private 
rights  under  these  circumstances,  and  there  should  be  no  hesitation  or 
vacillation  in  requiring  it. 

It  is  obvious  that  the  evacuations  of  the  intestinal  canal  of  the  attacked 
should,  without  loss  of  time,  be  carefully  disinfected.  But  by  no  means 
all  suffering  an  attack  of  cholera  infectiosa  are,  especially  in  the  earlier 
stages  of  the  disease,  so  ill  that  they  cannot  be  out  of  bed,  and  even  out  of 
doors  engaged  in  their  ordinary  vocations.     Yet  experience  has  abundantly 


906  CHOLERA    INFECTIOSA. 

proved  that  those  suffering  "a  walking  attack"  carry  in  their  intestinal 
canal  the  infectious  agent  of  cholera,  and  are  capable,  under  favoring  cir- 
cumstances, of  establishing  a  centre  of  infection  wherever  in  their  move- 
ments they  may  chance  to  void  those  intestinal  contents.  Hence  the  neces- 
sity of  temporarily  restricting  the  liberty  of  all  inmates  of  the  infected 
dwelling  and  of  all  persons  in  close  communication  with  it,  whether  at  the 
time  of  infection  they  are  evidently  suffering  or  not.  All  such  persons 
should  be  isolated  and  kept  under  strict  surveillance  until  the  extreme  limit 
of  the  period  of  incubation  (say,  five  days)  has  fully  elapsed,  counting  from 
the  commencement  of  the  surveillance.  If  during  these  five  days  no  sign  of 
even  a  slight  or  "  walking  attack"  has  made  its  appearance,  and  finally  if  a 
culture-test,  as  hereafter  described,  of  the  faeces  has  indicated  the  absence 
of  the  comma  bacilli  of  Koch,  the  individual  temporarily  restrained  of  his 
liberty  both  for  his  own  benefit  and  for  that  of  the  public  may  be  without 
danger  restored  again  to  the  full  enjoyment  thereof. 

As  suggestions  for  the  practical  application  of  public  measures  of  pre- 
vention, we  incorporate  here  an  abstract,  which  we  communicated  to  the 
Medical  News,  October  15,  1887,  of  the  section  on  Prevention  comprised 
in  our  Official  Report  of  Cholera  in  Europe  and  India,  1884  to  1886  : 

"  Measures  of  prevention,  to  give  the  greatest  possible  guarantee  of 
success  in  extinguishing  an  incipient  epidemic  of  cholera,  should,  in  the 
first  place,  be  based  upon  the  most  exact  knowledge  we  possess  of  the 
cause,  mode  of  attack,  and  manner  of  spread  of  the  disease  ;  and,  in  the 
second  place,  these  measures  should  be  intelligently,  thoroughly,  and  rigidly 
enforced. 

"  What  are  the  considerations  involved  in  the  first  category  ?  Probably 
nine-tenths  of  intelligent  and  experienced  physicians  all  over  the  world, 
even  including  those  of  India,  have  for  years  admitted  that  there  is  most 
convincing  proof  that  the  active  cause  of  the  disease  is  a  specific,  material, 
living  entity,  of  extremely  minute  size,  endowed  with  the  power  of  self-prop- 
agation and  of  exceedingly  rapid  multiplication  in  enormous  numbers ;  that 
among  animals  it  naturally  attacks  man  alone,  assailing  him  only  by  way  of 
the  intestinal  canal ;  that  the  evacuations  from  the  bowels  contain  the  active 
cause  of  the  disease,  and  that  when  this  agent  in  any  manner — as  through 
drinking-water,  milk,  food,  or  the  handling  or  washing  of  contaminated 
personal  effects,  etc. — reaches  the  intestines  of  another  susceptible  person, 
the  disease  may  be  thereby  transmitted  from  the  sick  to  the  healthy ;  that 
the  active  agent  exists  in  the  dejecta  of  the  lightest  and  most  imperceptible 
no  less  than  the  severest  and  most  deadly  forms  of  the  disease,  and  is  known 
to  be  transportable  from  place  to  place  through  the  movements  of  man  and 
his  personal  effects. 

"  Proceeding  from  this  basis,  logical  deduction  and  common  experience 
alike  demonstrate  the  absolute  necessity  and  efficiency  of  such  measures  of 
prevention  as  the  following  : 

"  a.  Speedy  recognition  and  isolation  of  the  sick  ;   their  proper  treat- 


CHOLERA   INFECTIOSA.  907 

ment ;  absolute  and  rapid  destruction  of  the  infectious  agent  of  the  disease 
not  only  in  the  dejecta  and  vomit,  but  also  in  clothing,  bedding,  and  in  or 
upon  whatever  else  it  finds  a  resting-place. 

"  h.  The  convalescents  should  remain  isolated  from  the  healthy  so  long 
as  their  stools  possibly  contain  any  of  the  infecting  agent ;  before  mingling 
again  with  the  well  they  should  be  immersed  in  a  disinfecting  bath,  and 
afterward  be  clothed  from  the  skin  outward  with  perfectly  clean  vestments 
which  cannot  possibly  contain  any  of  the  infectious  material. 

"  c.  The  dead  should  be  well  wrapped  in  cloth  thoroughly  saturated  in 
a  solution  of  corrosive  sublimate,  one  to  five  hundred,  and  without  delay, 
cortege,  or  lengthy  ceremonial,  buried  near  the  place  of  death  in  a  deep 
grave,  remote  as  possible  from  water  which  may  under  any  circumstances 
be  used  for  drinking,  washing,  culinary,  or  other  domestic  purposes,  (Cre- 
mation, of  course,  is  by  far  the  safest  way  of  disposing  of  cholera  cadavers.) 

"  d.  Those  handling  the  sick  or  the  dead  should  be  careful  to  disinfect 
their  hands  and  soiled  clothing  at  once,  and  especially  before  touching 
articles  of  food,  or  drinking  or  culinary  vessels. 

"  e.  In  the  case  of  maritime  quarantine,  the  well  should  be  disem- 
barked and  placed  under  observation  in  quarters  sj)acious  enough  to  avoid 
crowding,  and  so  well  appointed  and  furnished  that  none  will  suffer  real 
hardships. 

"/.  Once  having  reached  the  station,  those  under  observation  should  be 
separated  in  groups  of  not  more  than  twelve  to  twenty-four,  and  the  various 
groups  should  under  no  pretext  intermingle ;  the  quarters  for  each  group 
should  afford  stationary  lavatories  and  water-closets  in  perfect  working 
condition,  adequate  to  the  needs  of  the  individuals  constituting  the  group, 
and  supplied  with  proper  means  of  disinfection ;  there  should  be  a  bed 
raised  above  the  floor,  proper  coverings,  and  a  chair,  for  each  member  of 
the  group,  each  person  being  required  to  use  only  his  own  bed ;  there 
should  be  a  common  table  of  sufficient  size  to  seat  around  it  all  the  mem- 
bers of  the  group,  who  should  be  served  their  meals  from  a  central  kitchen, 
and  with  table-furniture  belonging  to  the  station  and  cleaned  by  the  common 
kitchen  scullions. 

"(7.  Drinking-water,  free  from  possible  contamination  and  of  the  best 
quality,  sliould  be  distributed  in  the  quarters  of  eacii  group  as  it  is  needed, 
and  in  such  a  manner  that  it  is  received  in  drinkiug-cups  only;  there 
should  be  no  water-buckets  or  other  large  vessels  in  which  handkerchiefs, 
small  vestments,  children's  diapers,  etc.,  can  be  washed  by  the  members  of 
any  group. 

"  h.  Immediately  after  being  separated  into  groups  in  their  respective 
quarters,  every  person  under  observation  should  be  obliged  to  strip  and  get 
into  a  bath  (a  disinfecting  one  is  preferable),  and  afterward  bo  clothed  with 
fresh,  clean  vestments  from  the  skin  outward.  Every  article  of  clothing 
previously  worn  should  l)e  taken  away  and  properly  disinfected. 

"  i.  Then  all  the  personal  effects  should  be  at  once  removed  to  a  separate 


908  CHOLERA   IKFECTIOSA. 

building,  washed, — if  possible, — and  thoroughly  disinfected,  or,  if  neces- 
sary, destroyed.  After  disinfection  they  should  be  temporarily  returned  to 
the  members  of  groups  when  occasion  requires  a  further  change  of  clothing. 

"  k.  Under  no  circumstances  whatever  should  washing  of  clothing  by 
those  under  observation  be  permitted.  All  used  clothing  should  be  first 
thoroughly  dismfected  (by  boiling,  when  possible),  and  then  should  be 
cleansed,  the  disinfection  and  washing  being  done  by  a  sufficiently  trained 
and  absolutely  reliable  corps  of  employees  supplied  with  adequate  appli- 
ances. 

''  l.  All  those  under  observation  should  be  mustered  in  their  own  quar- 
ters and  be  subjected  to  a  close  medical  inspection,  while  on  their  feet,  at  least 
twice  every  day,  in  order  to  discover  and  isolate  as  soon  as  possible  new 
cases  which  may  develop ;  and  of  course  the  clothing  and  bedding  of  these 
new  cases  should  be  treated  without  delay  in  the  manner  already  mentioned. 
In  the  mean  time,  a  watch  should  be  set  over  the  water-closets,  for  the  pur- 
pose of  discovering  cases  of  diarrhoea,  and,  when  discovered,  such  cases 
should  be  temporarily  separated  from  the  rest ;  they  should  receive  judicious 
medical  attention  at  once,  and  precautions  should  be  taken  as  if  they  were 
undoubted,  but  mild,  cases  of  cholera. 

"m.  The  quarters  should  be  kept  thoroughly  clean,  and  every  surface 
upon  which  infectious  material  could  possibly  be  deposited,  including  the 
floors,  should  be  washed  with  a  strong  disinfectant  twice  daily,  and  oftener 
when  necessary ;  evacuations  from  the  bowels  should  be  passed  into  a  strong 
disinfectant ;  the  hopper  of  the  closet  should  be  then  flushed,  and  finally 
drenched  with  a  quantity  of  the  same  disinfectant. 

"  n.  For  the  proper  attention  to  the  sick,  there  should  be  two  or  more 
competent  and  experienced  physicians,  assisted  by  a  sufficient  corps  of  in- 
telligent and  efficient  nurses,  with  hours  of  duty  so  arranged  that  a  physician 
with  a  sufficient  number  of  nurses  shall  be  in  constant  attendance  in  the 
wards  of  the  hospital. 

"  o.  For  the  prompt  recognition  and  separation  of  new  cases,  their  tem- 
porary medical  attention,  the  proper  treatment  of  discovered  cases  of  diar- 
rhoea or  cholerine,  and  of  other  maladies,  and  the  immediate  correction  of 
every  insanitary  practice  or  condition  by  constant,  vigilant,  and  intelligent 
supervision,  there  should  be  at  least  two  or  more  competent  and  experienced 
physicians,  with  hours  of  service  so  arranged  that  a  physician  is  on  duty 
night  and  day  among  those  under  observation ;  and  he  should  have  subject 
to  his  orders,  at  any  and  every  moment,  a  sufficient  and  efficient  corps  of 
nurses  and  laborers  to  carry  out  properly  and  promptly  his  directions. 

"p.  In  order  to  prevent  the  intermingling  of  the  various  groups,  to 
enforce  obedience  and  order,  and  to  make  it  absolutely  impossible  for  the 
quarantined  and  their  personal  eflects  to  have  any  communication  with  the 
exterior,  a  well-organized  and  sufficiently  large  police-corps  should  patrol 
the  borders  of  the  stations  and  the  buildings  day  and  night. 

"q.  Any  group  among  whom  there  have  developed  no  new  cases  of 


CHOLERA    INFECTIOSA.  909 

cholera,  or  of  choleraic  diarrhoea,  during  the  preceding  eight  or  ten  days, 
may  be  regarded  as  harmless,  and  allowed  to  leave  quarantine  after  each 
one  is  finally  immersed  in  a  disinfecting  bath  and  reclothed  with  clean  gar- 
ments from  the  skin  outward,  the  garments  removed  being  destroyed,  or 
thoroughly  disinfected  and  cleansed  as  above  indicated. 

"As  yet,  no  reference  has  been  made  to  the  crew,  ship,  and  cargo.  What 
has  been  said  of  the  treatment  of  those  under  observation  applies  to  every 
one  of  the  ship's  inhabitants.  The  observation,  isolation,  and  cleansing  of 
the  crew  and  their  effects  could  safely  be  performed  aboard  ship  if  necessary. 
The  ship  should  be  thoroughly  cleansed  and  disinfected,  particular  attention 
being  given  to  the  quarters  of  the  emigrants  and  crew." 

The  discovery  of  the  comma  bacillus  of  cholera  infectiosa  by  Koch  in 
1883  has  rendered  it  possible,  for  the  first  time  in  the  history  of  epidemics 
of  this  disease,  for  the  physician  and  the  health  officer  to  be  absolutely 
assured  of  the  infectious  nature  of  suspicious  cases.  It  is  almost  the  uni- 
versal experience  of  those  whose  duty  it  is  to  deal  with  the  first  apj^earance 
of  this  disease  in  a  locality,  that  there  is  great  doubt  and  contention  con- 
cerning its  real  nature ;  and,  as  a  rule,  it  is  only  after  these  doubts  have 
been  settled,  unfortunately,  by  the  starting  and  the  spreading  of  an  epidemic, 
that  the  authorities  become  convinced  of  the  necessity  of  enforcing  efficient 
restrictive  measures.  It  is,  however,  then  too  late  to  protect  the  community 
from  the  misfortunes  which  follow  in  the  track  of  this  devastating  scourge. 
It  is  only  in  the  judicious  handling  oi  the  first  suspected  cases,  as  a  rule,  that 
public  preventive  measures  can  be  enforced  with  much  hope  of  satisfactory 
results.  Commonly,  the  course  of  the  epidemic  passes  beyond  control  of 
the  authorities  after  it  has  once  commenced  actively  to  spread ;  at  least  its 
effective  management  is  then  exceedingly  difficult. 

The  discovery  of  Koch — since  amply  confirmed  in  all  parts  of  the  world 
by  competent  observers — that  in  the  presence  of  the  comma  bacillus  of 
cholera  is  furnished  a  practicable,  rapid,  and  reliable  means  of  the  certain 
diagnosis  of  epidemic  or  infectious  cholera,  has  its  greatest  value  for  the 
protection  of  the  public  health  just  at  this  point.  The  innumerable  observa- 
tions which  have  been  made  since  that  announcement  have  positively  shown 
that,  even  if  this  microbe  may  not  be  actually  the  exciting  cause  of  the  dis- 
ease, it  is  certainly  its  invariable  accompaniment,  and  has  never  yet  been 
found  associated  with  any  other  disease.  It  may  therefore  be  regarded  as 
absolutely  certain  that  whenever  the  comma  bacillus  of  Koch  is  recognized 
in  the  evacuations  from  the  bowels  or  fi'om  the  mouth  of  any  j:>erson,  we 
have  to  do  with  a  case  of  cholera  infectiosa,  and  the  most  tliorough  measures 
to  prevent  the  spread  of  infection  are  imperatively  called  for. 

It  is  not  necessary  in  an  article  of  the  scope  and  purpose  of  this  to  relate 
in  any  detail  the  history  of  this  discovery  and  of  the  observations  which  have 
subsequently  been  made  concerning  it.  We  may  state  in  this  connection 
that  for  ourselves  we  not  only  regard  the  presence  of  the  comma  bacillus  as 
an  absolute  proof  of  the  existence  of  the  infectious  principle  which  causes 


910  CHOLERA    IXFECTIOSA. 

cholera  infectiosa,  but  are  also  strongly  constrained  to  recognize  in  this 
microbe  the  active  living  principle  which  constitutes  the  cause  of  infection 
as  well,  although  we  freely  admit  that  the  proof  of  the  latter  is  as  yet  by 
no  means  so  strong  and  unanswerable  as  that  of  the  former. 

Morphology  of  the  Cholera-Microbe. — The  comma  bacillus  of  Ivoch 
should  perhaps  be  more  properly  classed  as  a  spirillum  than  as  a  bacillus. 
Koch  himself  now  is  inclined  to  this  opinion,  and  at  present  places  this 
micro-organism  between  the  bacilli  and  the  spirilli,  as  partaking  of  some 
of  the  peculiarities  of  both.  In  the  human  organism  this  microbe  is  limited 
to  the  digestive  tract.  It  exists  in  enormous  numbers  in  the  intestinal 
contents  in  the  early  stages  of  cholera,  and  is  especially  numerous  in  cases 
of  extremely  rapid  development,  such  as  the  foudroyante.  The  numbers 
gradually  decrease  with  the  duration  of  the  disease,  until  they  finally  dis- 
appear, having  already  become  rare  when  the  dejecta  begin  to  present  again 
their  natural  color  and  consistence.  They  swarm  in  myriads  in  the  serous 
fluid  of  the  intestinal  contents,  but  are  far  more  numerous  in  the  desqua- 
mated flakes  of  the  intestinal  epithelium,  those  bodies  which  give  to  the 
discharges  a  rice-water  aspect.  They  furthermore  have  been  found  in  some 
numbers  in  the  lumen  of  the  follicles  of  Lieberkiihn ;  they  have  sometimes 
been  found  below  the  epithelia,  between  it  and  the  subjacent  basement- 
membrane,  especially  in  the  Lieberkiihnian  follicles ;  and  occasionally  they 
have  been  found  to  penetrate  to  some  distance  into  the  surrounding  con- 
nective tissue  of  the  intestinal  mucosa.  It  is  doubtful  if  in  the  human 
being  they  ever  reach  the  circulating  blood  or  extend  as  far  along  the  lym- 
phatic tracts  as  the  location  of  the  lymph-glaucls,  and  they  have  never  been 
found  in  the  lacteals  :  so  that  in  the  human  subject  the  habitat  of  this  micro- 
organism may  be  said  to  be  limited  strictly  to  the  innermost  portion  of  the 
intestinal  canal. 

It  occasionally  happens  that  the  intestinal  contents,  especially  in  ex- 
tremely rapid  cases  of  cholera,  contain  almost  exclusively  myriads  of  the 
comma  bacilli,  as  shown  by  microscopic  examination.  But  in  the  vast 
majority  of  cases  these  micro-organisms  are  intermixed  with  various  other 
species  of  bacteria  in  considerable  numbers,  and  often  the  other  bacteria  are 
so  numerous  in  proportion  to  the  comma  bacilli  that  it  is  difficult  to  find 
more  than  two  or  three  of  the  latter  in  a  given  field  of  the  microscope. 

Photo.  No.  4  of  the  preceding  article  on  "  Outlines  of  Practical  Bacteri- 
ology," ^  by  the  author,  is  a  photo-micrograph  of  the  intestinal  contents  of  a 
case  of  cholera  of  the  latter  category.  By  reference  to  it,  it  is  seen  that 
there  are  not  more  than  two  comma  bacilli  present  in  the  microscopic  field 
represented,  whilst  the  other  bacteria  are  far  more  numerous.  In  those  cases 
where  the  comma  bacilli  exist  in  the  intestinal  contents  in  nearly  pure  culture 
and  but  little  intermixed  with  other  bacteria,  microscopic  examination  alone 
is  sufficient  to  base  a  diagnosis  upon.    But  in  such  cases  as  those  represented 

'  See  page  147,  cmte. 


CHOLERA    IXFECTIOSA.  911 

by  the  photo-micrograph  above  mentioned,  microscopic  examination  alone 
can  easily  mislead.  The  very  few  curved  bacilli  found  may  possibly  not  be 
those  of  the  comma  bacilli  of  Koch,  since  there  are  numerous  other  curved 
bacilli  which  more  or  less  closely  resemble  morphologically  those  of  cholera 
infectiosa.  In  these  cases,  and  in  fact  in  the  vast  majority  of  instances,  for 
the  purpose  of  diagnosis  it  is  safe  only  to  resort  to  culture  methods  for  the 
certain  recognition  of  the  comma  bacilli  of  Koch,  and  the  procedure  is  then 
as  follows.  A  series  of  three  test-tubes  containing  neutral  or  slightly  alkaline 
sterilized  flesh-peptone-gelatin  are  inoculated  with  a  minute  quantity  of  the 
intestinal  contents  as  evacuated  from  the  bowels,  and  plate-cultures  are 
made  from  each  after  the  manner  described  in  detail  in  the  preceding  article 
above  mentioned.  After  twenty-four  or  forty-eight  hours  it  is  usually  found 
that  the  colonies  developing  from  the  micro-organisms  contained  in  the 
intestinal  contents  are  almost  all  those  of  the  comma  bacilli  of  Koch.  For 
some  reason,  not  well  determined,  it  is  found  that  under  such  circumstances 
few  other  colonies  will  develop  in  the  gelatin,  so  that,  notwithstanding  the 
abundant  intermixture  of  various  other  bq,cteria  in  the  intestinal  contents 
itself,  the  gelatin  shows  almost  a  pure  culture  of  the  comma  bacilli.  This 
was,  in  fact,  the  case  with  the  intestinal  contents  represented  in  Photo.  No. 
4  above  referred  to.  After  twenty-four  or  forty-eight  hours,  a  microscopic 
examination  under  a  low  power,  say  thirty  diameters,  of  the  gelatin  plate, 
shows  the  comma-bacilli  colonies  presenting  the  appearance  represented  in 
Photo.  No.  7,  which  is  a  reproduction  of  a  photo-micrograph  of  a  colony 
in  a  gelatin  plate  made  from  the  intestinal  contents  represented  in  Photo. 
No.  4.  By  reference  to  Photo.  No.  7  the  following  peculiarities  of  the  aspect 
of  the  comma-bacillus  colony  will  be  noted.  There  is  a  rough  granular  centre 
of  a  gray  or  brownish-yellow  as]3ect,  having  the  appearance  of  a  collection 
of  highly  refracting,  finely-broken  glass,  surrounded  by  a  clear  circular  zone 
in  which  are  a  few  scattered,  dark,  refracting  granules.  This  colony  really 
rests  at  the  centre  of  the  bottom  of  a  saucer-like  cavity  depressed  below  the 
general  surface  of  the  surrounding  solid  gelatin,  and  containing  clear  fluid. 
In  their  development  the  colonies  of  comma  bacilli  have  the  faculty  of 
liquefying  the  surrounding  gelatin.  It  is  necessaiy  to  wait  until  the  devel- 
opment of  the  colony  has  sufficiently  far  advanced  to  produce  tliis  liquefy- 
ing effect  in  order  to  be  sure  that  one  has  under  observation  a  genuine  colony 
of  the  comma  bacilli  of  Koch.  For  in  the  earliest  appearance  of  the  cholera 
colonies  the  surrounding  ring  of  fluid  is  so  narrow  as  to  escape  observation, 
and  there  are  bacteria  which,  in  their  development  in  flcsh-peptone-gela- 
tin  plate-culture,  present  a  granular  aspect  so  nearly  resembling  that  of  the 
central  portion  of  this  comma-bacillus  colony  as  to  make  it  impossible,  or 
at  least  exceedingly  difficult,  to  distinguish  l)etween  them.  Photo.  No.  6 
represents  a  colony  of  a  micrococcus  sometimes  found  in  the  air;  tlie  as- 
pect of  this  colony  is  like  broken  glass  also.  This  latter  colony,  how- 
ever, as  may  be  seen,  is  more  or  less  regularly  circular  in  outline,  and  l^y 
reference  to  Photo.  No.  7  it  is  observed  that  the  outline  of  the  comma- 


912  CHOLERA    INFECTIOSA. 

bacillus  colony  is  quite  irregular;  in  fact,  it  is  often  found  to  be  niucli 
more  irregular  than  here  seen.  In  the  earlier  stages  of  develojDment  of 
the  comma-bacillus  colonies,  however,  their  outlines  are  more  or  less  regu- 
larly circular,  and  they  are  then  difficult  to  differentiate.  It  is  necessary 
to  proceed  a  step  further  in  the  examination  of  the  comma-bacillus  colony 
in  the  plate-culture  befoi^e  becoming  assured  of  its  character.  A  micro- 
scopic examination  of  the  individual  bacilli  constituting  the  colony  must  be 
made,  and  it  is  well  in  addition  to  make  an  inoculation  from  such  an  indi- 
vidual colony  into  a  test-tube  containing  solid  flesh-peptone-gelatin  in  the 
manner  described  in  the  preceding  article  before  mentioned.  After  twenty- 
four  or  forty-eight  hours,  the  puncture  made  by  the  inoculating  needle 
shows  along  its  track  a  growth  of  bacteria  more  or  less  advanced,  according 
to  the  length  of  time  which  has  elapsed  since  the  inoculation,  and  accord- 
ing to  the  temperature  to  which  the  test-tube  has  been  subsequently  exposed. 

Photo.  No.  10  is  a  photograph,  natural  size,  of  such  an  inoculated 
gelatin-tube,  forty-eight  hours  after  inoculation.  The  surface  of  the  solid 
gelatin  within  the  tube  is  seen  to  be  inclined.  The  culture  now  presents 
quite  a  characteristic  aspect.  The  upper  portion  of  the  culture  is  more  or 
less  funnel-shaped,  with  the  appearance  of  an  air-bubble  at  the  top.  The 
fluid  contained  in  the  funnel-shaped  cavity  beneath  the  apparent  air-bubble 
(which  latter  in  reality  is  an  optical  delusion,  the  portion  of  the  funnel 
represented  by  the  air-bubble  being  only  an  empty  cavity  containing  air) 
is  clear  or  slightly  opalescent.  At  the  bottom  of  the  funnel  and  along 
the  narrow  neck  below  is  deposited  a  grayish,  finely-granular  mass,  con- 
sisting of  the  subsided  bacilli.  Microscopic  examination  under  a  high 
power  of  the  individual  bacilli  constituting  the  colony  of  Photo.  No.  7  is 
made  in  the  manner  indicated  in  the  preceding  article.  If  the  microscopic 
examination  both  of  the  plate-colony  and  of  the  material  of  the  gelatin-test- 
tube  culture  shows  only  curved  bacilli,  it  may  at  once  be  inferred  that  one 
has  to  do  with  a  case  of  genuine  cholera  infectiosa.  In  order  to  be  abso- 
lutely certain  of  this,  however,  at  the  same  time  that  the  gelatin-tube 
culture  is  made  from  the  plate-colony,  the  surface  of  a  potato  prepared  after 
the  manner  indicated  in  the  preceding  article  mentioned  should  also  be  in- 
oculated from  the  same  colony,  and  the  potato  should  be  placed  for  twenty- 
four  hours  in  the  culture-oven,  A  growth  consisting  of  curved  bacilli  upon 
the  potato  is  positive  proof  that  the  bacilli  are  none  other  than  those  of 
cholera  infectiosa. 

Photo.  No.  13  is  a  photo-micrograph  of  a  cover-glass  preparation  made 
from  the  colony  represented  in  Photo.  No.  7,  which  was  obtained  from  the 
intestinal  contents  represented  in  Photo.  No,  4.  By  reference  to  Photo. 
No,  13  it  will  be  seen  that  we  have  a  pure  culture  of  curved  bacilli.  The 
forms  here  shown  are  in  the  main  those  of  a  simple  curve  in  one  direction ; 
but  there  are  numerous  instances  of  a  figure  S,  caused  by  the  juxtaposition 
or  attachment  end  to  end  of  two  bacilli  curved  in  opposite  directions. 
Under  cultivation  the  comma  bacillus  of  Koch  is  not  always  found  pre- 


CHOLERA    INFECTIOSA.  913 

senting  exactly  the  morphology  here  shown.  Growths  in  certain  media, 
especially  those  not  most  favorable  for  the  development  of  the  bacillus, 
show  more  or  less  numerous  threads  of  a  more  or  less  spiral  form.  These 
spirilli  may  be  more  or  less  jointed  and  consist  of  a  spiral  chain  of  a  number 
of  individual  curved  bacilli  joined  end  to  end  more  or  less  closely,  or  they 
may  present  the  appearance  of  a  continuous  curved  or  spiral  filament  with- 
out interruption.  The  spiral  forms  which  often  develop  in  cultures  of  the 
comma  bacillus,  and,  in  fact,  of  all  other  curved  bacilli  heretofore  culti- 
vated artificially,  are  well  represented  in  Photo.  No.  12,  which  is  a  photo- 
micrograph of  a  cover-glass  preparation  from  a  pure  cultui-e  of  the  curved 
bacillus  of  Finkler  (so  called,  of  cholera  nostras).  Photo.  No.  11  also  shows 
a  few  examples  of  short  spirilli  in  a  pure  culture  of  the  Deneke  or  cheese 
bacillus.  Comparison  of  these  photographs  with  that  reproduced  in  Photo. 
No.  13  also  shows  the  morphological  resemblance  of  the  individual  curved 
bacilli  of  Koch,  Finkler,  and  Deneke.  Other  curved  bacilli — such  as  those 
of  the  mouth,  one  form  of  which  was  isolated  and  cultivated  by  Miller, 
those  sometimes  found  in  intestinal  contents  in  cases  of  dysentery,  those  fre- 
quently found  in  leucorrhoeal  discharges,  those  occasionally  found  in  scrapings 
from  pneumonic  lungs,  those  often  found  in  ordinary  running  water  and  in 
numerous  other  places — also  so  closely  resemble  the  comma  bacillus  of  Koch 
morphologically  that  it  is  impossible,  or  at  least  unsafe,  to  undertake  to  dis- 
tinguish between  them,  by  means  of  the  microscope  alone,  for  the  purpose  of 
recognition,  except  under  the  circumstances  above  mentioned.  For  distinc- 
tion between  the  curved  bacilli  of  cholera  infectiosa  and  other  curved  bacilli 
it  is  a  sine  qua  non  that  plate-cultures,  tube-cultures,  and  potato-cultures  be 
resorted  to,  in  addition  to  microscopic  examination.  The  appearance  of 
gelatin-plate  colonies  of  the  curved  bacillus  of  Finkler  is  shown  in  Photo. 
No.  5,  which  is  a  reproduction  of  a  photo-micrograph  of  such  a  colony. 
As  is  seen,  the  outline  of  the  colony  is  regularly  circular;  its  aspect  is  finely 
granular,  and  its  color  is  yellowish  gray.  The  appearance  of  the  gelatin-tube 
culture  of  the  curved  bacillus  of  Finkler  is  represented  in  the  two  tubes  to 
the  right  in  Photo.  No.  9,  as  compared  with  the  appearance  of  gelatin- 
tube  cultures  of  the  curved  bacillus  of  cholera  infectiosa,  as  shown  in  the 
two  tubes  to  the  left  in  the  same  photo.  The  curved  bacilli  of  Finkler  also 
have  the  power  of  liquefying  gelatin,  but  in  their  growth  in  ten-per-cent. 
gelatin  there  is  no  appearance  of  an  air-bubble  at  any  time,  but  development 
is  far  more  rapid  than  in  the  case  of  cholera  infectiosa,  and  the  fluid  con- 
tained in  the  liquefied  portion  completely  fills  the  cavity,  and  is  of  a  homo- 
geneous opaque  aspect.  The  curved  bacillus  of  Deneke  in  its  growth  in 
the  gelatin-plate  forms  a  colony  which  also  has  the  power  of  rendering  the 
surrounding  gelatin  fluid,  and  the  aspect  of  the  colony  slightly  resembles 
that  of  genuine  cholera.  But  its  development  is  much  more  rapid,  the 
fluidification  of  the  gelatin  proceeds  with  much  greater  speed,  and  the  zone 
of  fluid  surrounding  the  central  colony  which  rests  in  the  bottom  of  the 
saucer-like  depression  is  not  clear,  but  more  or  less  cloudy.  The  growth  in 
Vol.  I.— 58 


914  CHOLERA    INFECTIOSA. 

gelatin-tubes,  is  funnel-shaped,  and  there  is  an  apparent  air-bubble  at  the 
top.  When,  however,  resort  to  the  potato-culture  is  had,  it  is  found  that 
the  comma  bacillus  of  Koch  grows  abundantly  upon  it  at  normal  room- 
temperature  and  in  the  culture-oven,  while  that  of  Deneke  refuses  to  grow. 
Photo.  No.  8  represents  a  number  of  gelatin-plate  colonies,  which  do  not 
render  the  surrounding  gelatin  fluid,  of  a  curved  bacillus  morphologi- 
cally identical  with  that  of  cholera  infectiosa,  isolated  by  the  writer  from 
the  water  of  a  well  which  constituted  the  common  water-supply  of  a  small 
village  in  Sicily  where  an  outbreak  of  cholera  had  occurred.  It  is  sufficient, 
as  these  photographs  indicate,  to  cultivate  these  different  organisms  in  gela- 
tin-plates, in  order  to  distinguish  readily  between  them.  In  the  experience 
of  the  author  in  the  examination  of  the  intestinal  contents  of  cholera  infec- 
tiosa at  the  quarantine  station  in  New  York,  and  at  various  places  in  Spain, 
France,  Italy,  Sicily,  and  India,  the  comma  bacillus  of  Koch  has  been 
invariably  present,  whilst  none  of  the  other  curved  bacilli  have  been  found 
therein.  He  has  compared  its  biological  characters  with  those  of  all  other 
curved  bacilli  known,  and  he  has  no  hesitation  in  affirming  his  opinion  that 
there  are  none  of  them  identical  with  it. 

Various  methods  of  recognizing  the  presence  of  the  comma  bacillus  of 
Koch  without  resort  to  the  microscope  and  to  plate-cultures  have  been 
proposed  for  practical  use,  such  as  those  of  Bujwid,  Buchner,  Gruber, 
Brieger,  and  others ;  but  in  our  opinion,  however  valuable  they  may  be  in 
exceptional  cases  as  supplementary  to  those  above  described,  they  should 
by  no  means  be  substituted  in  the  place  of  the  latter. 

Symptomatolog-y. — The  symptoms  met  with  in  cholera  infectiosa  are 
extremely  varied,  according  to  the  stage  and  the  character  and  rapidity  of 
the  attack.  Clinicians  Avho  have  treated  of  this  disease  have  generally 
recognized  four  stages  :  a,  of  premonitory  diarrhoea ;  b,  of  serous  diarrhoea ; 
c,  of  collapse,  algidity,  or  asphyxia ;  d,  of  reaction. 

a.  As  to  whether  the  premonitory  diarrhoea  is  to  be  properly  regarded 
as  the  actual  commencement  and  an  essential  part  of  the  disease,  or  whether 
it  is  to  be  considered  as  a  frequent  predisposing  simple  disorder  of  the 
digestive  apparatus,  opinions  have  differed,  and  experienced  physicians  are 
still  far  from  harmonious.  Whilst  in  most  epidemics  of  cholera  perhaps 
the  majority  of  sufferers  experience  the  so-called  premonitory  diarrhoea, 
yet  observers  have  repeatedly  noted  its  general  absence.  And,  again,  where 
such  diarrhoeas  have  been  widely  prevalent,  common  experience  has  shown 
that  only  a  comparatively  small  percentage  develop  into  recognized  chol- 
eraic attacks.  If  the  premonitory  diarrhoea  indicates  a  genuine  inva- 
sion of  the  organism  by  the  specific  infection  of  the  disease,  certain  it  is, 
nevertheless,  that  there  are  many  grave  and  even  fatal  attacks  without  its 
presence.  But  it  is  in  the  experience  of  all  who  have  had  much  to  do  with 
epidemics  of  cholera  that  any  one  of  the  recognized  stages  of  the  disease 
may  be  wanting.  It  therefore  seems  unwarrantable,  on  the  ground  of  its  fre- 
quent absence,  to  exclude  the  first  stage  of  premonitory  diarrhoea  as  a  part 


CHOLERA   INFECTIOSA.  915 

of  the  real  disease,  ^nd  from  the  stand-point  of  tlierapeutics  it  is  wise  to 
treat  this  stage  as  the  commencement  of  an  attack  of  cholera,  which  if 
neglected  at  this  time  may  ultimately  have  a  fatal  termination.  If  not  con- 
trolled, the  diarrhoea  may,  after  persisting  for  hours  or  days,  be  followed  b}' 
the  onset  of  symptoms  which  remove  all  doubt,  during  the  existence  of  an 
epidemic,  of  the  commencement  of  an  attack  of  the  dreaded  disease.  It  is 
during  the  night  that  this  onset  occurs  in  the  majority  of  cases. 

h.  Serous  diarrhoea  is  the  symptom  which,  with  its  usual  accompaniment 
of  intense  thirst,  nausea,  or  vomiting,  cold,  shrunken,  wrinkled  skin, 
sunken  eyeballs,  husky  voice,  weak,  frequent,  thready  pulse,  great  prostra- 
tion, restlessness,  anxiety,  and  cramps,  by  far  the  most  frequently  marks 
both  for  the  family  of  the  suiferer  and  for  the  physician  the  commencement 
of  the  feared  attack.  If  diarrhoea  has  been  present,  the  alvine  evacuations 
imdergo  usually  a  striking  and  more  or  less  characteristic  change,  as  well  as 
often  become  much  more  copious  and  frequent.  Up  to  this  point  the  disease 
has  been  essentially  localized,  and  the  intensity  of  action  of  the  specific 
poison  has  fallen  upon  the  lining  of  the  intestinal  canal.  The  intestinal 
epithelia  lose  their  functions  and  vitality  and  desquamate  in  flakes.  Prob- 
ably even  before  this  the  specific  poison  has  reached  the  circulation  and  in- 
duced a  paralysis  of  the  intestinal  capillaries  and  venules.  With  the  des- 
quamated flakes  of  epithelia  the  lumen  of  the  intestine  noAV  contains  serous 
fluid  exuded  from  the  paralyzed  capillaries.  The  intestinal  contents  are 
free  of  bile,  resemble  a  more  or  less  thick  meal-gruel  or  macaroni-  or  rice- 
water,  and  the  alvine  evacuations  present  the  well-known  appearance  of 
such  material,  but  often  somewhat  foamy,  and  they  are  strongly  alkaline 
in  reaction.  Besides  the  symptoms  above  indicated,  any  of  which  may  be 
wanting  or  but  little  prouounced,  there  is  now  more  or  less  suppression  of 
urine.  This  symptom  has  by  some  authors  been  ascribed  to  a  mechanical 
effect  of  the  enormous  exudation  of  the  fluid  of  the  blood  into  the  intestinal 
canal.  But  there  is  a  pathological  state  of  the  secretory  elements  of  the  kid- 
neys now  present  which  is  closely  analogous  if  not  identical  to  that  existing 
in  many  of  the  infectious  fevers,  and  it  is  highly  probable  that  the  suppres- 
sion of  urine  is  in  great  part  the  result  of  the  poisonous  action  upon  the 
kidney  of  the  specific  ptomaine  contained  in  the  blood. 

Whilst  serous  diarrhoea  is  customarily  an  exceedingly  prominent  symp- 
tom in  cholera  infectiosa,  yet  there  are  genuine  cases  of  the  disease  where  it 
is  totally  absent, — the  so-called  cases  of  cholera  sicca,  dry  cholera.  In  these 
cases,  although  there  may  be  no  diarrhoea  at  all,  the  autopsy  shows  almost 
invariably  an  enormous  quantity  of  the  grnmous  fluid  retained  in  the  intes- 
tinal canal  which  it  distends.  Moreover,  the  characteristic  aspect  of  the 
intestinal  contents  and  alvine  discharges  above  described  is  by  no  means 
invariable  :  instead  of  a  colorless  material  there  may  be  a  yellowish  or 
even  a  bloody  tinge,  and  there  may  be  a  certain  admixture  of  ordinary  in- 
testinal contents.     The  intellect  is  generally  clear. 

c.  The  stage  of  serous  diarrhoea  or  of  rice-water  discharo-cs  from  the 


916  CHOLERA    INFECTIOSA. 

bowels,  with  the  accompanying  symptoms,  lasts  for  a  variable  period  of  two 
or  three  to  several  hours.  Reaction  may  occur  at  the  end,  or,  what  is  more 
frequently  the  case,  collapse  may  set  in.  In  this  stage  the  vomiting  ceases, 
the  serous  discharges  are  interrupted,  or  the  contents  of  the  intestines  dribble 
away  unceasingly  and  involuntarily.  The  heart  almost  stops  its  pulsations ; 
the  thickened  blood  almost  ceases  to  flow ;  respiration  becomes  extremely 
shallow,  slow,  and  irregular ;  aphonia  is  complete,  as  also  is  anuria ;  the 
surface  is  cold  as  marble,  and  livid,  especially  that  of  the  orbit,  nose,  lips, 
fingers,  and  toes.  Even  the  tongue  and  the  breath  are  cold.  This  stage 
may  last  for  several  hours,  to  end  in  death  or  reaction. 

Although  the  surface-temperature,  as  estimated  by  the  hand  or  by  the 
ordinary  application  of  the  surface-thermometer,  is  usually  below  the  normal 
both  in  the  stage  of  serous  diarrhoea  and  in  that  of  collapse,  the  tempera- 
ture of  the  rectum  is  higher  than  in  health,  and  in  some  cases  is  greatly 
elevated.  Indeed,  notwithstanding  the  striking  coldness  of  the  cutaneous 
surfaces,  at  times  cadaveric,  the  patient  is  usually  sensible  of  the  most  con- 
suming internal  heat.  And  if  death  supervene  during  these  stages,  the 
temperature  of  the  corpse  may  ascend  several  degrees  above  the  normal 
body-heat  and  remain  there  for  some  hours.  Another  post-mortem  phe- 
nomenon, which  is  sometimes  startling  to  the  uninitiated,  is  the  not  infre- 
quent occurrence  of  marked  muscular  contractions  of  the  muscles  of  the 
face  and  extremities,  productive  of  various  facial  contortions  and  move- 
ments of  the  limbs. 

d.  The  stage  of  reaction  succeeds  that  of  serous  diarrhoea  or  of  collapse. 
In  the  most  fortunate  cases  convalescence  begins  at  once  and  proceeds  regu- 
larly to  the  rapid  restoration  of  health,  with  the  appearance  of  bile  and  of 
normal  fseces  in  the  intestinal  canal.  But  if  destruction  of  the  intestinal 
epithelia  and  involvement  of  the  subjacent  connective  tissue  of  the  mucosa 
have  been  extensive,  or  if  the  formed  elements  of  the  blood  have  seriously 
suffered,  as  not  infrequently  happens,  especially  in  the  so-called  toxic  form 
of  cholera,  one  of  three  issues  may  follow :  there  may  be  prolonged  anasmia 
with  all  its  usual  sequences,  or  there  may  be  a  long-continued  series  of 
digestive  derangements,  and  in  either  case  a  very  tardy  re-establishment  of 
health  ;  or  the  denuded  and  inflamed  intestinal  surfaces  may  afford  entrance 
to  septic  germs,  and  the  unfortunate  patient  pass  from  the  active  choleraic 
seizure  into  a  scarcely  less  dangerous  typhoid  condition  of  reactionary  septic 
fever. 

During  the  stage  of  reaction  numerous  and  extremely  varied  cutaneous 
manifestations  have  been  frequently  noted.  A  few  authors  have  also  re- 
corded the  occasional  occurrence  of  various  cutaneous  eruptions  during 
some  of  the  earlier  stages  of  the  disease,  even  during  that  of  premonitory 
diarrhoea. 

According  to  the  character,  gravity,  and  rapidity  of  the  attack,  besides 
those  already  noted,  various  qualifying  terms  have  been  employed  in  the 
description  of  cholera,  among  which  the  principal  are  cholerine,  cholera  fou- 


CHOLERA    INFECTIOSA.  917 

droyante,  cholera  toxica.  By  cholerine  is  meant  an  exceedingly  mild  form 
of  the  infectious  disease,  without  the  development  of  the  stage  of  collapse  or 
of  typhoid  reaction.  The  term  foudroyante  is  applied  to  those  exceedingly 
rapid  and  grave  cases  which  run  their  frightful  course  from  beginning  to 
end  in  a  very  few  hours.  In-  cholera  toxica  there  seems  but  little  evidence 
of  localization  of  the  initial  attack  upon  the  intestinal  canal ;  but  the  ner- 
vous centres  and  the  great  internal  organs  are  quickly  overwhelmed  with 
toxic  quantities  of  the  poison. 

Differential  Diagnosis. — During  the  prevalence  of  an  epidemic  of 
cholera  there  is  usually  no  difficulty  in  recognizing  an  attack  if  seen  in  the 
stage  of  serous  diarrhoea  or  of  collapse.  During  the  stage  of  typhoid  reac- 
tion the  course  of  the  fever  and  the  state  of  the  nervous  system  constitute 
an  ensemble  of  symptoms  very  closely  resembling  the  typlioid  state  of  sev- 
eral febrile  diseases  in  which  septicaemia  plays  an  important  role.  The 
typhoid  condition  in  cholera  infectiosa  is,  as  has  already  been  mentioned, 
essentially  a  septicaemia,  but  it  has  as  complications,  which  more  or  less 
influence  the  type  of  the  fever,  usually  serious  disorders  of  the  liver  and 
kidneys.  The  history  of  the  attack,  together  with  the  prevalence  of  the 
disease,  will  remove  all  doubt.  As  to  the  stage  of  premonitory  diarrhoea, 
we  have  already  declared  that  for  the  purpose  of  treatment  it  is  always  safe 
to  regard  it  as  the  beginning  of  an  attack  of  cholera  infectiosa. 

But  there  is  always  a  time  in  the  course  of  cholera  invasions  when  the 
difficulty  of  an  absolute  diagnosis  is  very  great,  if  not  really  impossible, 
unless  recourse  be  had  to  the  most  recent  discoveries.  Yet,  as  we  have 
pointed  out  already,  this  is  the  time  when  for  the  purposes  of  prophylaxis 
an  absolute  differential  diagnosis  should  be  promptly  made.  The  physician 
is  at  such  times  often  required  to  decide  between  the  presence  of  Asiatic 
cholera,  cholera  nostras,  pernicious  malarial  fever,  or  some  form  of  ptomaine 
or  mineral  poisoning.  The  existence  of  the  comma  bacillus  of  Koch  either 
in  the  dejecta  or  in  the  vomit  determines  at  once  the  presence  of  cholera 
infectiosa;  its  absence  and  the  presence  in  the  blood  of  the  plasmodium 
malariae  prove  tlie  existence  of  malaria. 

Treatment. — Knowledge  of  efficient  methods  of  treatment  of  cholera 
infectiosa  has  by  no  means  kept  pace  with  that  of  the  etiology  and  prophy- 
laxis of  the  disease.  Unless  the  so-called  methods  of  hypodcrmoclysis  and 
enteroclysis  shall  prove  as  effective  as  the  recent  experience  of  some  Italian 
observers  would  seem  to  indicate,  there  appears  to  have  been  no  marked 
advance  made  in  the  therapeutics  of  severe  attacks  of  cholera.  In  this  class 
of  cases  the  mortality  varies  from  thirty  per  cent,  to  eighty  or  ninety  per 
cent.,  and  seems  to  be  far  more  influenced  by  the  period  and  intensity  of  the 
epidemic  and  by  hygienic  surroundings  than  by  therapeutic  interference.  It 
has  often  happened  that  the  ratio  of  deaths  to  the  number  of  pronounced 
attacks  has  been  nearly  as  great  under  the  management  of  skilful  and  expe- 
rienced European  physicians  as  in  the  hands  of  native  East  Indian  attendants 
whose  chief  reliance  is  ui)on  charms  and  invocations.     Wliilst  tliis  is  true 


918  CHOLEEA   INFECTIOSA. 

of  severe  attacks  of  cholera,  nevertheless  there  is  scarcely  any  grave  disease 
which  is  more  manageable  if  it  be  properly  and  promptly  treated  during 
the  earlier  stages.  If  the  mortality  of  cases  in  the  later  stages  often  rises 
above  ninety  per  cent,  in  spite  of  active  and  intelligent  interference,  judicious 
management  of  the  disease  in  the  earlier  stages  is  usually  followed  by  as 
great  a  percentage  of  cure  or  abortion  of  the  attacks. 

In  the  stage  of  premonitory  diarrhcea,  absolute  rest  in  bed,  with  warm 
clothing  and  abstention  from  food,  should  be  enjoined ;  and  appropriate 
doses  of  laudanum,  either  alone  or  in  conjunction  with  some  form  of  cam- 
phor, such  as  chlorodyne,  should  be  administered ;  or  salicylate  or  tannate 
of  bismuth  may  be  used.  Nearly  always  this  simple  treatment  will  prove 
efficient. 

If,  however,  the  simple  diarrhoea  persists  or  shows  a  tendency  to  assume 
the  serous  type,  with  or  without  vomiting,  coldness,  prostration,  and  cramps, 
more  vigorous  treatment  is  urgently  called  for.  The  body  should  be  envel- 
oped in  hot  flannels,  and  heat  applied  to  the  extremities ;  cramps  should  be 
combated  by  local  frictions,  either  dry  or  with  whiskey-and-salt  or  the  like ; 
vomiting  should  be  checked,  if  possible,  by  swallowing  small  lumps  of 
cracked  ice,  and  by  sinapisms  applied  over  the  epigastrium.  The  two  reme- 
dies which  appear  to  be  most  efficacious  in  this  stage  of  the  attack  are,  how- 
ever, the  warm  bath  and  tannic  enterodyses.  The  temperature  of  the 
bath  should  be  38°  or  39°  C,  and  the  j)atient  should  be  immersed  in  it  to 
the  chin  and  kept  there  for  twenty  minutes.  After  removal  from  the  bath 
the  surface  should  be  very  quickly  dried  and  enveloped  again  in  hot  flannels, 
and  warm  aromatic  drinks  be  given.  The  bath  may  be  repeated  pro  re  nata 
in  two  or  more  hours.  The  effect  of  the  warm  bath,  in  arresting  or  allay- 
ing the  vomiting  and  in  quieting  the  general  nervous  system,  as  well  as  in 
restoring  warmth  to  the  cutaneous  surface,  arresting  the  cramps,  stimulating 
the  flagging  circulation  of  the  blood,  and  relieving  the  general  prostration, 
is  often  marked  to  the  eye  of  the  observer ;  and  it  is  usually  so  comfort- 
ing to  the  patient  that,  although  objected  to  at  first,  it  is  frequently  called 
for  after  being  once  experienced. 

But  the  enterodyses  of  tannic  acid  introduced  by  Prof.  Cantani,  of 
Naples,  and  so  frequently  used  by  other  Italian  physicians  during  the 
recent  cholera  epidemic  in  Italy,  would  seem  to  afford  the  greatest  reliance  in 
the  treatment  both  of  the  premonitory  diarrhoea  and  of  the  active  stages  of 
the  disease. 

If  a  slight  attack  of  a  seemingly  simple  diarrhoea  does  not  yield  at  once 
to  rest  in  bed  and  the  administration  of  a  dose  or  two  of  warm  infusion  of 
chamomile  to  which  chlorodyne  or  laudanum  has  been  added  in  proper 
quantity,  then  recourse  should  be  had  without  loss  of  time  to  the  warm 
enterod^yds  of  tannic  acid.  This  enteroclysis  is  essentially  an  injection  into 
the  colon  per  rectum  of  a  considerable  quantity  of  warm  water  holding  in 
solution  a  certain  percentage  of  tannin.  The  rectal  syringe  by  means  of 
which  the  injection  is  made  is  furnished  with  an  elastic  tube  three  metres  in 


CHOLERA    INFECTIOSA.  919 

length,  with  a  nozzle  at  the  free  extremity  and  a  cock  at  the  proximal  end. 
With  such  an  instrument  not  only  the  whole  length  of  the  colon  can  be 
filled  with  the  desired  fluid,  but  also  not  infrequently  a  quantity  can  be 
made  to  pass  beyond  the  ilco-ceeeal  valve  into  the  small  intestine. 

The  tannic  solution  recommended  by  Cantani  is  constituted  for  an  adult 
as  follows : 

U    Boiled  water  or  infusion  of  chamomile,  ivar77i,  2  litres  ; 

Tannin,  5  to  10  grammes  ; 

Laudanum,  30  to  50  drops  ; 

Powdered  gum-arabic,  50  grammes. 

The  temperature  of  the  mixture  and  the  quantity  to  be  injected  should 
vary,  according  to  the  age  of  the  patient  and  other  circumstances,  in  the 
judgment  of  the  physician.  The  most  convenient  time  for  administration 
of  an  enteroclyster  is  immediately  following  an  evacuation. 

It  is  the  experience  of  those  who  have  followed  this  method  of  treatment 
that  in  almost  every  case  of  cholera  taken  at  the  beginning  it  has  proved 
successful  in  a  surprising  manner  in  arresting  the  diarrhoea  and  stopping  the 
disease. 

In  the  language  of  Ramello,  "  If  all  of  those  who  suffer  from  diarrhoea 
in  time  of  cholera  would  at  once  have  recourse  to  tannic  enteroclysters,  the 
grave  cases  of  this  disease  would  be  very  rare."  But  the  first  and  the  second 
phase  of  the  disease,  in  which  medical  treatment  promises  its  most  certain 
triumphs,  are  usually  through  neglect  passed  before  the  physician  is  called. 
When  first  seen  the  patient  has  generally  advanced  far  towards  or  is  already 
in  the  stage  of  collapse,  when  the  system  is  nearly  overwhelmed  by  the 
quantity  of  specific  poison  already  absorbed  from  the  intestinal  caual  and 
by  the  excrementitious  substance  retained  in  the  economy  through  the  failure 
of  the  liver  and  the  kidneys  to  perform  their  excretory  functions,  and  when 
neither  the  substances  swallowed  per  os  nor  those  injected  per  rectum  are 
longer  absorbed. 

In  this  desperate  condition  the  warm  bath  repeated  every  hour  or  two 
may  be  resorted  to  with  some  prospect  of  benefit.  But  it  should  be  supple- 
mented by  an  attempt  to  restore  to  the  tissues  of  the  body  the  large  quanti- 
ties of  fluids  which  have  been  lost,  and  to  wash  out  from  them  some  of  the 
excrementitious  substances  which  have  not  been  eliminated.  For  this  pur- 
pose intravenous  injections  have  been  proposed,  and  during  the  last  epidemic 
were  more  or  less  extensively  practised,  but  Avithout  great  success,  as  a  rule. 
Another  method  of  accomplishing  the  end  in  view,  less  objectionable  and 
more  easy  of  application,  has  also  been  proposed  by  Cantani,  of  Naples,  and 
practised  by  him  and  his  countrymen  with  great  success,  as  reported.  It 
has  been  named  hypodermodysis.  It  is  claimed  that  this  method  is  neither 
irrational  nor  dangerous  nor  painful  nor  difficult  nor  lengthy  nor  inappli- 
cable in  a  large  number  of  cases.  The  method  of  hypodermodysis  is  based 
by  Cantani  upon  the  follcnviug  reasonable  considerations  : 


920  CHOLERA    INFEeriOSA. 

1.  The  death  of  cholera  patients  supervenes  either  by  asphyxia  in  the 
algid  period  or  in  consequence  of  a  tumultuous  reaction  in  the  typhoid  stage, 
because  the  organism  tlirough  diarrhoea  and  vomiting  has  lost  a  very  large 
quantity  of  its  aqueous  constituents,  and  has  retained  or  cannot  longer  elimi- 
nate the  excrementitious  materials, — the  products  of  combustion  and  of 
decay, — on  account  of  suppression  of  the  functions  of  the  kidneys. 

2.  Recovery  occurs  when  absorption  is  resumed,  in  the  intestinal  canal, 
of  the  fluids  which  furnish  to  the  blood  and  to  the  tissues  the  water  which 
is  indispensable  to  them. 

The  office  of  the  physician  is  therefore  to  introduce  this  water  into  the 
blood  and  tissues :  not  being  able  to  do  so  either  by  the  stomach  or  by  the 
rectum,  he  should  have  recourse  to  subcutaneous  injections,  and  in  this 
rational  manner  satisfy  the  need  of  the  whole  organism. 

Cantani  suggests  as  the  most  successful  time  for  resort  to  hypodermo- 
clysis  the  first  indications  of  insufficiency  of  Avater  in  the  body,  such  as 
discoloration  of  the  skin,  cramps,  coldness,  etc., — that  is  to  say,  in  the 
beginning  of  the  algid  period. 

The  formula  for  the  fluid  used  by  Cantani  for  hypodermoclysis  is,  for 

an  adult,  as  follows  : 

R   Pure  sodium  chloride,  80  grammes  ; 

Sodium  carbonate,  6  grammes. 
Dissolve  in  2  litres  of  boiled  water. 

The  quantity  to  be  injected  each  time  varies,  according  to  circumstances, 
from  one  to  two  and  one-half  litres.  The  temperature  of  the  solution 
should  be  38°  C,  unless  that  of  the  rectpm  be  very  low,  in  which  case  it 
has  been  sometimes  raised  as  high  as  43°  C. 

The  apparatus  required  is  very  simple.  One  of  the  best  forms  consists 
of  an  ordinary  fountain  syringe  having  a  long  elastic  tube,  to  the  distal  end 
of  which  is  attached  a  fine-pointed  metallic  cauula  supplied  with  a  cock. 

The  operation  is  as  simple  as  the  apparatus.  The  region  preferred  is 
either  the  mammary  or  the  ileo-costal.  A  fold  of  the  skin  is  raised,  and  the 
canula,  previously  filled  with  fluid,  is  inserted  quite  a  distance  between  the 
skin  and  the  subjacent  fascia.  The  fountain  of  the  syringe  is  elevated  until 
the  fluid  begins  to  flow  by  gravity.  In  fifteen  to  twenty  minutes  one  to 
two  litres  can  be  thus  injected.  During  the  process  the  current  should  be 
interrupted  at  intervals  by  means  of  the  cock.  Upon  withdrawal  of  the 
cauula  after  completion  of  the  operation,  the  tumor  should  be  gently  rubbed, 
when  the  fluid  will  very  soon  be  absorbed. 

The  warm  bath,  in  conjunction  with  hypodermoclysis,  appears  to  exer- 
cise a  powerful  influence  upon  absorption  also. 

After  hypodermoclysis,  hypodermic  injections  of  stimulants,  often  so 
u?gently  called  for,  especially  during  the  stage  of  collapse  or  rigidity,  become 
active,  whilst  they  have  before  been  inert. 

If  after  a  first  injection  the  coldness  and  the  wrinkling  of  the  skin  per- 
sist and  the  secretion  of  urine  be  not  re-established, — if,  in  a  word,  we  be 


CHOLEP.A   IXFECTIOSA.  921 

convinced  that  the  tissues  are  not  yet  supplied  with  the  Mater  which  they 
have  lost, — the  operation  should  be  repeated  some  hours  later. 

"  in  the  majority  of  cases,  however,  after  the  first  hypodermoclysis,  if 
the  internal  losses  have  not  been  such  as  to  be  incompatible  with  a  good 
reaction,  the  circulation  is  re-established,  the  eyes  open,  bathed  once  more 
with  their  natural  fluids,  and  show  an  expression  of  consciousness.  Little 
by  little  the  lividity  of  the  skin  diminishes,  and  the  timbre  of  the  voice 
becomes  normal.  In  less  than  an  hour,  a  person  who  Avas  at  the  mouth 
of  the  grave  is  restored  to  life. 

"The  physician  who  knows  how  to  use,  with  courage  and  reliance, 
laudanum,  tannic  enteroclysis,  warm  baths,  and  hypodermoclysis  will  have 
to  record  among  the  victims  of  cholera  only  those  unfortunates  who  when 
he  was  called  were  already  well  advanced  in  the  stage  of  cyanosis  and 
collapse." 

Such  are  the  confident  expressions  of  an  author  who  has  repeatedly  seen 
the  marvellous  results  of  this  new  practice.  In  summarizing  the  treatment 
he  says : 

"  First  Period  of  cholera,  improperly  called  premonitory  diarrhoea :  Rest 
in  bed,  warm  infusions  with  laudanum  or  chlorodyne  and  cognac ;  warm 
bottles  to  the  feet,  warm  general  baths,  and  warm  tannic  enterodysters. — 
Certain  cure. 

"  Second  Period,  specific  or  rice-form  diarrhcea :  Always  warm  baths, 
lemonade  acidulated  by  chlorohydric  or  tannic  acid,  with  laudanum,  spiritu- 
ous liquors,  warm  tannic  enterodysters,  lumps  of  ice  swallowed. — Cure 
almost  certain. 

"  Third  Period,  vomiting,  diarrhoea  always  more  profuse,  cramps  and 
coldness,  commencing  cyanosis  :  Hypodermoclysis  and  warm  baths,  alter- 
nated with  tannic  enteroclysis,  hypodermic  injections  of  stimulants,  revul- 
sives externally. — Very  many  cures." 

In  the  stage  of  typhoid  reaction  the  skill,  judgment,  experience,  and 
watchfulness  of  the  physician  are  taxed  to  the  utmost.  In  the  selection  of 
the  line  of  treatment  to  be  folloM^ed,  it  should  be  always  borne  in  mind  that 
we  have  to  do  with  a  fever  of  a  septic  character  consequent  upon  extensive 
abrasion  or  destruction  of  the  mucous  surfaces  of  the  intestinal  canal,  and 
complicated  by  serious  involvement  of  the  liver,  of  the  kidneys,  sometimes 
also  of  the  blood,  and  of  the  general  nervous  system. 

Prognosis, — The  mortality  of  cholera  infectiosa,  as  is  known,  is  some- 
times frightful.  It  is  usually  greatest  in  the  earlier  course  of  the  epidemic, 
and  it  is  limited  almost  entirely  to  those  who  neglect  to  invoke  the  aid  of 
the  physician  until  the  attack  has  become  exceedingly  grave.  If  the  patient 
is  seen  early  and  is  promptly,  judiciously,  and  constantly  cared  for,  the 
danger  of  a  fatal  issue  is  not  great.  If  the  practice  of  enteroclysis  and 
hypodermoclysis  meet  the  claims  made  for  them,  the  disease  will  be  robbed 
of  many  of  its  terrors. 


JOINED  twins; 

By  WILLIAM  WRIGHT  JAGGAED,  M.D, 


Joined  Twins,  or  double  monsters,  are  those  malformations  that  appear 
to  be  two  individuals  Avhich  are  united  to  a  greater  or  less  degree,  and  which 
have  mutually  influenced  development  at  the  site  of  union.  In  very  many 
cases,  each  of  the  individuals  which  constitute  the  monster  is  symmetrically 
developed,  and  the  vice  of  development  at  the  site  of  union  affects  both 
individuals  in  an  equal  degree.  In  other  cases,  however,  one  individual  is 
larger  and  more  perfectly  developed  than  the  other.  The  larger  frame  will 
then  represent  the  main  body,  or  parent  stock,  while  the  smaller  individual 
will  appear  as  a  parasitic  appendage.  There  are,  then,  two  general  groups 
of  joined  twins  :  1,  the  equal  or  perfect  double  monsters,  and,  2,  the  unequal 
or  parasitic  double  monsters.  This  division  is  merely  for  the  sake  of  con- 
venient discussion,  since  a  difference  of  degree  alone  exists  between  coequal 
duplex  individuals  and  those  congenital  tumors  that  contain  bone,  nerve, 
fat,  and  the  like,  of  a  second  foetus. 

Isidore  Geoifroy  Saint-Hilaire  has  formulated  certain  general  laws  with 
reference  to  the  attitudes  of  the  individuals  that  enter  into  the  constitution 
of  double  monsters.  These  laws  may  be  regarded  as  demonstrated.  They 
are : 

When  two  or  more  individuals  are  united  in  the  composition  of  a  monster, 
double  or  more  than  double,  the  union  takes  place  between  homologous 
surfaces  of  the  bodies.  Thus,  in  a  double  monster,  if  one  of  the  individuals 
is  adherent  by  the  ventral  surface,  it  is  to  the  ventral  surface  of  the  fellow 
that  it  is  generally  united,  and  not  to  the  dorsal  nor  to  one  of  the  lateral 
surfaces.     The  same  law  is  true  of  triplex  monsters. 

Furthermore,  if  the  two  individuals  that  compose  a  double  monster  are 
compared,  they  will  be  found  to  be  placed  and  their  organs  disposed  more 
or  less  symmetrically  upon  the  two  sides  of  the  line  or  of  the  plane  of  their 
union.     The  same  law  is  true  of  triplex  monsters. 

Genesis. — Double  monsters  and  homologous  twins  are  the  product  of  a 
single  ovum,     Tiio  view  is  no  longer  tenable  that  twins  within  separate 

'  The  manuscript  of  this  article  was  received  too  late  for  it  to  appear  in  the  place  origi- 
nally assigned  to  it. 
922 


JOINED   TWINS.  923 

envelopes  may  come  in  the  course  of  their  development  to  be  so  close  to 
each  other  that  the  membranous  partition  disappears,  and  coalescence  of  the 
foetuses  takes  place. 

Opinions,  however,  differ  widely  as  to  the  mode  in  which  double  mon- 
sters originate  in  a  single  ovum.  There  still  remain  a  few  observers  who 
think  these  beings  arise  from  the  fertilization  of  a  single  ovum,  containinir 
two  germinative  vesicles,  and  from  the  fusion  of  the  two  resultant  germinal 
masses.  But  the  weight  of  evidence  and  opinion  is  greatly  in  favor  of  the 
notion  that  double  monsters  have  their  origin  not  only  in  a  single  ovum, 
but  also  in  a  single  blastodermic  vesicle.  While  the  proposition  is  generally 
accepted  that  all  double  monsters  origmate  in  a  single  ovum  and  are  developed 
out  of  a  single  germinative  vesicle,  numerous  hypotheses  have  been  suggested 
to  explain  the  modality  of  the  further  grow^th  and  development  of  these 
beings.  At  the  present  time,  two  principal  hypotheses,  apparently  con- 
tradictory propositions,  are  vigorously  defended  in  the  explanation  of  the 
phenomena.  They  are,  1,  the  hypothesis  of  Fusion,  and,  2,  the  hypothesis 
of  Fission.  To  these  may  be  added  a  third  supposition, — though  of  minor 
significance, — the  hypothesis  of  Radiation.  These  three  attempts  at  the 
interpretation  of  the  phenomena  by  no  means  exhaust  the  possibilities  in 
the  conception  of  the  genesis  of  double  monsters,  with  the  records  of 
which  the  literature  of  the  subject  abounds. 

1.  The  Hypothesis  of  Fusion. — According  to  this  hypothesis,  when  the 
first  traces  in  the  germinal  disk  become  visible,  two  distinct  embryonic  areas 
are  already  present,  which  either  persist  entirely  separate  and  develop  into 
homologous  twins,  or  which  unite  with  each  other  to  a  variable  extent.  This 
notion  is  maintained  chiefly  in  France,  and  Claudius,  Panum,  and  B.  &, 
Schultze  may  be  named  among  its  defenders. 

The  Germans  reject  this  hypothesis,  calling  it  "  naive,"  for  the  follow- 
ing reasons : 

1.  Foetal  malformations  present  an  uninterrupted  transition-series  from 
a  supernumerary  terminal  phalanx  to  a  complete  double  monster.  It  is  not 
easily  conceivable  that  a  supernumerary  terminal  phalanx  could  arise  from 
a  twin  pregnancy  in  which  all  of  the  one  twin  except  its  terminal  phalanx 
had  disappeared.  In  foetal  malformations,  moreover,  there  is  no  evidence 
of  the  disappearance  of  any  organ  :  the  rudimentary  organs  appear  only  as 
aplastic. 

2.  Double  monsters  in  all  their  variations  show  a  certain  regularity  and 
symmetry  of  formation  ;  only  synonymous  organs  and  systems  are  con- 
joined, a  condition  that  would  not  occur  in  case  of  accidental  fusion.  An 
apparent  exception  to  this  rule  is  observed  in  craniopagus,  in  which  the 
frontal  may  be  found  joined  to  the  parietal  bone. 

3.  The  fusion  of  two  embryos  has  never  been  observed.  When  two 
embryos  lie  too  close  to  each  other  in  the  cavum  uteri,  one  is  often  found 
pressed  out  flat, — foetus  papyraceus, — but  it  is  never  seen  to  be  fused  with 
its  fellow  (Perls). 


924  JOINED   TWINS. 

2.  Tlie  Hypothesis  of  Fission  is  that  the  blastoderm  in  all  cases  is  simple 
in  the  beginning,  but  that  this  primitive,  single  germinal  mass  splits  up 
more  or  less  completely,  and  gives  origin  in  this  mode  either  to  joined  twins 
or  to  individuals  that  are  separate.  This  hypothesis  also  includes  the  notion 
of  external  gemmation  or  budding.  Among  the  sponsors  of  the  hypothesis 
may  be  mentioned  the  names  of  Reichert,  Donitz,  F5rster,  Bruch,  Ditt- 
mar,  Virchow,  Ahlfeld,  Ollacher,  and  Gerlach.  As  already  intimated,  the 
hypothesis  of  fission  is  warmly  defended  in  Germany.  This  view  offers  a 
plausible  explanation  of  the  uninterrupted  transition-series  of  malformations 
from  polydactylus  to  the  complete  double  monster,  and  the  weight  of  prob- 
able evidence  is  in  its  favor.  In  this  connection,  mention  must  also  be  made 
of  the  important  experimental  observation  of  Gerlach,  who  has  succeeded 
in  producing  anterior  duplicity  in  at  least  one  case.  Valentin,^  at  a  much 
earlier  period,  claimed  to  have  brought  about  duplicity  of  development  in 
the  embryo  of  the  chick  by  artificial  fission,  but  the  facts  in  his  cases  hav^e 
been  seriously  questioned.  Perls  ^  makes  an  ingenious  attempt  at  the  recon- 
ciliation of  these  two  hypotheses,  which,  as  before  remarked,  are  apparently 
contradi ctory  propositions. 

3.  Hypothesis  of  Radiation. — Rauber  has  announced  a  third  hypothesis, 
which  differs  in  essential  points  from  the  two  views  just  mentioned.  This 
observer  assumes  a  principle  of  radiation  as  the  basis  of  his  hypothesis.  In 
the  earliest  period  of  ontogenesis,  the  primitive  embryonal  germ  sustains  a 
radial  arrangement  to  the  centre  of  the  area  pellucicla.  Rauber  calls  this 
mode  of  development  monoradial.  In  the  genesis  of  a  multiple  monstrosity, 
several  primitive  embryonal  germs  arrange  themselves  in  a  radial  fashion, 
and  the  mode  of  development  is  termed  pluriradial.  The  process  of  radia- 
tion is  described  in  the  following  words  :  "  Just  as  under  normal  conditions 
the  anterior  embryonal  germ  of  the  vertebrates  appears  as  a  projection,  as 
a  ray,  from  the  marginal  elevation,  so  the  multiple  formations  appear  as 
multiple  projections,  or  rays,  from  the  marginal  elevation." 

Causation. — The  discussion  of  the  cause  of  double  monsters  is  foreign 
to  the  purpose  of  this  paper,  inasmuch  as  the  subject  is  of  a  purely  specu- 
lative nature.  Mention,  however,  must  be  made  of  the  views  of  Marchand, 
that  refer  the  duplicity  of  the  embryonic  germ  to  factors  that  are  in  opera- 
tion before  segmentation  of  the  yolk, — that  is,  to  conditions  of  the  ovum  or 
spermatozoid  before  fertilization.  Like  Fol,  he  is  of  the  opinion  that  the 
penetration  of  the  vitelline  membrane  by  two  or  more  spermatozoids  may 
give  origin  to  two  or  more  centres  of  segmentation. 

The  influence  of  materual  impressions  in  the  explanation  of  the  occur- 
rence of  double  monsters  is  often  invoked,  and,  unfortunately,  not  merely 
by  the  laity.  Although,  as  remarked  by  Parvin,  the  belief  that  the  un- 
born child  mav  be  affected  through  the  mother's  mind  has  the  alleged  crite- 
rion  of  truth  that  it  is  universal  and  perennial,  nevertheless  the  notion 


1  Arch.  f.  phys.  Heilk.,  1851.  ^  AUgemeine  Pathologie,  1886,  p.  668. 


JOINED    TWINS.  925 

rests  upon  no  basis  in  objective  fact.  Experience  teaches  that  fright,  bodily 
violence,  and  the  like  may  cause  structural  alterations  in  the  ovum  as  the 
effect  of  hemorrhage,  partial  rupture  of  the  membranes,  incomplete  loss  of 
their  contents,  that  sometimes  result  in  the  production  of  monstrosities. 
But  the  direct  influence  of  the  mental  attitude  of  the  mother  upon  the 
phvsical  development  of  the  foetus  in  utero,  in  the  absence  of  any  such 
coarse  physical  cause,  is  an  item  of  absolute  conjecture.  Then  it  must  be 
borne  in  mind  that  all  gross  errors  of  development  are  announced  at  a  very 
early  period  in  the  history  of  the  embryo, — before  the  expiration  of  the 
eighth  week, — a  period  considerably  antecedent  to  the  time  frequently  ap- 
pointed by  the  popular  mind  for  the  operation  of  maternal  impressions. 

Nomenclature. — The  nomenclature  of  double  monsters  is  extraordi- 
narily rich.  In  this  article  the  terms  employed  by  Gurlt  and  Forster  will 
be  chiefly  used. 

When  the  common  portion  is  relatively  extensive,  the  monster  creates 
the  impression  of  being  a  single  individual  of  which  some  particular  part 
is  duplex,  and  is  less  suggestive  of  two  individuals.  Under  these  con- 
ditions, the  designation  is  selected  that  is  made  up  out  of  the  name  of  the 
duplex  portion,  and  the  termination  -didymus  (Stdu/j-oq,  "double"),  or  the 
prefix  0!-,  is  used. 

On  the  other  hand,  when  the  common  portion  is  relatively  small,  the 
monster  creates  the  impression  of  being  two  individuals  that  are  united, 
and  is  less  suggestive  of  a  single  being.  Xow  the  name  is  chosen  from  the 
portion  common  to  the  two  individuals,  and  the  termination  -pagus  {izriY'^oin, 
to  "  unite"),  or  the  prefix  o-yv-,  is  employed.  Then  there  are  also  analogical 
terms,  as  Janiceps. 

Classification. — As  remarked  by  Harrison  Allen,  it  is  an  open  ques- 
tion to  what  extent  a  malformation  like  a  double  monster  can  be  called  a 
genus,  and  to  what  degree  the  subdivision  of  each  genus  may  be  designated 
a  species,  so  long  as  naturalists  are  not  agreed  as  to  the  restriction  of  these 
terms  in  normal  plants  and  animals.  For  the  purpose  of  discussion,  how- 
ever, some  systematic  arrangement  of  these  objects  is  absolutely  necessary. 
The  original  classification,  proposed  by  Isidore  Geoffroy  Saint-Hilaire,  has 
been  variously  modified  by  Gurlt,  Forster,  and  others,  in  accordance  with 
the  hypothesis  of  the  development  of  these  beings  by  the  fission  of  a  single 
germinal  area. 

The  axial  structures  may  be  split  from  above  downward,  giving  origin 
to  double  monsters  that  are  joined  at  their  caudal  extremity,  but  whose 
cerebro-spinal  axes  diverge  in  varying  degrees  as  they  ascend, — hence  Terata 
kaiadidymo,  monsters  with  downward  cleavage. 

Double  monsters  may  be  joined  at  the  cephalic  pole  with  divergence 
of  the  caudal  extremities.  In  this  manner  are  produced  beings  that  are 
single  above  and  double  below, —  Terata  anadidyma,  monsters  with  upward 
cleavage. 

Finally,  fission  may  occur  at  the  same  time  from  above  downward  and 


926  JOINED   TWINS. 

from  below  upward,  but  the  process  is  arrested  before  complete  separation, 
and  there  result  beings  whose  cephalic  and  caudal  extremities  are  divergent 
while  the  intermediate  region  is  continuous  in  a  greater  or  less  degree, — 
Terata  anakatadidyma,  monsters  with  both  upward  and  downward  cleavage. 

DOUBLE   MONSTERS. 

A.  Terata  Katadidyma. 

Monocranus. 

Dicranus, 

Diprosopus. 

Iniodymus  (Fig.  1). 

Opodymus  (Fig.  2). 
Dicephalus. 

D.  dibrachius  (Fig.  3). 

D.  tribrachius. 

D.  tetrabrachius  (Figs.  4  and  5). 

D.  tetrabrachius  tripus  (Fig.  6). 

D.  parasiticus. 
Ischiopagus. 

I.  tetrapus  (Figs.  7  and  8). 
Pygopagus  (Figs.  9  and  10). 

P.  parasiticus. 

B.  Terata  Anadidyma. 

Dipygus. 

D,  dibrachius  tetrapus  (Figs.  11  and  12). 

D.  dibrachius  tripus  parasiticus  (Fig.  13). 
Syncephalus. 

Janiceps  asymmetros  (Figs.  14  and  15). 

Janiceps  (Fig.  16). 
Craniopagus  (Figs.  17  and  18). 

C.  parasiticus. 

C.  Terata  Anakatadidyma. 

Prosopo-thoracopagus  (Fig.  19). 

P.  parasiticus. 
Thoracopagus. 

Xiphopagus  (Fig.  20). 

Sternopagus  (Figs.  21  and  22). 

S.  parasiticus  (Figs.  23  and  24). 

Terata  Katadidyma.  Monocranus, — single  cranium,  face  double  in 
part,  three  or  four  eyes,  brain  duplex  in  various  degrees. 

Dicranus, — double  cranium,  face  single  or  double  and  fused,  lower  jaw 
single. 

Diprosopus, — face  more   or   less  double;    the   faces,  and   in  part  the 


Fig.  1. 


Fig.  2. 


iNiuDYMUS  (Depaul). 


Fig.  3. 


Opodymus  (Soemmering). 


UlCKl'IIALVS   DiBKACHIL-S. 


JOINED    TWINS.  927 

cranium  to  the  occiput,  completely  separate  (luiodvmus),  or  the  faces  are 
separated  to  the  zygomatic  arch  (Opodymus) ;  in  both  cases,  double  lower 
jaw  (Figs.  1  and  2). 

Dicephalus, — characterized  by  the  presence  of  two  distinct  and  separate 
heads,  either  equal  or  unequal,  with  various  degrees  of  duplicity  in  the 
vertebral  column.  The  bodies  are  joined  laterally,  the  faces  look  forward 
and  commonly  in  the  same  direction.  According  to  Fisher,^  out  of  five 
hundred  cases  of  human  double  monsters  that  are  recorded,  about  one-third 
belong  to  this  genus.  The  female  sex  preponderates  in  the  proportion  of 
two  to  one.  In  very  rare  cases,  one  of  the  embryonal  masses  persists  in  a 
rudimentary  state,  and  forms  an  appendix  to  its  fellow, — Dicephalus  para- 
siticus.    Under  Dicephalus  are  included  the  following  species : 

DicepjJialus  dibraehius. — A.  Otterson^  has  given  the  following  excellent 
report  of  a  case  of  this  species  : 

History. — Mother,  a  multipara ;  utero-gestation  was  unattended  by  any 
event  at  all  noteworthy ;  earlier  stages  of  labor  prolonged ;  a  head  was 
finally  delivered  by  forceps,  after  which  no  progress  was  made  for  some 
hours.  Dr.  Otterson  attempted  to  introduce  his  hand  into  the  uterus  for 
exploration ;  partial  version  of  the  retained  parts,  engagement  of  the 
breech ;  efficient  contractions  with  expulsion  of  the  breech  and  body,  fol- 
lowed by  the  second  head.  The  child  was  dead  when  delivered.  The 
mother  made  an  uninterrupted  recovery. 

The  specimen  was  presented  to  the  Museum  of  the  Brooklyn  Anatomi- 
cal and  Surgical  Society,  and  has  been  accurately  described  in  the  following 
words  by  Lewis  S.  Pilcher^  (Fig.  3)  : 

The  child  has  two  distinct  and  perfect  heads  and  necks,  one  trunk,  two 
upper  and  two  lower  extremities ;  length,  forty-eight  centimetres.  The  tAvo 
heads  differ  slightly  in  size ;  circumference  of  the  left  head  thirty-six  centi- 
metres, that  of  the  right  head  thirty-three  centimetres.  There  is  no  anal 
orifice.     The  genitals  are  male,  single  and  perfect. 

Skeleton. — The  vertebral  columns  are  distinct  and  perfect  throughout ; 
they  approach  each  other  gradually  from  above  downward  as  far  as  to  the 
lumbar  region,  whence  they  run  parallel  to  each  other,  being  separated  by 
a  small  interval ;  the  sacra,  each  distinct  and  perfect,  articulate  with  each 
other  by  means  of  an  interarticular  fibro-cartilage  that  unites  the  contiguous 
auricular  surfaces  of  the  two  bones.  From  each  sacrum  springs  the  in- 
nominate bone  that  forms  the  wall  of  the  pelvis  upon  that  side;  at  the 
symphysis  pubis  the  two  unite  as  usual.  The  corresponding  dorsal  verte- 
brae of  the  two  columns  are  united  by  a  series  of  bony  arches  formed  by 
coalesced  ribs ;  each  arch  or  compound  rib  has  two  normal  heads,  one  at 
either  extremity,  by  which  it  articulates  with  the  proper  vertebrae.     The 


1  Transactions  New  York  State  Medical  Society,  1865,  18G6,  1807,  and  1868. 

2  Annals  of  Brooklyn  Anatomical  Society,  1880. 

3  Annals  of  the  Anatomical  and  Surgical  Society,  Brooklyn. 


928  JOINED   TWINS. 

ribs,  which  spring  from  the  free  sides  of  the  two  vertebral  columns,  are 
connected  to  a  common  single  sternum  in  front  by  unusually  long  costal 
cartilages,  and  thus  complete  the  thorax. 

The  clavicle  and  scapula  of  either  side  are  normally  related  to  the 
sternum  and  ribs.  Resting  upon  the  posterior  face  of  the  upper  compound 
ribs,  in  the  middle  of  the  back  between  the  two  series  of  dorsal  spines,  is  a 
compound  scapula  formed  by  the  fusion  of  two  bones  along  their  anterior 
edges ;  an  acromion  process,  club-shaped,  projects  forward  from  the  middle 
of  the  upper  edge  of  this  compound  scapula ;  articulating  with  this  process, 
and  passing  directly  forward  to  articulate  with  the  sternum  at  its  upper 
border,  the  episternal  notch  affording  an  articulating  surface,  is  a  slender 
compound  clavicle. 

Respiratory  System. — Two  sets  of  respiratory  organs  are  present,  each 
independent  and  perfect.  There  are  four  pleural  sacs.  By  the  blending  of 
the  pleural  layers  that  lie  in  contact  in  the  middle  line,  a  fibro-serous 
septum  is  formed  that  divides  the  thorax  into  two  cavities  posteriorly; 
these  middle  pleural  sacs  and  their  contents  are  hidden  from  view  anteriorly 
by  a  large  pericardial  sac,  with  the  posterior  wall  of  which  the  anterior 
margin  of  the  septum  described  becomes  blended. 

Circulatory  System. — The  pericardium  lies  in  the  middle  line,  directly 
behind  the  sternum,  and  extends  to  some  distance  on  each  side  of  it.  The 
sac  is  single,  and  encloses  a  compound  heart,  the  ventricular  portions  of 
which  remain  separate,  while  the  auricles  are  blended  together.  Consti- 
tuting the  left  mass  of  the  heart  are  two  ventricles  and  one  auricle  (the  left), 
which  are  of  normal  size,  shape,  and  relative  position.  The  origins  and 
relation  of  the  aorta  and  pulmonary  artery  upon  this  side  are  normal.  Into 
the  auricle  enter  four  pulmonary  veins.  The  elements  of  the  right  mass 
are  more  changed  :  there  is  but  one  ventricle,  which,  however,  is  larger  than 
either  of  the  ventricles  of  the  other  mass ;  from  the  right  side  of  its  base 
springs  a  second  aorta ;  there  is  no  pulmonary  artery  on  this  side.  There 
is  no  apparent  attempt  at  differentiation  of  the  auricles :  there  is  simply  a 
single  capacious  auricle,  which  is  blended  with  the  right  auricle  from  the 
left  mass,  forming  a  huge  venous  reservoir.  At  the  right  posterior  side  of 
this  reservoir  enter  two  small  pulmonary  veins  from  the  right  pair  of  lungs. 
A  single  ascending  vena  cava  collects  the  blood  from  the  lower  portion  of 
the  body ;  above,  the  left  innominate  vein  of  the  left  child  crosses  trans- 
versely its  neck  to  the  point  of  junction  of  the  two  necks,  receiving  the 
right  internal  jugular  in  its  course ;  here  it  is  joined  by  tlie  left  internal 
jugular  of  the  right  neck,  and  by  a  large  anomalous  vein  from  behind ;  the 
large  descending  vena  cava  thus  formed  descends  in  a  straight  course  to  the 
middle  of  the  compound  auricle.  The  right  innominate  vein,  formed  by 
the  right  internal  jugular  and  right  subclavian  veins  of  the  right  neck, 
empties  into  tiie  compound  auricle  at  its  right  side.  The  two  aortas  descend 
each  upon  the  left  side  of  their  proper  vertebral  colunnis ;  they  do  not  unite 
below,  nor  bifurcate,  but  each  diverging  continues  as  a  common  iliac,  and. 


Fig.  4. 


Fig.  5. 


Rita-Christina  (Serres). 


DiCEPHALUS  Tetrabrachius  (Serres). 


Fig.  6. 


Rose-Mahil;  Drovin,  "the  Saint  BfeNoiT  Twins." 


JOINED   TWIXS.  929 

after  giving  off  the  umbilical  artery,  passes  on  to  be  distributed  to  a  lower 
limb. 

Digestive  System. — There  are  two  stomachs.  The  left  is  of  normal 
shape  and  size,  and  occupies  its  usual  place  in  the  abdomen.  To  its  cardiac 
end  is  attached  a  normal  spleen, — the  only  one  present.  The  right  stomach 
is  smaller,  pyriform,  hidden  behind  the  liver,  and  lies  very  obliquely,  with 
its  pylorus  pointing  towards  the  pylorus  of  the  other.  Its  duodenum  joins 
at  once  the  left  duodenum,  and  the  two  bowels  appear  fused  together  for 
about  one-sixth  of  their  entire  length ;  a  well-marked  longitudinal  groove 
so  marks  the  fused  bowel  that  the  appearance  of  a  double-barrelled  gun  is 
produced  ;  transverse  section  shows  that  they  are  divided  by  a  membranous 
septum  into  two  distinct  tubes,  each  with  its  own  mesentery ;  this  persists 
through  a  length  equal  to  one-third  of  the  whole ;  then  they  again  fuse,  and 
the  double-barrelled  arrangement  persists  through  a  length  somewhat  greater 
than  at  the  beginning ;  the  small  intestine  finally  becomes  single,  and  con- 
tinues thus  to  its  junction  with  the  large  intestine,  which  likewise  remains 
single  to  its  termination ;  at  the  point  of  beginning  of  the  single  tube  a 
small  nipple-like  diverticulum  exists.  The  rectum  descends  to  the  bottom 
of  the  pelvis,  where  it  ends  in  a  cul-de-sac.  The  liver,  upon  its  surface, 
appears  to  be  a  simple  organ,  but  from  its  posterior  inferior  border  project 
supernumerary  lobes,  the  evident  remains  of  a  second  liver.  There  is  but 
one  gall-bladder. 

Geniio-TJnnary  System. — There  are  three  kidneys, — a  large  compound 
kidney  lying  in  the  mid-lumbar  sulcus,  and  one  in  either  lateral  lumbar 
region.  The  left  kidney  is  greatly  atrophied.  The  bladder  is  single ;  the 
genital  organs  are  single  and  well  developed. 

Nervous  System. — Each  head  and  neck  and  each  lateral  half  of  the 
body  is  supplied  by  its  own  cerebro-spiual  axis ;  along  the  line  of  fusion 
only  is  there  any  communication  between  the  branches  of  the  two  axes. 

The  important  question  as  to  the  viability  of  this  monster,  apart  from 
the  accidents  of  birth,  has  been  answered  in  the  negative  by  Pilcher,  from 
consideration  of  the  structure  of  the  heart  and  great  vessels.  The  left  mass 
of  the  compound  heart  was  complete,  and  apparently  equal  to  the  perform- 
ance of  its  functions,  so  far  as  they  related  to  tlie  left  child ;  but  the  right 
mass,  composed  of  but  one  auricle  and  one  ventricle,  with  no  pulmonary 
artery,  was  obviously  unequal  to  its  task.  There  was  present  no  anastomosis 
between  any  large  arteries  of  the  two  systems  to  permit  the  admixture  of  ar- 
terial blood  with  the  venous  current  of  the  right  system.  Accordingly,  had 
the  monster  been  born  alive,  the  right  child  would  have  perished  at  once 
from  asphyxia,  and  the  speedy  death  of  the  left  child  ^vonld  liave  followed. 

Dicephalus  tribrachius. 

Dicephalus  tetrabrachius  is  an  example  of  anterior  duplicity  in  which 
cleavage  extends  downward  through  the  thorax  as  far  as  to  the  abdomen. 
These  beings  possess  two  hearts  and  two  pairs  of  lungs,  and  are  viable. 
Occasionally  the  sacrum  and  ilia  are  double. 
Vol.*  I.— 59 


930  JOINED    TWIXS. 

A  specimen  of  dicephalas  tetrabrachius  dipus  is  presented  in  tlie  weii- 
known  case  of  Rita-Christina,  who  died  at  Paris,  November  23,  1829. 
having  reached  an  age  of  eight  months  and  eleven  days.  The  autopsy 
was  conducted  by  Serres,  from  whose  report  Figs.  4  and  5  are  taken. 

Sometimes  a  third  lower  extremity,  either  rudimentary  or  perfect,  is 
present, — dicephalus  tetrabrachius  tripus  (Fig.  6).  Of  this  species  the 
living  female  double  monster  known  as  the  St.  Benoit  twins  is  a  typical 
example. 

Prof.  Duncan  C.  MacCallum,  of  Montreal,  gives  ^  the  following  descrip- 
tion of  this  specimen  : 

These  children  are  the  products  of  a  second  gestation.  They  were  born 
at  St.  B§noit,  county  of  Two  Mountains,  Quebec,  on  February  28,  1878. 
The  mother  is  a  fine,  healthy-looking  woman,  aged  twenty-six  years.  Her 
labor  lasted  seven  hours,  commencing  at  one  a.m.  and  terminating  at  eight 
A.M.  One  head  and  body  were  born  first ;  this  was  shortly  followed  by 
the  lower  extremities,  and  immediately  afterw^ards  the  second  body  and 
head  were  expelled. 

The  names  Marie  and  Rose  have  been  given  to  the  right  and  left  child 
respectively ;  surname,  Drouiu. 

Marie  is  more  strongly  developed  and  healthier-looking  than  her  sister 
Rose,  who  is  smaller,  darker,  and  more  delicate-looking.  They  are  both 
bright,  lively,  and  intelligent-looking  children.  The  two  bodies,  from  the 
heads  as  far  as  the  abdomen,  are  well  formed,  perfectly  developed,  and  in  a 
state  of  good  nutrition.  The  union  between  them  commences  at  the  lower 
part  of  the  thorax  of  each,  and  from  that  part  downwards  they  present  the 
appearance  of  one  female  child ;  that  is,  there  is  but  one  abdomen  with  one 
navel,  a  genital  fissure  with  the  external  organs  of  generation  of  the  female, 
and  two  inferior  extremities.  The  floating  ribs  are  distinct  in  each,  as  is 
also  the  ensiform  cartilage.  The  lateral  halves  of  the  abdomen  and  the  in- 
ferior extremities  correspond  in  size  and  development  respectively  to  the 
body  of  the  same  side ;  and  the  same  remark  applies  to  the  labia  majora. 
The  spinal  columns  are  distinct  and  appear  to  meet  at  a  pelvis  common  to 
both,  although  the  fusion  of  the  children  commences  at  some  distance  above 
their  junction.  From  near  the  extremity  of  each  spine  a  fissure  extends 
dowuAvard  and  inward,  meeting  its  fellow  of  the  opposite  side  at  the  cleft 
between  the  buttocks  near  the  anus,  including  a  somewhat  elevated  soft 
fleshy  mass,  thicker  below  than  above.  At  a  central  point  between  these 
fissures,  at  the  distance  of  sixty-fi)ur  millimetres  from  the  point  where  the 
vertebral  columns  meet,  and  eighty-nine  millimetres  from  the  anus,  there 
projects  a  rudimentary  limb  with  a  very  movable  attachment.  This  limb, 
which  measures  one  hundred  and  twenty-seven  millimetres  in  length,  and  is 
provided  with  a  joint,  tapers  to  a  fine  point,  which  is  furnished  with  a  dis- 
tinct nail.    It  is  very  sensitive,  and  contracts  strongly  when  slightly  irritated. 

1  Canada  Medical  and  Sursical  Journal,  October,  1878. 


Fig.  7. 


Fig.  8. 


IscHioPAGUS  (Prochaska). 


Fig.  9. 


Pelvis  of  an  Ischiopagus  (after  Du 
Verney). 


The  Two-Headep  Nightingale. 


,\\\lii'S'pK\i\ 


Helen  and  Judith. 


DiPYGis  Tetrapus.— Four-legged  female 
infant,  J.  Myrtle  Corban  (from  photograph 
taken  in  Nashville,  Tennessee,  June  16, 1S68). 


JOINED   TWINS.  931 

The  spinal,  respiratory,  circulatory,  and  digestive  systems  of  these  chil- 
dren are  quite  distinct.  They  have  each  a  separate  diaphragm,  and  the 
abdominal  muscles  on  each  side  of  the  mesial  line  and  the  limbs  of  that  side 
are  supplied  with  blood  by  the  vessels  and  are  under  control  of  the  nervous 
system  of  the  corresponding  child.  They  have  each  a  distinct  stomach  and 
a  separate  alimentary  canal  (the  two  alimentary  canals  probably  joining  at 
a  point  close  to  the  common  anus).  It  would  follow  that  the  accessory 
organs  of  the  digestive  system  are  distinct  for  each  child.  The  two  fissures 
behind  are  evidently  the  original  clefts  between  the  buttocks  of  each  child, 
one  buttock  remaining  in  its  integrity,  whilst  the  other  in  a  rudimentary 
condition  is  fiised  with  that  of  the  opposite  child,  forming  the  soft  fleshy 
mass  from  the  upper  part  of  which  the  rudimentary  limb  projects. 

The  St.  Benoit  twins  were  seen  and  photographed  by  Lewis  S.  Pilcher 
when  they  had  attained  the  age  of  thirteen  months.  Pilch er's  observations 
correspond  with  those  of  MacCallum.  He  says,  "  Its  vital  functions  were 
all  being  performed  regularly  and  properly,  and  the  mental  development  of 
the  two  parts  was  equal  to  that  usual  in  children  of  its  age.  It  apparently 
had  as  good  an  expectation  of  living  to  maturity  as  any  other  infant." 

It  is  claimed  that  the  St.  Benoit  twins  survived  their  birth  a  longer 
period  than  any  other  recorded  case  of  the  three- footed,  four-armed  di- 
cephalic  monster.  MacLaurin's  case^  lived  only  two  months.  The  St. 
Benoit  twins  lived  about  three  years.  The  alleged  cause  of  death  was  ex- 
treme exposure  and  fatigue  consequent  upon  exhibition  in  various  museums. 

Ischiopagus. — The  ischiopagi  are  characterized  by  the  pelvic  union  of 
two  individuals,  with  common  umbilicus,  placed  end  to  end  and  in  a 
similar  position, — that  is,  the  trunks,  necks,  and  faces  are  in  the  same  plane, 
and  at  right  angles  to  the  direction  of  the  lower  extremities  (Saint-Hilaire). 
The  pelvic  bones,  duplex,  form  a  ring,  from  which  four,  or  in  case  of 
asymmetrical  disposition  three,  lower  extremities  proceed. 

Preenay  records  an  example  of  this  species.  The  twins,  female,  had 
club-feet ;  they  lived  for  several  mouths.  Serres's  case  lived  four  weeks. 
(Figs,  7  and  8.) 

Pygopagus. — According  to  Veit,^  this  genus  includes  those  double 
monsters  in  which  two  complete  individuals  are  united  in  the  region  of  the 
buttocks  by  the  sacrum  and  the  coccyx,  or  only  by  the  latter  and  the  adjacent 
soft  parts.  Each  individual  has  a  distinct  umbilicus.  Forster  has  collectol 
ten  examples  of  this  monstrosity.  All  were  viable.  Of  the  internal  organs, 
only  the  rectum,  and  in  a  number  of  the  cases  the  vagina,  were  single. 

The  best-known  example  of  this  genus  is  presented  in  the  case  of  the 
Hungarian  sisters  Helen  and  Judith,  who  were  born  in  1701  and  died  in 
1723.  According  to  Geoflfroy  Saint-Hilaire,  who  has  described  this  remark- 
able case  in  detail,  at  the  birth  of  the  twins  Helen  presented  by  the  vertex 


1  Philosophical  Transactions,  London,  1723,  vol.  xxxii.  p.  340. 

^  Die  Geburton  missgestalteter,  kranker  unci  todter  Kinder,  Halle,  1850. 


932  jorxED  TWINS. 

and  Avas  delivered  as  far  as  the  umbilicus ;  after  the  lapse  of  three  hours  the 
rest  of  her  body  was  expelled,  followed  at  once  by  the  birth  of  Judith,  who 
presented  by  the  feet  (Fig,  9). 

Helen  and  Judith  are  alleged  examples  of  the  influence  of  maternal 
impressions.  Dr.  Torkos^  begins  the  description  of  this  monstrosity  by 
citing  the  proof  which  it  furnishes  of  the  influence  of  the  imagination  of 
the  mother  on  the  foetus ;  for  at  the  commencement  of  her  pregnancy  the 
mother  witnessed,  with  extreme  attention,  two  dogs  glued  together  during 
the  act  of  coition,  their  heads  turned  each  to  its  respective  side,  and  she  was 
unable  to  eiface  this  pictm^e  from  her  mind. 

In  the  cases  of  pygopagi  reported  by  Xorman,  Jungmann-Kleinwachter, 
the  delivery  of  the  twins  occurred  in  much  the  same  way  as  in  the  case  of 
Helen  and  Judith.  At  a  recent  period  the  two-headed  nightingale,  Ckristie 
and  Millie,  has  attracted  attention  (Fig.  10). 

R.  P.  Harris  informs  us  that  the  celebrated  South  Carolina  twins,  born 
July  11,  1851,  were  brought  into  the  world  by  the  same  method,  but  the 
mother,  having  a  large  pelvis,  "  had  a  brief  and  easy"  delivery.  The  larger 
of  the  two  girls  also  came  first,  as  in  the  Tzoni  case  of  1701.  I  believe 
these  twins  are  still  living. 

The  attempt  at  separating  the  two  individuals  in  pygopagus  by  opera- 
tive procedure  proved  fatal  in  one  case. 

Teeata  Axadidyma, — The  double  monsters  that  are  examples  of 
posterior  duplicity  seldom  present  symmetrically  developed  forms  in  the 
human  race. 

Dipygus. — The  dipygi  are  examples  of  posterior  duplicity  in  which 
cleavage  upward  occurs  through  the  pelvis  and  the  posterior  aspect  of  the 
lower  portion  of  the  spinal  column.  These  monsters  consist  of  a  single 
head  and  neck,  single  or  double  thorax,  two  or  four  upper  extremities, 
sino'le  or  double  abdomen,  and  three  or  four  lower  extremities.  Svmmetri- 
cal  development  of  the  dui)lex  regions  is  rare.  Commonly,  asymmetrical 
forms — dipygus  parasiticus — are  observed,  in  which  larger  or  smaller  por- 
tions of  the  parasite  protrude  from  the  autosite.  It  has  been  noted  that 
the  higher  the  development  of  the  parasite  the  nearer  to  the  cephalic  end 
of  the  autosite  it  comes  to  lie.  Thus,  if  the  parasite  is  composed  of  a  trunk 
and  upper  and  lower  extremities,  it  is  attached  to  the  mouth,  neck,  or  chest 
of  the  autosite;  if  composed  only  of  lower  extremities,  these  take  their 
origin  in  the  pelvis  of  the  autosite.  When  the  spinal  column  and  pelvis 
are  single,  the  transition  into  polymelia  of  the  lower  extremities  is  presented. 
The  parasite  is  always  without  a  heart,  and  its  blood-vessels  are  derived 
from  the  autosite. 

As  at  present  informed,  the  most  remarkable  example  of  posterior 
dichotomy  on  record  is  the  case  of  Mrs.  Clinton  Bicknel,  ncc  J.  ]\Iyrtle 
Corban,  of  Blount  County,  Alabama.    This  being  is  an  example  of  dipygus 

1  Histoire  des  Accouchement?,  etc.,  G.  J.  Witkowski,  Pari?.  18^7. 


Fig.  12. 


DiPYGUS  DiBRACHius  Tetrapus.  (From  American  Jour- 
nal of  Obstetrics  and  Diseases  of  Women  and  Children, 
December,  1888.) 


Fig.  16. 


Janiceps  (Bordenave). 


Fig.  18. 


Fig.  19. 


Prosopo-Thoracopagus. 


DiPYGUS  TAKAblTICUb. 


JOINED    TAVINS.  933 

dibrachilis  tetrapus.  Joseph  Jones  and  Paul  F.  Eve,  of  the  University 
of  Nashville,  made  an  examination  of  this  individual  soon  after  her  birth, 
and  have  written  the  following  history  :  ^ 

"Josephine  Myrtle  is  the  third  child  of  W.  H,  and  Nancy  Corban,  aged 
twenty-five  and  thirty-four  years,  the  wife  being  the  senior  by  nine  years. 
They  are  so  much  alike  in  appearance — both  having  red  hair,  blue  eyes, 
and  very  fair  complexion — as  to  produce  the  impression  of  their  being  blood 
kin,  which,  however,  is  not  the  case.  Mrs.  Corban,  from  North  Alabama, 
has  borne  one  child  to  a  former  husband ;  the  child  has  dark  hair  and  eyes, 
resembling  the  father.     Her  four  children  are  girls. 

"  The  subject  of  this  history  was  born  May  12,  1868.  The  course  of  the 
pregnancy  was  normal.  Labor,  normal ;  presentation,  vertex.  Weight  of 
child  Avhen  three  weeks  old,  ten  pounds.  The  head  and  thorax  are  single, 
while  the  lower  portion  of  the  trunk  is  divided  into  the  members  of  two 
distinct  individuals.  The  spinal  column  divides  at  the  third  lumbar  ver- 
tebra ;  there  are  two  pelvic  arches  supporting  the  four  lower  extremities. 
An  inch  below  the  navel  is  the  mark  of  an  apparent  failure  in  the  develop- 
ment of  a  second  umbilicus.  The  external  genito-urinary  organs  are  double 
and  separate ;  the  internal  genito-urinary  organs  are  presumably  duplex. 
The  rectum  is  double,  with  two  anal  orifices.  The  nates  from  below  appear 
as  those  of  two  individuals,  with  a  distinct  cleft  between  them.  The  urine 
and  fseces  are  commonly  passed  at  the  same  time  upon  both  sides.  There 
are  four  distinct,  fairly  well-developed  lower  extremities.  They  exist  in 
pairs  on  both  sides  of  the  median  groove,  which  resembles  the  cleft  of  an 
ordinary  pair  of  legs.  The  outer  legs  of  both  sides  are  the  more  natural  of 
the  four  (though  the  foot  of  the  right  one  is  clubbed),  but  are  widely  sep- 
arated by  the  two  supernumerary  ones,  which  are  less  developed,  except  at 
their  junction  with  the  body,  from  which  point  they  taper  to  the  feet  and 
diminutive  toes  ;  the  toes  are  turned  inwards.  One  toe  on  the  left  inner  foot 
is  bifid.     At  birth  these  extra  legs  were  folded  flat  upon  the  abdomen." 

Lewis  Whaley,^  of  Birmingham,  Alabama,  completes  the  history  of  the 
case.  In  the  spring  of  1887  he  was  called  to  see  Mrs.  B.,  who  had  been 
married  about  one  year,  on  account  of  the  following  symptoms  :  pain  in  the 
left  side,  nausea,  capricious  appetite,  headache  and  fever,  amenorrhoea  of  two 
months'  duration.  She  suifered  from  pain  above  the  pubes,  and  thought  an 
abscess  was  forming.  Upon  being  informed  that  she  was  pregnant,  she 
replied  that  she  thought  the  physician  was  mistaken,  but  tliat  she  could 
have  believed  it  more  readily  if  the  alleged  pregnancy  had  been  on  the  right 
side.  Eight  weeks  later,  after  consultation  with  Drs.  Haden  and  Aldridge, 
abortion  was  induced,  under  the  twofold  indication  of  contracted  pelvis 

1  Journal  of  the  American  Medical  Association,  October  20,  1888,  p.  545. 

2  Atlanta  Medical  and  Surgical  Journal,  September,  1888;  British  Medical  Journal, 
September  22,  1888,  p.  67(5 ;  Transactions  of  the  State  Medical  Association  of  Alabama, 
1888;  The  Medical  Standard,  October,  1888,  p.  105;  American  Journal  of  Obstetrics,  etc., 
December,  1888,  p.  12tio. 


934  JOINED   TWINS. 

(antero-posterior  diameter  of  outlet  of  left  pelvis  two  inches,  transverse  one 
and  one-half  inches)  and  incoercible  vomiting,  by  puncture  of  the  mem- 
branes. She  was  delivered  of  a  well-developed  foetus  of  three  months  and 
one-half;  her  recovery  was  rapid  and  complete. 

As  described  by  Dr.  Whaley,  Mrs.  B.  is  a  refined  woman,  of  some 
musical  taste.  Her  very  large  hips  are  the  chief  thing  noticeable  about 
her.  Her  waist  is  also  rather  disprojDortionate  to  her  height.  She  is  a 
well-developed  woman  from  the  umbilicus  up.  About  an  inch  from  the 
navel  is  a  second  one  partially  developed.  The  lower  extremities  are 
present  in  pairs  on  either  side  of  the  median  groove,  which  resembles  the 
cleft  of  an  ordinary  pair  of  legs,  except  that  there  is  no  evidence  of  anus  or 
genital  organ.  Between  each  pair  of  legs  there  is  a  complete,  distinct  set 
of  genital  organs,  both  external  and  internal,  each  supported  by  a  pubic 
arch.  Each  set  acts  independently  of  the  other,  except  at  the  menstrual 
period.  There  are  apparently  two  sets  of  bowels  (sic),  and  two  ani ;  both 
are  perfectly  independent,: — diarrhoea  may  be  present  on  one  side,  constipa- 
tion on  the  other.  Menstruation  began  at  the  usual  age,  is  normal,  and 
occurs  simultaneously  from  both  sides.  The  two  outer  limbs,  on  which  the 
woman  walks,  are  well  developed,  though  the  foot  of  the  right  is  in  a  state 
of  equino-varus.  The  inner  limbs  are  smaller,  atrophied  from  disease,  and, 
below  the  knee,  very  rudimentary.  The  accompanying  cut  is  from  a  draw- 
ing by  Dr.  AVhaley,  and  was  made  under  the  direction  of  Dr.  Brooks  H. 
Wells.     (Figs.  11,  12.) 

An  interesting  case  of  dipygus  dibrachius  tripus  parasiticus  has  been 
recently  described  by  J.  Bechtinger,^  Para,  Brazil  (Fig.  13).  Bechtinger 
writes,  "This  person  is  twenty-five  years  of  age,  a  native  of  Martinique 
(French  West  Indies),  her  father  a  Frenchman,  her  mother  a  quadroon. 
Both  healthy,  not  remembering  any  deformity  in  their  family  or  kindred, 
no  constitutional  disease, — syphilis,  scrofula,  nor  allied  maladies.  The 
third  leg  is  attached  to  a  continuation  of  the  processus  coccygeus  of  the  os 
sacrum,  such  as  I  have  noticed  among  some  Malay  tribes  in  the  interior  of 
Sumatra  (Dutch  East  Indies) ;  however,  not  in  such  proportion  even  ap- 
proximately. She  is  still  living,  but  left  her  native  country  for  Paris, 
where  this  photograph  was  taken,  about  one  year  ago.  Besides  the  two 
well-developed  mamrnse  in  their  natural  position,  a  third  one,  that  is  double, 
is  seen  above  the  os  pubis.  The  hair  surrounding  the  lower  segments  of  the 
abnormal  mammae  covers  the  vulvae,  that  are  supplied  with  well-developed 
vaginae.  Both  vaginae  are  properly  supplied  with  nerves,  and  normal 
sexual  connection,  with  natural  sensations,  is  possible  in  either  vagina.  The 
sexual  appetite  is  very  markedly  developed.  Being  informed  of  the  exist- 
ence of  a  man  in  France  who  had  two  sets  of  genitals, — two  penes,  four 
testicles,  and  three  legs, — she  at  once  removed  to  Paris  to  make  his 
acquaintance. 

1  The  Medical  Standard,  October,  1888,  p.  107  ;  Annals  of  Gynecology,  May  1,  1888. 


Fig.  14. 


Janiceps  Asymmetros,  Fkont  View  (Sterley). 


Fig.  15 


Janiceps  asymmetkos,  Side  Vikw  ^Sterley). 


JOINED   TWINS.  935 

Syncephahis. — Under  this  genus  are  included  those  beings  that  represent 
the  higher  degrees  of  posterior  duplicity.  The  typical  form  of  this  group 
is  presented  in  the  not  uncommon  double  monster  known  as  the  Janus  head. 
The  thoraces  are  confluent  above  the  single  umbilicus,  the  left  head  and 
superior  trunk  being  so  united  as  to  give  to  the  anterior  surface  the  appear- 
ance of  a  single  individual.  At  the  same  time,  the  axes  of  the  bodies  are 
commonly  not  exactly  parallel,  but  inclined  to  each  other  at  an  angle,  and, 
in  consequence,  there  is  an  arrest  of  development  of  the  median  portion  of 
the  anterior  surface.  In  these  forms — Janiceps  asymmetros — there  is  a 
perfectly  developed  face  only  on  one  side ;  on  the  other  there  is  present  a 
rudiment,  that  shows  varying  degrees  of  fission, — agnathia,  synotia,  synoph- 
thalmia, and  the  like. 

Figs.  14  and  15  are  anterior  and  posterior  views  of  a  case  of  Janiceps 
asymmetros  that  occurred  in  the  practice  of  Dr.  J,  B.  Sterley,  of  Reading, 
Pennsylvania, — then  living  in  St.  Mary's,  Elk  County, — February  23, 
1878.     The  specimen  at  present  is  in  the  Army  Medical  Museum. 

The  history  of  this  case,  as  recorded  by  Parvin,^  is  :  Mother,  a  German, 
eighteen  years  of  age,  one  child  before  this  pregnancy ;  the  labor,  thought 
to  be  premature  by  one  month,  protracted,  the  child  living  when  it  began, 
but  dying  during  its  course.  Cephalic  presentation,  spontaneous  delivery. 
Weight  of  monster,  six  pounds  ten  ounces. 

Inspection  of  the  rudimentary  face.  Figs.  14  and  15,  shows  synotia, 
synophthalmia,  and  agnathia.  The  monster  was  of  the  female  sex.  This 
case  resembles  closely  a  specimen  of  cephalothoracopagus  in  the  Giessen 
collection,  described  by  Yrolik.^ 

In  rarer  forms,  the  two  bodies  are  exactly  parallel  to  each  other,  so  that 
each  surface  of  the  monster  shows  a  fully-developed  face,  and  the  perfect 
type  of  the  Janus  head — Janiceps — is  produced  (Fig.  16). 

In  syncephalus,  when  the  body  of  one  of  the  twins  is  not  developed, 
there  results  the  form  known  as  Janus  parasiticus. 

The  characters  of  the  varieties  Iniops  {iviov^  the  "  occiput,"  and  ^4',  the 
"  eye,"  the  "  face")  and  Synote  {<ro'j^  "  with,"  and  ooq,  wror,  an  "  ear")  have 
been  pointed  out  in  connection  with  Dr.  Sterley 's  case. 

Craniopagus. — In  crtiniopagi,  the  highest  degree  of  posterior  duplicity 
is  observed.  Two  symmetrically  developed  forms  are  united  at  the  cephalic 
extremity.  According  as  the  site  of  union  is  the  occiput,  the  vertex,  or  the 
forehead,  there  result  three  varieties,  res]iectively, — craniopagus  occipitalis, 
parietalis,  and  frontalis.  Each  individual  has  a  separate  navel  and  umbili- 
cal cord.  Forster  collected  seventeen  examples  of  this  monstrosity ;  one  or 
two  additional  cases  have  been  recorded  within  a  recent  period.  Union  at 
the  vertex  is  most  frequent,  so  that  the  two  individuals  lie  in  the  same 
plane.     The  axes  of  their  bodies  may  be  inclined  to  each  other  at  an  angle, 

1  American  System  of  Obstetrics,  vol.  i.  p.  780. 

2  Peris,  loo.  cit.,  p.  654. 


936  JOIXED    TWIXS. 

or  they  may  be  rotated  so  that  the  faces  look  in  opposite  directions. 
Homologous  bones  are  not  always  united.  Thus,  the  frontal  bone  of  one 
child  may  coalesce  with  the  occiput  of  the  other.  At  the  site  of  union 
there  is  either  lacking  a  portion  of  the  skin  and  bone,  or  the  dura  mater 
may  also  be  involved.  The  brains,  however,  are  commonly  distinct  and 
the  beings  are  viable.  Several  have  lived  from  six  to  ten  years.  (Figs.  17 
and  18.) 

Craniopagi  seldom  occasion  difficult  labor,  unless  the  axes  of  the  bodies 
are  inclined  to  each  other  at  an  angle.  Vottem  records  a  case  in  which 
a  shoulder  presented,  that  terminated  after  the  performance  of  podalic 
version. 

An  interesting  case  of  craniopagus  frontalis  is  recorded  in  Miinster's 
"  Cosmographia"  (1552).  The  twins,  female,  were  born  in  1495,  and  lived 
ten  years.  Upon  the  death  of  one  of  the  children  the  l)ond  of  union  was 
severed,  but  the  other  child  perished*  within  a  short  period.  As  the  mother, 
during  her  pregnancy,  was  talking  with  another  woman,  a  third  individual 
is  said  to  have  stepped  up  behind  them  and  to  have  brought  the  heads  of 
the  two  in  forcible  contact. 

Tee  AT  A  AxAKATADiDYMA. — Prosopo-tlioracopagl  include  joined  twins 
in  which  the  inferior  portions  of  the  two  faces,  the  necks,  and  the  thoraces 
are  fused,  while  the  cranial  bones  and  cavities  as  well  as  the  lower  abdomen 
are  distinct  and  separate.  Examples  of  this  double  monster  are  very  rare. 
(Fig.  19.) 

Prosopo-thoracopagus  parasiticus. — Thoracopagi  are  double  monsters 
that  are  united  by  the  thoi^ax  and  superior  abdomen.  They  are  of  relatively 
frequent  occurrence.  Since  they  possess  a  single  navel  and  umbilical  cord, 
they  are  included  under  the  class  of  omphalopagi.  The  degrees  of  union 
are  manifold,  and  different  forms  accordingly  arise. 

Xiphopagi  include  those  forms  that  are  united  at  the  processus  xiphoi- 
deus  by  a  cartilaginous  bond.  The  best-known  example  of  xiphopagus  is 
presented  in  the  case  of  the  Siamese  Twins  Chang  and  Eng,  who  died  at 
the  age  of  sixty  years.     (Fig.  20.) 

As  informed  by  R.  P.  Harris,  "  The  mother  of  these  twins  was  a  Chinese 
half-breed,  short,  and  with  a  broad  pelvis,  and  had  borne  several  children 
previously.  She  stated  on  several  occasions,  in  conversation  Avith  parties  in 
Siam,  that  the  twins  were  born  reversed,  the  feet  of  one  being  followed  by 
the  head  of  the  other,  and  that  they  were  very  small  and  feeble  at  birth  and 
for  several  months  afterwards.  The  twins  confirmed  this  statement  by 
affirming  that  they  could,  when  little  boys  at  play  on  the  ground,  turn 
themselves  end  for  end  upon  the  ensiform  attachment,  up  to  the  age  of  ten 
or  twelve,  the  attachment  being  then  soft  and  pliable." 

The  bond  of  union  in  the  case  of  the  Siamese  Twins  was  much  smaller 
than  is  commonly  observed ;  in  position  it  was  strictly  ventral,  and  con- 
tained hepatic  tissue  that  seemed  to  unite  the  two  livers.  Sir  Astley  Cooper, 
in  view  of  this  possibility,  declined  to  separate  the  two  individuals.     In 


Fig.  1- 


Fig.  18. 


i^. 


Craniopagus  Parietalis  (De  Baer). 


C'RANioPAGUs  Parietalis. 


Fig.  21. 


The  Siamese  Twins  (Xiphopauus).    (From  u  plaster 
cast  in  the  College  of  Physieiaiis  of  Philadelphia.) 


JOIXED   TWIXS.  937 

two  cases,  in  which  the  cavities  of  the  abdomeu  did  not  communicate,  the 
operation  of  division  has  been  successfully  performed.     (Figs.  21,  22.) 

Sternopagi  have  a  common  thoracic  cavity,  with  a  double  or  single 
sternum.  Two  of  the  upper  extremities  may  be  fused,  when  the  variety  is 
termed  thoracopagus  tribrachius ;  fusion  of  two  lower  extremities  and  the 
pelvis,  thoracopagus  tripus.  In  this,  as  in  the  other  groups  of  double 
monsters,  the  parasitic  form  is  also  observed. 

An  example  of  thoracopagus  parasiticus  (sternopagus)  is  presented  in 
the  case  of  Laloo.^  "  The  subject  ^  is  a  lad  from  Oudh,  aged  seventeen, 
about  five  feet  two  inches  in  height,  and  of  a  very  dark  complexion.  His 
expression  is  pleasing  and  intelligent,  and  his  disposition  veiy  cheerful. 
There  is  no  family  history  of  any  monstrosity.  The  mass,  which  appears 
to  be  of,  at  the  most,  very  limited  sensibility,  is  attached  chiefly  to  the  epi- 
gastric region.  It  consists  of  the  structure  forming  the  shoulder-girdle,  in- 
cluding the  integuments,  which  bear  a  pair  of  nipples ;  and  of  a  second 
part,  including  the  buttocks  and  lower  extremities.  The  pubes  is  hairy, 
the  penis  well  formed  and  its  glans  uncovered,  urine  occasionally  passing 
from  it.  The  anus  appears  to  be  imperforate.  The  arms  are  veiy  long, 
like  those  of  an  American  spider-monkey  (Ateles) ;  the  buttocks  form  a  pro- 
jection rather  bulkier  than  a  cocoa-nut ;  the  left  foot  hangs  down  nearly  as 
low  as  the  knee.  Both  extremities  present  numerous  deformities.  Xext  to 
the  fact  that  there  is  a  large  parasitic  foetus  dependent  from  the  epigastrium, 
the  most  singular  feature  of  the  case  is  the  complete  separation  of  the 
shoulder-girdle  from  the  lower  parts  of  the  parasite.  The  two  parts  appear 
to  be  separately  united  to  the  boy's  trunk  by  freely  movable  joints ;  they 
are  invested  by  a  common  integument  and  divided  from  each  other  by  a 
deep  groove."     (Figs.  23,  24.) 

About  fifty  cases  of  epigastrius  have  been  recorded  up  to  the  present. 
The  most  famous  case  of  all  is  that  of  Bartholin, — Lazaro  Colloredo,  of 
Genoa,  born  in  1716.  This  individual  lived  to  manhood,  with  a  highly- 
developed  epigastrius,  consisting  of  a  head,  trunk,  arms,  and  one  lower 
extremity.  The  face  of  the  parasite,  had  closed  eyes  and  distinct  ears  and 
lips.  The  mouth  bore  teeth,  saliva  continually  dribbled  from  it,  and  it  did 
not  take  in  any  nourishment,  yet  it  was  said  to  breathe  distinctly.  A  small 
beard  grew  from  the  parasite's  face  at  puberty. 

All  double  monsters  confluent  on  their  ventral  surface,  with  the  excep- 
tion of  a  recently-described  ischiopagus  and  a  dipygus  (Fig.  12),  possess  a 
common  navel  and  a  common  umljilical  cord.  They  are  all  accordingly 
included  under  the  class  of  omphalopagi.  The  umbilical  cord  is  commonly 
composed  of  two  arteries  and  one  vein ;  occasionally  two  veins  are 
observed. 

In  the  highest  degree  of  duplication,  as  in  the  xiphopagi,  the  twins  are 

^  Eeport  to  the  Pathological  Society  of  London,  Messrs.  Sutton  and  Shattuck,  Febru- 
ary 15,  1888. 

2  The  British  Medical  Journal,  February  11  and  2-5,  1888,  pp.  312  and  436. 


S38  JOINED    TWINS. 

viable  and  lead  existences  that  are  in  a  measure  mutually  independent.  In 
the  other  forms,  in  which  the  bond  of  union  is  of  greater  extent, — thoraco- 
pagus, syncephalus,  dicephalus, — important  internal  organs  are  confluent, 
and  their  development  is  disturbed  so  that  the  twins  are  either  still-born  or 
perish  soon  after  birth.  Only  in  isolated  cases  of  ischiopagus,  dipygus, 
dicephalus,  has  a  birth-survival  of  a  few  weeks  been  observed. 

The  development  of  the  liver  is  found  to  be  disturbed  in  the  highest 
degree  and  in  the  largest  number  of  cases.  Thus,  in  thoracopagi,  to  which 
attention  is  restricted,  the  liver  is  always  double.  The  jejunum,  and  a 
portion  of  the  ileum  are  single,  while  the  remainder  of  the  intestinal  tract 
is  double.  In  the  thorax  the  lungs  are  double,  while  the  heart  shows 
various  degrees  of  coalescence,  from  two  separate  hearts,  each  in  its  own 
pericardium,  to  a  large,  broad,  single  heart  that  shows  signs  of  duplication 
in  its  interior. 

Literature. — F5ESTER,  Die  Missbildungen  des  Menschen,  Jena,  1865.  Panxjm,  Un- 
tersuchungen  iiber  die  Entstehung  der  Missbildungen,  Berlin,  1860,  und  Virch.  Arch.,  Bd. 
Ixxii.  Ahlfeld,  Arch.  f.  Gyn.,  Bd.  ix..  Die  Missbildungen  des  Menschen,  Leipzig,  1880 
and  1882.  Marchand,  Eulenberg's  Kealencyclopaedie  der  ges.  Heilkunde,  art.  Missbil- 
dungen. L.  Gerlach,  Sitzungsber.  d.  Phys.-Med.  Soc.  zu  Erlangen,  1880,  die  Entste- 
hungs-Weise  der  Doppelmissbildungen,  Stuttgart,  1883.  Fol,  Eecherches  sur  la  Eeconda- 
tion,  etc.,  1879.  Lancereaux,  Traite  d'Anat.  pathol.,  i.,  Paris,  1875-1877.  Geoffroy  St.- 
Hilaire,  Hist.  gen.  et  partic.  des  Anomalies  de  I'Organisation  chez  I'Homme  et  les  Animaux, 
Paris,  1832-1837.  Dareste,  Eecherches  sur  la  Production  des  Monstrosites,  Compt.-rend. 
Acad,  des  Sciences,  1861,  1863,  1864,  1865,  1866.  Ivormann,  Ueber  lebende  Doppelmiss- 
bildungen der  Neuzeit,  Schmidt's  Jahrb.,  cxliii.,  1869. 


Fig.  22. 


Sternopagus  (Herrgott).    (Annales  de  Gyuucologie.) 


Fig.  23. 


Fig.  24. 


Lai.00.  Lai.oo. 

Sternopagus  Parasiticus.    (British  Medical  Journal,  February  11  and  25, 1888.) 


embryology; 


By  HORACE  JAYI^E,  M.D. 


;/ 


\ ; 


Man,  in  common  with  all  Metazoa,  is  developed  from  an  egg.  This  is 
formed  and,  for  a  time,  nourished  in  the  ovary.  The  ovary  (Fig.  1)  con- 
sists of  a  connective-tissue 

skeleton    or    stroma    sup-  • 

porting  the  blood-vessels, 
lymphatics,  and  nerves. 
Within  this  framework  are 
found  the  ova,  contained  in 
follicles  or  Graafian  vesi- 
cles. The  outer  surface  of 
the  ovary  is  covered  by  a 
layer  of  columnar  epithelial 
cells  (a),  and  beneath  this 
layer  the  stroma  of  the 
ovary  is  condensed  to  form 
a  protective  region,  known 
as  the  albuginea,  which  does 

not  contain  any  ova.     Be-  ^^  ^  jF' 

low  this  is  found  the  cor-  m^\    ^,,a^<__^/  ^  - 

tical  layer,  which  contains 
a  large  number  of  small 
Graafian  vesicles  with  the 
diameter  of  about  one-hun- 
dredth of  an  inch.  These 
small  follicles  are  especially 
numerous  in  the  growing 
ovary  (c,  c).  Below  the  cortical  layer,  the  vesicles  increase  in  size  as  they 
approach  the  highly-vascular  centre  of  the  organ,  which  is  known  as  the 
medullary  substance;  here  they  reach  the  size  of  one-thirtieth  of  an  inch 
(d).     The  ova  appear  at  first  as  spherical  cells  lying  between  the  columnar 


Section  of  the  Ovary  (Schafer)  — n,  germ-epithelium;  b, 
egg-tubes ;  c,  c,  small  follicles ,  d,  more  ad\  anced  follicle ;  e, 
discus  proligerus  and  ovum  ;  /,  second  ovum  in  the  same  fol- 
licle (this  occurs  but  rarely);  g,  outer  tunic  of  the  follicle;  h, 
inner  tunic ;  i,  membrana  granulosa  ;  k,  collapsed  retrograded 
follicle;  I,  blood-vessels;  m,  m,  longitudinal  and  transverse 
sections  of  tubes  of  the  parovarium ;  y,  involuted  portion  of 
the  germ-epithelium  of  the  surface  ;  2,  place  of  the  transition 
from  peritoneal  to  germinal  or  ovarian  epithelium. 


^  The  manuscript  of  this  article  was  received  too  late  for  it  to  ajjpear  in  the  place 
originally  assigned  to  it. 

939 


940 


EMBRYOLOGY. 


cells  of  the  germinal  epithelium,  which  covers  the  developing  ovary  (Fig. 
2,  KE).  These  spherical  cells  are  carried  down  into  the  substance  of  the 
ovary  in  the  lumen  of  tubular  invaginations  {PS)  of  the  germinal  epi- 
thelium, which  thus  forms  the  lining  of  the  so-called  ovarian  tubes,  which 
soon  become  closed  and  separated  from  the  surface.  Each  of  these  spheri- 
cal cells  or  primordial  ova  becomes 
invested  by  a  capsule  formed  by  the 
ingrowth  of  partitions  into  the  tube 
from  the  stroma,  and  the  entire  capsule 
lined  by  the  epithelium  or  membrana 
granulosa  {Mg),  derived,  as  we  have 
seen,  from  the  germinal  epithelium, 
becomes  the  Graafian  follicle  {Mg). 
The  follicle  now  enlarges  and  fluid 
begins  to  appear  in  the  interior  {Lf). 


Fig.  3. 


g        g  So  Ei     Mp  K 

Section  thkgugh  a  Portion  op  the  Ovary  < 
OP  A  Mammal:  illustrating  the  development 
of  the  Graafian  follicles  (Wiedersheim).— D, 
discus  proligerus ;  El,  ripe  ovum ;  G,  follicular 
cells  of  germinal  epithelium ;  g,  g,  blood-ves- 
sels; K,  germinal  vesicle  (nucleus)  and  germi- 
nal spot  (nucleolus) :  KE,  germinal  epithelium  ; 
Lf,  liquor  folliculi ;  Mg,  membrana— or  tuni- 
cata — granulosa  or  follicular  epithelium ;  Mp, 
zona  pellucida ;  PS,  ingrowths  from  the  ger- 
minal epithelium,  ovarian  tubes,  by  means  of 
which  some  of  the  nests  retain  their  con- 
nection with  the  epithelium ;  S,  cavity  which 
appears  within  the  Graafian  follicle ;  So,  stroma 
of  ovary;  Tf,  theca  folliculi  or  capsule;  U, 
primitive  ova.  When  an  ovum  with  its  sur- 
rounding cells  has  become  separated  from  a 
nest,  it  is  known  as  a  Graafian  follicle.  (From 
Haddon.) 


Ovum  of  the  Cat  :  highly  magnified ;  semidia- 
grammatic  (after  Schafer).— grs,  germinal  spot ;  gv,  ger- 
minal vesicle ;  vl,  vitellus  or  protoplasm  of  ovum, 
filled  with  yolk-granules,  round  which  a  delicate 
membrane  was  seen ;  zp,  zona  pellucida  (zona  radi- 
ata) ;  only  a  few  radial  pores  are  drawn. 


The  layer  of  lining  cells  or  membrana  granulosa  is  elevated  at  one  part, 
to  embrace  and  attach  the  ovum  to  the  wall  of  the  follicle.  This  growth 
of  cells,  which  completely  surrounds  the  ovum,  is  known  as  the  discus  pro- 
ligerus {D).  The  ripening  follicle,  supported  by  a  vascular  layer  from  the 
ovary  proper,  the  theca  folliculi  {Tf),  sinks,  at  first,  towards  the  centre  of 
the  ovary,  but,  when  fully  ripe  and  about  to  burst,  rises  to  the  surface,  the 
intervening:  tissue  becoming;  thinner  and  less  vascular.  The  ovum  in  the 
follicle  is  nothing,  more  than  a  typical  undifferentiated  cell.  It  possesses  a 
thick,  elastic  cell-wall  (Fig.  3,  zjy),  called  the  zona  pellucida,  enclosing  the 
protoplasmic  cell-contents,  known  as  the  vitellus  {vi),  embedded  in  which  is 
found  the  nucleus  or  germinal  vesicle  {gv),  which  in  turn  contains  the  nude- 


EMBRYOLOGY, 


941 


olus  or  germinal  spot  (gs).  The  cell-wall  appears  to  be  made  up  of  at  least 
two  membranes  :  the  external  one,  stout  and  perforated  by  innumerable  fine 
pores,  is  the  zona  radiata  or  true  zona  pellucida  (zjji) ;  the  inner  membrane  is 
extremely  delicate  and  lies  in  contact  with  the  vitellus.  The  origin  of  these 
membranes  is  still  a  matter  of  much  dispute.  They  are  regarded  by  some  as 
derivatives  from  the  wall  of  the  follicle,  and  by  others  as  secretions  from  the 
ovum  itself.  The  vitellus  consists  of  protoplasm,  contained  in  which  can 
be  seen  so-called  yolk-granules  of  albuminoid  food-material.  The  amount 
of  this  yolk  in  the  mammalian  ovum  is  inconsiderable.  In  many  of  the 
lower  animals,  however,  it  is  enormously  developed,  the  protoplasm  appear- 
ing only  as  a  reticulum  or  supporting  framework.  The  nucleus  or  ger- 
minal vesicle,  which  is  about  one  five-hundredth  to  one  six-hundred-and- 
twenty-fifth  of  an  inch  in  diameter,  resembles  in  structure  the  ovum  itself. 
It  contains  in  addition,  however,  a  substance  which,  readily  stained  by 
certain  reagents,  has  been  called  chromatin.  In  young  developing  ova 
this  chromatin  occurs  as  a  long,  contorted  filament,  but  in  the  more  mature 
the  filament  is  condensed  into  a  single  or  several  spheres, — the  nucleoli  or 
germinal  spots.  Before  fertilization  the  egg  undergoes  certain  processes 
which  are  known  as  the  maturation  of  the  ovum.  These  changes  begin 
by  the  nucleus  abandoning  its  central  position  in  the  midst  of  the  cell-con- 
tents (Fig.  4,  A)  and  approaching  one  pole  of  the  egg, — that  pole  where 


FoRMAixON  OF  ro^.-vR  CELLS  I^  A  Sx^E-FiSH  (from  Haddon,  after  GeJdes,  Fol,  and 
Hertwig).— ^,  ripe  ovum  with  eccentric  germinal  vesicle  and  spot;  B-D,  gradual  metamor- 
phosis of  germinal  vesicle  and  spot,  as  seen  in  the  living  egg,  into  two  asters ;  F,  forma- 
tion of  first  polar  cells  and  withdrawal  of  remaining  part  of  nuclear  spindle  within  ovum ; 
G,  surface  view  of  living  ovum  and  the  first  polar  cell ;  H,  completion  of  second  polar  cell ; 
/,  a  later  stage,  showing  the  remaining  internal  half  of  the  spindle  in  the  form  of  t\vo  clear 
vesicles;  K,  ovum  with  two  polar  cells  and  radial  strise  round  female  pronucleus,  as  seen  in 
the  living  egg ;  L,  expulsion  of  first  polar  cells. 

the  upper  layer  of  cells,  or  epiblast,  will  be  developed.  Here  the  nucleus 
apparently  disappears  or  becomes  diffiised  (B,  C,  D).  At  this  point  a 
swelling  or  bud  {F)  appears  on  the  surface,  fonned  partly  of  a  portion  of 
the  nucleus  and  partly  of  the  general  cell-contents.  A  little  later  this  bud 
is  segmented  off  from  the  cell,  but  still  lies'  under  the  cell-wall.  The 
process  is  now  repeated  at  the  same  point,  and  thus  two  particles  {H)  of 
cell-contents  are  cast  out  from  the  ovum,  and  are  known  from  their  position 
as  the  polar  cells.  These  cells  are  not  again  used,  ^nd  contribute  nothing 
to  the  construction  of  the  embrvo.  We  do  not  know  the  meanino;  of  these 
phenomena,  but  from  studies  on  lower  types  of  animals  it  would  appear 


942 


EMBRYOLOGY, 


that  they  are  cast  forth  to  make  room  for  the  male  element,  the  sperma- 
tozoon. It  has  been  shown  that  in  certain  lower  forms  the  addition  of  the 
male  element  is  not  necessary  to  their  subsequent  develoj)ment,  which  is 
thus  termed  asexual.  The  presence  of  a  male  element  seems  called  for 
rather  to  add  fresh  energy  to  the  cell-contents  of  the  ovum  than  to  supply 
something  different  from  what  is  already  there.  When  the  protoplasm  of 
the  egg  possesses  sufficient  vigor  the  development  of  the  embryo  may  take 
place  directly,  but  when  the  energy  is  small  some  of  the  weakened  material 
appears  to  be  cast  out  to  make  room  for  the  new.  The  exclusion  of  the 
polar  vesicles  renders  further  development  impossible  unless  the  male 
element  is  supplied.  The  portion  of  the  nucleus  which  is  left  after  the 
formation  of  the  polar  cells  again  takes  a  central  position  in  the  ovum, 
and  is  known  as  the  female  pronucleus.  The  egg,  when  fully  ripe  and 
freed  from  the  ovary  by  the  rupture  of  its  wall  and  the  bursting  of  the 
follicle,  is  seized  by  the  fimbriated  extremity  of  the  Fallopian  tube,  which 
has  undergone  erection  for  this  purpose,  and  is  fertilized  by  the  sperma- 
tozoon. 

The  spermatozoa  are  developed  in  the  spermatic  tubules  of  the  testicles. 
These  tubules  are  lined  by  a  germ  epithelium  resting  on  a  basement  mem- 
brane containing  flattened  nuclei.  This  epithelial  lining  is  now  known  to 
consist  of  four  layers  of  cells  which  represent  four  generations  of  sperma- 
tozoa,— the  undifferentiated  cells  lying  in  the  outer  or  first  layer,  the  fully- 
formed  spermatozoa  in  the  inner  or  fourth,  and  the  intermediate  stages 
between.  We  find  three  kinds  of  cells  in  the  outer  layer :  (1)  supporting 
cells,  derived  probably  from  the  nuclei  of  the  basement  membrane,  for 
they  apparently  never  develop  further,  but,  like  the  lining  of  the  Graafian 
follicles,  support  and  nourish  the  true  sexual  cell ;  (2)  growing  cells ;  and 
(3)  spore-ceUs.  The  second  layer  consists  of  growing  cells  only,  and  the  third 
of  the  young  spermatozoa.  The  cycle  of  growth  begins  when  the  fully-ripe 
spermatozoa  forming  the  inner  layer  are  cast  into  the  lumen  of  the  tube. 
The  spore-cells  in  the  outer  layer  divide  to  form  the  growing  cells  and 
new  spore-cells,  which  latter  remain  quiet  until  a  new  cycle  sets  in.  The 
new  growing  cells  push  those  already  existing  into  the  second  layer,  Avhere 
they  actively  divide  and  are  arranged  in  groups  or  clusters,  and  the  groups 
of  cells  which  formed  the  second  layer  now  advance  into  the  third  layer  as 
young  spermatozoa,  while  the  immature  spermatozoa  forming  this  third 
layer  develop  into  the  fully-rij)e  sexual  elements  of  the  inner  layer.  The 
supporting  cells  of  the  outer  layer  are  at  first  stationary.  When  the  clusters 
of  growing  cells  have  been  formed  in  the  second  layer,  however,  they  send 
prolongations  up  between  them  to  meet  and  enclose  the  young  spermatozoa 
lying  in  the  third  layer.  As  the  spermatozoa  increase  in  length  the  sujjport- 
ing  cells  again  contract  into  the  outer  layer,  so  that  the  main  portion  of  the 
spermatozoon,  the  part  Avhich  will  become  the  head,  lies  in  this  layer,  while 
the  long  slender  portion  which  develops  into  the  cilium  extends  through  to 
the  inner  layer.     When  the  spermatozoa  break  loose,  the  supporting  cells 


EMBRYOLOGY.  943 

pass  into  a  condition  of  rest  until  the  next  layer  of  young  spermatozoa  is 
ready  for  their  support.  In  the  development  of  the  spermatozoa  from  the 
growing  cells,  we  find  that  the  nuclear  membrane  thickens  at  one  side,  the 
cell  elong-ates,  the  nucleus  occupying  one  pole,  -while  a  delicate  thread  is 
formed  in  the  cell-protoplasm,  connected  at  one  end  with  the  nucleus  and 
projecting  freely  as  a  delicate  lash  from  the  opjDosite  pole  of  the  cell.  The 
whole  cell  continues  to  increase  in  length,  the  nucleus  at  one  pole,  most  of 
the  rest  of  the  cell-contents  collected  at  the  other  in  the  form  of  a  globule, 
the  filament  occupying  the  intermediate  part  and  the  cilium  projecting 
freely  beyond  the  globule.  The  nucleus  thus  forms  the  head,  the  general 
cell-protoplasm  the  middle  piece,  and  by  its  growth  outside  the  cell  the 
cilium.  Later  the  globule  breaks  free  from  the  spermatozoon,  and,  like  the 
polar  vesicles  of  the  ovum,  appears  to  have  no  further  function,  but  is  found 
inert  in  the  seminal  fluid,  as  the  seminal  granule. 

The  spermatozoa  of  man  are  fifty  micro-millimetres  long,  and  consist  of 
a  head,  a  middle  piece,  and  a  delicate  thread-like  prolongation  or  tail.  They 
are  contained  in  the  seminal  fluid,  a  complex  secretion  from  the  cells  of  the 
testis  proper,  the  glands  of  the  vas  deferens,  the  seminal  vesicles,  and  Cow- 
per's  and  the  prostate  gland.  They  possess  the  power  of  rapid  movement 
for  days,  the  movements  appearing  energetic  at  first  and  gradually  becoming 
feebler.  They  are  not  affected  by  normal  secretions  of  the  female  organs, 
but  their  movements  are  paralyzed  by  certain  reagents  and  very  acid  or 
alkaline  secretions.  By  virtue  of  their  power  of  motion  they  are  able  to 
traverse  the  cavity  of  the  uterus,  enter  the  Fallopian  tube,  and  make  their 
wav  against  the  down^vard  lashing  motion  of  the  cilia  of  the  cells  lining 
that  canal.  It  is  possible  that  they  may  be  assisted  by  the  peristaltic  move- 
ments of  the  uterus  and  Fallopian  tube. 

The  fertilization  of  the  ovum  may  take  place  in  the  ovary,  resulting  in 
abdominal  pregnancy.  That  it  normally  occurs  in  the  Fallopian  tubes  is 
well  settled ;  and  if  the  ovum  is  thereafter  unable  to  find  its  way  to  the 
uterus,  tubal  pregnancy  ensues.  It  has  been  most  positively  stated  by 
competent  authority  that  fertilization  in  the  uterus  is  impossible. 

"When  a  spermatozoon  reaches  the  ovum  (and  it  is  almost  certain  that 
one  only  takes  any  direct  part  in  the  process  of  normal  fertilization),  it 
becomes  attached  by  the  head  to  the  membrane  (Fig.  5,  C).  In  some  cases 
it  has  been  observed  that  the  cell-contents  of  the  ovum  which  have  con- 
tracted away  from  the  wall  and  more  closely  around  the  nucleus  rise  to 
meet  the  spermatozoon  at  the  point  of  attachment  (.1).  Whether  there  is 
an  opening  in  the  cell-wall,  a  so-called  micropyle  which  is  found  in  the 
eggs  of  some  of  the  lower  animals  at  this  point,  is  not  known.  However 
this  may  be,  one  spermatozoon  penetrates  the  membrane,  the  tail  disap- 
pears, and  the  head,  star-like  in  form  and  now  called  the  male  jpi^onucleus, 
sinks  to  meet  the  female  pronucleus  {E  and  H)  in  its  position  near  the 
centre.  Here  the  two  fuse  together  {F,  G),  forming  the  new  spherical 
nucleus  of  the  ovum  enclosing  a  distinct  nucleolus.     This  nucleus  is  to  be 


944 


EMBRYOLOGY, 


distinguished  as  the  segmentation  nucleus,  from  the  one  possessed  by  the 
egg  before  fertilization,  which  alone  should  be  termed  the  germinal  vesicle. 
After  fertilization  the  ovum  divides  or  segments.  This  process  appears  to 
begin  in  the  nucleus ;  it  loses  the  spherical  form  and  is  converted  into  a 
spindle  of  fine  fibres,  at  each  pole  of  which  the  protoplasm  of  the  cell  is 

Fig.  5. 


}^&?S'^W'  V«oBi2Ao%f   4°^.-^iii%^   TM^r^fifHi 


EW;S^ 


G 


Fertilization  of  Ovum  of  a  Stae-Fish  (from  Haddon,  after  Geddes  and  Fol).— In 
A-D  the  spermatozoa  are  represented  as  embedded  within  the  mucilaginous  coat  of  the 
ovum.  In  ^  a  small  prominence  is  rising  from  the  surface  of  the  ovum  towards  the  nearest 
spermatozoon,  in  B  they  have  nearly  met,  and  jn  Cthey  have  met.  In  D  the  spermatozoon 
has  penetrated  the  ovum,  and  a  vitelline  membrane  with  a  crater-like  opening  has  been 
formed,  which  prevents  the  entrance  of  other  spermatozoa.  H,  ovum  showing  polar  cells 
and  approach  of  the  male  and  female  pronuclei ;  the  protoplasm  is  radially  striated  round 
the  former.    E,  F,  G,  later  stages  in  the  coalescence  of  the  two  nuclei. 


arranged  in  radiating  lines.  Since  this  spindle  stains  with  difficulty,  it  has 
been  termed  the  achromatin  portion  of  the  nucleus.  That  part  of  the 
nucleus  which  is  known  as  chromatin  collects  around  the  centre  of  the 
spindle,  probably  first  as  a  continuous  looped  fibre.  The  fibre  breaks  be- 
tween the  loops,  giving  a  series  of  U-shaped  rods  arranged  radially  around 
the  central  circumference  of  the  spindle,  the  points  of  the  rods  directed 
towards  the  periphery  of  the  ovum.  Each  rod  divides  longitudinally  to 
form  two  U-shaped  loops,  producing  two  stars,  the  double  star,  or  diaster. 
The  angles  of  the  loops  now  become  directed  towards  the  opposite  poles. 
The  stars  so  formed  travel  along  the  spindle  to  the  poles  to  form  the 
daughter  stars,  which  reverse  the  process  just  described,  becoming  wreaths 
and  finally  diffused  as  a  delicate  reticulum.  The  achromatin  spindle  disap- 
pears. When  the  daughter  stars  are  formed,  the  cell-contents  become  con- 
stricted in  a  plane  passing  at  right  angles  through  the  centre  of  the  spindle, 
and  the  ovum  has  divided  into  two  before  the  two  new  nuclei  have  reached 
a  condition  of  rest.  This  process,  which  is  known  as  karyoUnesis,  is 
common  to  many  dividing  tissue-cells. 

Each  of  the  two  cells  thus  produced  (Fig.  6,  a,  ent,  ect)  now  divides, 
the  spindle  being  formed  in  the  same  plane  as  the  former  one,  but  at  right 
angles  to  it.  In  this  way  four  cells  (6)  are  formed,  each  of  which  divides 
horizontally,  the  plane  of  segmentation  intersecting  the  former  plane  at 
right  angles  (c).  If  the  segmentation  be  perfectly  regular,  sixteen  cells 
are  now  produced,  then  thirty-two,  then  sixty-four,  and  so  on  until  a  great 
number  of  small  cells  are  found,  the  whole  having  a  rounded  form  and 
known  as  the  morula  or  mulberry  stage  (e).  Segmentation  is  said  to  be 
completed  in  the  human  ovum  by  the  end  of  the  tenth  day ;  and  in  the 


EMBRYOLOGY. 


945 


rabbit  we  know  that  by  the  end  of  segmentation  the  ovum  has  readied  the 
uterus.     On  optical  section  this  blastosphere  is  seen  to  be  made  up  of  an 


First  Stages  of  Segmentation  of  a  Rabbit's  Ovum  :  semidiagrammatic  (from  Quain). — 
a,  two-cell  stage ;  b,  four-cell  stage ;  c,  eight-cell  stage ;  d,  e,  later  stages  and  the  enclosure  of 
the  inner-layer  cells ;  eci,  outer-layer  cells ;  ent,  inner-layer  cells ;  pgl,  polar  cells ;  zp,  zona 
pellucida. 

outer  layer  of  smaller  cells  (Fig.  7,  ep)  surrounding  a  central  group  of 
larger,  more  granular  cells  (%).     The  ovum  now  enlarges  rapidly  by  the 


Optical  Sections  of  a  Rabbit's  Ovum  at  Two  Stages  closely  following  upon  Seg- 
mentation (from  Balfour,  after  E.  van  Beneden).— ep,  epiblast ;  hy,  primary  hypoblast :  the 
shading  of  the  epiblast  and  hypoblast  is  diagrammatic. 

secretion  within  of  fluid,  and  the  outer  layer  of  cells  is  forced  away  from 
those  it  surrounds,  except  at  one  spot,  where  the  latter  still  adhere  closely 
(Fig.  7,  B).  The  blastosphere  consists  at  this  stage  of  one  layer  of  cells, 
except  at  the  points  where  there  is  also  an  inner  lining  (Fig.  8,  hy).  The 
double  membrane  thus  formed  is  known  as  the  blastodermic  membrane. 

Its  inner  layer  is  known  as  the  hypoblast ;  the  outer  is  usually  regarded 
as  the  epiblad,  although  it  lias  been  shown  that  in  some  ova  this  is  merely 
a  protective  layer,  the  so-called  Dcckschicht  of  the  German  embryologist, 
which  does  not  enter  into  the  formation  of  the  embryo,  but  thins  away 
and  disappears  or  becomes  later  fused  with  the  enveloping  membranes,  the 
Vol.  1.— 60 


946 


EiMBRYOLOGY. 


true  epiblast  developing  from  the  inner  cells.     This  inner  layer  of  cells 
gradually  spreads  and  extends  downward,  lining  the  outer  layer,  towards 


Fig.  8. 


Rabbit's  Ovum  between  seventy  and  ninety  hours  after  Impregnation  (from  Bal- 
four, after  E.  van  Beneden).— 6u,  cavity  of  blastodermic  vesicle  (yolk-sac) ;  ep,  epiblast;  hy, 
primitive  hypoblast;  zp,  mucous  envelope. 

the  lower  pole  of  the  egg.    At  the  upper  pole,  where  the  hypoblast  was  first 
developed,  there  is  seen  a  lens-shaped  darker  spot  (Fig.  9,  ag),  for  here  the 

Fig.  9. 


Views  of  the  Blastodermic  Vesicle  of  a  Rabbit  on  the  seventh  day,  without  the 
zona:  left-hand  figure  from  above,  right-hand  figure  from  the  side  (from  Balfour,  after 
Kolliker). — ag,  embryonic  area ;  ge,  boundary  of  the  hypoblast. 

hypoblast  consists  of  more  than  one  layer :  this  is  known  as  the  germinal 
disk  or  area  germinatioa,  and  here  alone  the  embryo  develops. 

The  first  step  in  this  process  is  marked  by  the  formation  at  one  end  of 
the  germinal  disk,  called  the  posterior,  of  a  longitudinal  thickening  of  the 
epiblast,  in  which  is  subsequently  developed  a  groove.  These  are  called 
respectively  the  j)i^i'>nitive  trace  and  the  primitive  streak  (Fig.  10,  pr).  The 
anterior  part  of  the  area  germinativa  is  translucent,  and  has  been  called  the 
area  pellucida,  while  the  posterior  part  where  the  primitive  trace  is  formed 


EMBRYOLOGY. 


947 


Fig.  10. 


is  opaque,  because  here  there  now  appears  a  new  layer  of  cells  between  the 
epiblast  and  the  hypoblast, — the  middle  layer,  or  mesoblast  It  has  been 
shown,  from  the  recent  researches 
on  development  of  the  mole,  that 
the  mesoblast  is  developed  as  fol- 
lows :  the  epiblast  and  hypoblast 
fuse  in  the  region  of  the  primitive 
streak,  and  from  either  side  of  the 
point  where  the  two  primary  layers 
blend  a  mass  of  cells  grows  out- 
ward and  also  forward  between  the 
latter,  so  that  the  mesoblast  may  be 
said  to  arise  on  either  side  of  the 
primitive  trace  or  of  lateral  out- 
growths of  the  fused  epiblast  and 
hypoblast  (Fig.  11,  C),  and  is 
therefore  apparently  derived  from 
both.  In  front  of  the  primitive 
trace  it  can  be  discovered  split  off 
on  each  side  of  the  median  line 
from  the  hypoblast  (Fig.  11,  B). 
After  the  formation  of  the  meso- 
blast in  the  posterior  part  of  the  germinal  area,  there  appear  at  the  anterior 

Fig.  11. 


Embryonic  Area  of  a  seven  days'  Embryo  Rab- 
bit (KoUiker). — o,  place  of  future  area  vasculosa ;  rf, 
medullary  groove;  pr,  primitive  streak;  ag,  embry- 
onic area. 


Sections  through  the  Blastoderm  of  a  Mole  (after  Heape).— ^,  longitudinal  section  through 
the  middle  line  of  part  of  an  embryonic  area  in  which  the  primitive  streak  has  commenced  to  form; 
the  blastoderm  is  perforated  in  front  of  the  primitive  streak  ;  Ji,  transver.se  section  through  the  middle 
of  a  well-developed  primitive  streak  ;  the  epiblast  and  mesoblast  are  fused,  but  the  hypoblast' is  dis- 
tinct; the  mesoblast  area  extends  beyond  the  embryonic  area;  C,  same  as  B,  but  through  the  hind 
knob  of  the  primitive  streak.  All  the  layers  are  fused  in  the  embryonic  area,  but  are  distinct  beyond- 
ep,  epiblast ;  hy,  hypoblast ;  m,  mesoblast ;  p.sk,  primitive  streak. 

end  two  parallel  longitudinal  thickenings  of  the  epiblast,  producing  two 
closely-approximated  ridges.      These  extend  backwards  and  embrace  the 


948 


EMBRYOLOGY. 


Fig.  12. 


anterior  end  of  the  primitive  trace,  which  gradually  disappears  (Fig.  10,  rf). 
This  longitudinal  groove  in  the  epiblast  is  called  the  medullary  groove  (Fig. 

The  epiblastic  ridges  on  each  side  of  the  groove  grow  upward  to  form 
the  medullary  plates,  or  laminse  dor  sales,  which,  considerably  later,  arch  over 
the  groove  and  meet  in  the  middle  line  to  form  a  canal, — the  neural  or 
medullary  canal.  This  tube,  consisting  of  a  layer  several  cells  deep,  becomes 
detached  from  the  ej^iblast,  and  lies  beneath  and  disconnected  from  the 
original  epiblastic  stratum  which  grows  over  it.  The  closure  of  the  neural 
canal  begins  some  little  distance  behind  the  head  end  of  the  embryo  and 
progresses  forward  and  backward.     While  the  neural  groove  is  developing, 

the  axial  mesoblast  has  been  formed  'as  two 
separate  masses  lying  on  each  side  of  the  median 
line,  where  epiblast  and  hypoblast  are  in  contact 
(Fig.  12,  li).  A  new  structure  has  also  arisen, 
in  the  shape  of  a  rod  of  cells  split  off  dorsally 
from  the  hypoblast  and  lying  under  the  neural 
canal  and  between  the  lateral  masses  of  the 
mesoblast.  This  is  the  notochord,  and,  although 
in  the  higher  vertebrates  it  does  not  contribute 
to  the  actual  formation  of  the  axial  skeleton,  it 
is  the  axis  around  which  the  centra  or  bodies  of 
the  vertebrae  are  subsequently  developed. 

The  lateral  masses  of  the  mesoblast  are  seen 
to  consist  of  two  parts  :  a  plate  lying  on  each 
side  of  the  neural  canal  and  notochord,  which, 
later,  splits  up  by  transverse  division  into  cubical 
blocks, — the  so-called  protovertebrse ;  and  a  lat- 
eral portion  formed  of  two  layers  connected  to- 
gether near  the  protovertebrse  but  peripherally 
separated ;  the  one  layer  applied  to  the  under 
surface  of  the  epiblast,  the  other  to  the  upper 
surface  of  the  hypoblast  (Fig.  14),  leaving  a  cavity  between  them  which  is 
known  as  the  coelum  or  body,  or  pleuroperitoneal  cavity.  The  upper  layer 
of  the  mesoblast  is  called  the  somatic  layer,  and  with  the  epiblast  forms  the 
somatopleure ;  the  lower  layer  is  the  splanchnic  layer,  and  ^^•ith  the  hypo- 
blast forms  the  splanchnopleure. 

The  wall  of  the  blastodermic  vesicle,  which  is  enclosed  in  the  zona 
radiata,  now  consists  of  the  embryo  surrounded  by  a  translucent  ring, — the 
area  pellucida  (Fig.  13,  ap), — and,  beyond  tliis,  by  a  dark  ring, — the  area 
opaca, — in  which  the  epiblast  is  thickened,  the  mesoblast  is  well  developed, 
and  the  blood-vessels  begin  to  appear.  At  the  opposite  pole  of  the  vesicle 
the  wall  comprises  only  the  two  primary  layers. 

We  have  thus  far  been  regarding  the  embryo  as  lying  flat  upon  the 
surface  of  the  blastodermic  vesicle ;  but  very  early  in  tlie  development,  be- , 


Embryo     Rabbit     of     eight 

DAYS   AND   NINE    HOURS,    with   five 

protovertebrse.  X  18.  (From  K61- 
liker. )—ao,  area  opaca;  ap,  area 
pellucida ;  mp,  medullary  plate  of 
head;  h',  region  of  future  fore- 
brain  ;  h",  region  of  future  mid- 
brain ;  rf,  medullary  groove ;  hz, 
heart;  pr,  primitive  streak. 


EMBRYOLOGY. 


94y 


Fig.  13. 


h"- 


■f- — fip 


An  Eight-day-and-nine-hour  Rakbit  Embryo  with  five  protovertebrse.  Of  the 
blastodermic  vesicle,  only  the  area  opaca  is  shown.  X  14.  (From  Kolliker.)— ao,  area 
opaca  or  vasculosa;  «p,  area  pellucida;  mp,  medullary  plate  of  head;  h',  h",  region  of 
future  brain;  hz,  rudiments  of  heart;  pr,  primitive  streak;  slz,  axial  zone;  pz,  parietal 
zone. 


Fig.  14. 


Transverse  Section  of  an  Embryo  Fowl  of  three  days'  Incvbation.  The  rela- 
tive size  of  the  embryo  is  exaggerated.  (From  Kolliker.)— ojre,  amniotic  cavity ;  Uk,  ex- 
tension of  pleuropentoneal  cavity  outside  the  embryo :  d,  vitelline  membrane ;  dr, 
intestinal  groove;  eel,  epiblast;  enl,  hypoblast;  g,  yolk;  vies,  border  of  the  splanchnic 
mesoblast  (area  vasculosa) ;  r,  edge  of  the  blastoderm,  here  consisting  only  of  epiblast 
and  hypoblast ;  s,  serous  or  subzonal  membrane  or  false  amnion. 


950 


EMBRYOLOGY. 


fore,  indeed,  the  neural  groove  is  converted  into  a  canal,  it  becomes  folded 
off  from  the  vesicle.  This  is  brought  about,  at  first  at  the  anterior  end,  by 
the  embryo  growing  more  rapidly  than  the  surrounding  embryonic  area,  so 
that  it  projects  over  the  now  underlying  blastodermic  membrane.    (Fig.  15.) 


Fig.  15. 


N.C 


Diagrammatic  Longitudinal  Section  through  the  Axis  of  an  Embryo  (Balfour). 
The  section  is  supposed  to  be  made  at  a  time  when  the  head-fold  has  commenced  but  the 
tail-fold  has  not  yet  appeared.— F.So,  fold  of  somatopleure ;  F.Sp,  fold  of  splanchnopleure ; 
D,  fore-gut ;  pp,  pleuroperitoneal  cavity  between  somatopleure  and  splanchnopleure ;  Am, 
commencing  (head)  fold  of  amnion ;  N.C,  neural  canal ;  Ch,  notochord ;  A,B,C,  epi-,  meso-, 
and  hypoblast. 

The  same  process  is  repeated  posteriorly,  and  gives  rise  to  the  appearance 
of  the  membrane  at  the  head  and  tail  having  beeii  tucked  under  the  em- 
bryo proper.  Cavities  are  thus  formed  in  the  embryo  in  front  and  behind 
(Fig.  15,  D)  which  are  still  in  communication  with  the  general  cavity  of  the 
vesicle,  and  which  will  become  the  anterior  and  posterior  ends  of  the  intes- 
tinal canal.  The  elevation  of  the  embryo  above  the  general  surface  is 
further  accomplished  by  the  growing  down  of  the  sides  or  laminae  ventrales 
(Fig.  14).  The  first  traces  of  the  heart  are  seen  as  a  tube  on  each  side, 
formed  by  involution  of  the  splanchnopleure.  As  the  sides  of  the  embryo 
grow  down  and  together  underneath,  the  two  halves  of  the  heart  become 
united  in  the  middle  line  and  form  a  median  undivided  organ.  On  each 
side,  the  lower  layer  of  the  mesoblast  with  its  ventral  lining  of  hypoblast 
curves  downward  and  meets  its  fellow  of  the  opposite  side  to  form  the  intes- 
tinal tract  (Fig.  17,  H).  The  region  of  the  intestinal  tract  at  the  middle  of 
the  body  of  the  embryo  does  not  close  below  until  later.  The  upper  layers 
of  the  mesoderm  covered  by  the  epiblast  do  not,  at  first,  meet  underneath, 
so  that  the  coelum  or  body-cavity  is  in  open  communication  with  the  space 
between  the  two  layers  of  mesoblast  which  extend  beyond  the  embryo  lat- 
erally, anteriorly,  and  posteriorly.  Pressure  upon  the  embryo  by  the  sur- 
rounding maternal  structures  has  caused  it  to  sink  down  into  the  blasto- 
dermic vesicle  as  the  latter  grows  in  size,  and  there  is  thus  formed,  at  first 
in  front,  where  the  head  of  the  embryo  begins  to  be  bent  downward  in  the 
cephalic  flexure,  an  external  and  upward  fold  of  the  blastodermic  membrane. 
This  fold  is  formed  of  the  epiblast  and  its  underlying  somatic  mesoblast. 
A  similar  fold  then  appears  behind  the  tail,  and  as  the  embryo  sinks  deeper 
and  deeper  into  the  vesicle  the  two  folds  rise  higher  at  the  ends  (Fig.  16,  2), 
while  lateral  folds  arise  on  either  side  until  they  all  meet  above  the  embryo. 


E.MBRYOLOGY. 


951 


Five  Diagrammatic  Figures  illustrating  the  Formation  of  the  Fcetal  Mem- 
branes OF  A  Mammal  (from  Haddon,  after  Kolliker). 

In  1,  2,  3,  4,  the  embryo  is  represented  in  longitudinal  section. 

1.  Oosperm  with  zona  pellucida,  blastodermic  vesicle,  and  embryonic  area.  2.  Oosperm 
with  commencing  formation  of  umbilical  vesicle  and  amnion.  3.  Oosperm  with  amnion 
about  to  close  and  commencing  allantois.  4.  Oosperm  with  villous  subzonal  membrane, 
larger  allantois,  and  mouth  and  anus.  5.  Oosperm  in  which  the  vascular  mesoblast  of 
the  allantois  has  extended  round  the  inner  surface  of  the  subzonal  membrane,  and  united 
with  it  to  form  the  chorion ;  the  cavity  of  the  allantois  is  aborted.  The  yolk-sac  (umbilical 
vesicle)  has  greatly  diminished.  The  large  amniotic  cavity  surrounds  the  umbilical  cord. 
This  figure  represents  an  early  human  ovum. 

a,  epiblast  of  embryo;  a',  epiblast  of  non-embryonic  part  of  the  blastodermic  vesicle; 
ah,  cavity  of  the  amnion  ;  al,  allantois ;  am,,  amnion  ;  as,  amniotic  sheath  round  the  umbilical 
cord ;  ch,  chorion  ;  ch.z.  villi  of  chorion  ;  d,  zona  pellucida  (radiata);  d',  processes  of  zona; 
dd,  embryonic  hypoblast;  df,  area  vaM!ulosa;  dg,  stalk  of  yolk-sac;  ds,  yolk-sac  (umbilical 
vesicle);  e,  embryo;  hh.  pericardial  cavity;  i,  non-embryonic  hypoblast;  kh,  cavity  of  the 
blastodermic  vesicle,  which  practically  is  equivalent  to  the  yolk-sac ;  ks,  head-fold  of  amnion ; 
m,  embryonic,  m',  non-embryonic,  mesoblast;  r,  space  between  chorion  and  amnion  con- 
taining albuminous  fluid ;  sh,  subzonal  (serous)  membrane ;  si,  sinus  terminalis;  sz.  subzonal 
villi ;  vl,  ventral  body-wall  in  the  region  of  the  heart. 


952 


EMBEYOLOGY. 


The  lower  sheets  of  the  fold,  consisting  of  epiblast  and  mesoblast,  fuse  on  the 
middle  line  just  over  the  back  of  the  embryo  to  form  a  sac  surrounding  the 
embryo  above, — the  amnion  (Fig.  16,  2,  am).  The  upper  sheets  of  the  fold 
also  fuse  and  become  detached  from  the  amnion  to  form  the  false  amnion,^ 
or  serous  envelope  (Fig.  16,  3,  sh),  which,  as  can  be  seen  from  the  figures,  is 
continuous  below  with  the  epiblast  covering  the  whole  blastodermic  vesicle. 
The  amnion  is  thus  covered  externally  by  mesoblast,  which  subsequently 
is  said  to  develop  muscular  fibres,  and  lined  by  epiblast,  in  more  or  less 
intimate  contact,  at  first,  with  the  outside  epiblast  of  the  embryo,  while  in 
the  false  amnion  the  mesoblast,  if  it  here  really  reaches  out  so  far  from 
the  body  of  the  embryo,  lines  the  epiblast.  The  other  or  splanchnic  layer 
of  the  mesoblast  and  the  hypoblast,  after  having  been,  as  it  were,  tucked 
in  under  the  embryo  to  form  the  intestinal  tract,  are  spread  out  (Fig.  17) 

Fig.  17. 


<*--. 


Diagram  of  the  Fcetal  Membranes  of  a  Mammal  (from  Balfour,  after  Turner). 
Structures  which  either  are,  or  have  been  at  an  earlier  period  of  development,  continuous 
with  each  other  are  represented  by  the  same  character  of  shading.— pc,  zona  with  villi ; 
sz,  subzonal  membrane ;  E,  epiblast  of  embryo ;  am,  amnion ;  A  C,  amniotic  cavity  ;  M,  meso- 
blast of  embryo ;  H,  hypoblast  of  embryo ;  UV,  umbilical  vesicle  ;  al,  allantois ;  ALC,  allantoic 
cavity. 

again  over  the  contents  of  the  vesicle,  to  form  the  yolk-sac  (Fig.  16, 
ds).  The  whole  ovum  at  this  stage,  therefore,  consists  of  two  sacs  lying 
within  the  zona  pellucida  or  vitelline  membrane.  The  upper  sac  contains 
the  embryo,  the  lower  the  yolk,  and  the  body  of  the  embryo  forms  the 
septum  between  the  two  sacs.  The  yolk-sac  communicates  with  the  intes- 
tinal canal  within  the  embryo  by  means  of  its  upper  constricted  part,  the 
omphalo-mesenteric  or  vitello-intestinal  duct,  which  will  later  be  reduced  to 
a  tube  by  the  complete  ingrowth  of  the  somatopleure  in  the  form  of  laminae 

1  The  false  amnion  of  Kolliker  and  Von  Baer  is  not  the  same  as  that  of  some  later 
writers. 


EMBRYOLOGY, 


95^ 


S.T-i 


ventrales.  The  yolk-sac  represents  the  blastodermic  vesicle  less  that  portion 
which  has  been  included  within  the  embryo  to  form  the  intestine  bv  this 
folding-in  process. 

As  each  sac  is  covered  by  mesoblast,  the  space  between  the  sacs  is  a 
direct  continuation,  outside,  of  the  space  which  lies  between  the  two  layers 
within  the  embryo,  the  coelum  or  body-cavity,  but  by  the  subsequent  grow- 
ino-  too-ether  of  the  laminae  ventrales  the  embryonic  body-cavity  is  shut  off 
from  the  non-embryonic.  The  amnion,  at  first  small  and  in  contact  with 
the  dorsum  of  the  embryo,  begins  to  grow  rapidly  (at  the  fourth  or  fifth 
week)  by  the  accumulation  within  the  amniotic  fluid  (Fig.  16,  ah).  This 
increases  until  about  the  sixth  month,  after  which  it  diminishes.  In  the 
middle  of  pregnancy  it  weighs  from  two  to  three  pounds ;  by  the  end  of  that 
period  it  is  reduced  to  one 
pound.  The  nutritive  func- 
tion of  the  yolk-sac  in  higher 
mammals  is  not  important. 
The  yolk,  which  appears  iu 
the  form  of  granules,  is  ab- 
sorbed by  the  hypoblast  cells 
and  by  blood-vessels  which 
have  already  made  their  ap- 
pearance in  the  peripheral 
splanchnic  mesoblast,  in  that 
opaque  portion  which  is 
called  the  area  opaca  or  vas- 
culosa.  The  vessels  coming 
from  the  embryo  traverse 
the  walls  of  the  omphalo- 
mesenteric duct,  spread  out 
on  the  surface  of  the  yolk- 
sac,  and  terminate  peripher- 
ally in  a  circular  vessel,  the 
dnus  terminalis  (Fig.  18, 
8.T)  in  the  margin  of  the 
mesoblast  covering  the  yolk- 
sac.  From  this  area  the 
blood  is  returned  to  the  heart 
of  the  embryo  by  two  long 
trunks  (the  oraphalo-mesen- 
teric  veins  (Fig.  18,  R.of,  L.of) 
entrance  into  the  uterus,  become 


Diagram  of  the  Circulation  of  the  Yolk-Sac  of  Chick 
AT  THE  End  of  the  Third  Day  of  Incubation  (Balfour).— 
H,  heart:  A  A,  the  second,  third,  and  fourth  aortic  arches;  the 
first  has  become  obliterated  in  its  median  portion,  but  is  con- 
tinued at  its  proximal  end  as  the  external  carotid,  and  at  its 
distal  end  as  the  internal  carotid;  Ao,  dorsal  aorta;  L.of. A, 
left  vitelline  artery  ;i2.o/.. 4,  right  vitelline  artery;  S.T.  sinus 
terminalis;  L.of,  left  vitelline  vein  ;  R.of,  right  vitelline  vein; 
S.V,  sinus  verosus';  D.C,  ductus  Cuvieri;  S.Ca.V,  superior 
cardinal  vein;  V.Ca,  inferior  cardinal  vein.  The  veins  are 
marked  in  outline  and  tlie  arteries  are  black.  The  whole 
blastoderraa  has  been  removed  from  the  egg,  and  is  supposed 
to  be  viewed  from  below.  Hence  the  left  is  seen  on  the  right, 
and  vice  versa. 


The  ovum,  almost  immediately  u})on  its 
attached  to  the  uterine  wall.  This  union 
is  at  first  superficial,  tlie  outer  membrane  enclosing  the  egg  being  covered 
with  hollow  finger-like  processes  or  villi ;  but  very  soon  a  new  and  perma- 
nent structure  arises  from  the  embryo  by  wliich  this  connection  is  rendered 
more  intimate.     This  organ  is  called  the  aUantois. 


954  EMBRYOLOGY. 

The  origin  of  the  allantois  in  man  appears  to  be  peculiar,  and  its  devel- 
opment is  precocious  and  abbreviated.  Whatever  may  be  the  details  of  its 
•early  appearance  (and  we  are  still  in  doubt,  since  few  observations  are  re- 
corded of  such  early  ova),  this  much  appears  settled  from  the  study  of  the 
lower  forms  :  The  allantois  arises  first  as  a  bud,  in  the  second  week,  from 
the  caudal  part  of  the  primitive  intestinal  canal  (Fig.  16,  3,  aC).  This  bud 
grows  forward  within  the  body-cavity  as  a  hollow  sac,  and  passes  out  from 
the  embryo  into  the  space  between  amnion  and  yolk-sacs  (Fig.  16,  4,  aV). 
As  it  is  derived  from  the  intestinal  canal,  it  consists  of  two  layers,  inter- 
nally of  hypoblast,  externally  of  splanchnic  mesoblast.  We  know  that  in 
many  forms  the  cavity  in  the  allantois  persists  for  a  long  time,  but  it  is 
almost  certain  that  in  man  the  hypoblast  does  not  extend  into  the  organ 
much  beyond  the  embryo,  and  that  the  allantois,  in  the  space  between  am- 
nion and  yolk-sac,  consists  of  a  nearly  solid  organ  formed  of  mesoblastic 
tissue.  The  allantois  grows  rapidly  in  this  space  and  reaches  the  vitelline 
membrane  of  the  ovum,  which,  it  will  be  remembered,  now  consists  of  the 
epiblastic  false  amnion,  called  also  the  subzonal  membrane,  within,  and  of 
the  zona  radiata  without :  there  being  no  mesoblast,  since  the  somatic  layer 
thinned  out  in  covering  the  amnion  and  the  splanchnic  layer  has  been  split 
oif  from  the  primitive  epiblast  of  the  vesicle  (now  the  false  amnion)  and 
•covers  the  umbilical  vesicle  or  yolk-sac.  The  appearance  of  the  allantois 
antedates  the  complete  folding  off  of  the  embryo  from  the  blastodermic 
vesicle,  and  even  the  development  of  the  amnion.  The  allantois  increases  in 
size  (Fig.  17,  at),  and  at  the  fourth  week  forms  a  complete  lining  to  the 
subzonal  membrane  (Fig.  16,  5).  The  union  of  allantois  with  subzonal 
membrane  forms  the  organ  known  as  the  chorion  (Fig.  16,  5,  ch).  As  we 
have  seen,  at  a  very  early  period  in  its  development,  in  the  first  weeks,  the 
ovum  becomes  covered  with  hollow  villous  outgrowths  from  the  envelop- 
ing membrane.  In  the  primitive  attachment  of  the  ovum  to  the  uterine 
wall,  the  mucous  membrane  of  the  latter,  which  has  undergone  preparatory 
changes,  grows  around  and  encloses  it  in  a  distinct  capsule.  The  mucous 
membrane  is  therefore  divided  into  the  part  which  covers  the  ovum,  the 
deddua  reflexa,  and  the  part  lining  the  general  uterine  cavity,  the  decidua 
vera.  When  the  allantois  lines  the  epiblastic  layer  or  false  amnion,  it  sends 
mesoblastic  prolongations  into  the  villi  and  develops  a  rich  net-work  of 
blood-vessels  in  them.  This  net-work  is  supplied  by  blood  from  the  aorta 
of  the  embrvo  throug-h  the  arteries  arisins;  in  the  mesoblastic  tissue  of  the 
allantois,  and  returns  the  blood  through  two  veins  which  join  the  omphalo- 
mesenteric or  vitelline  veins  coming  from  the  yolk-sac.  As  the  part  of  the 
allantois  which  remains  within  the  embryo,  that  part  which  is  lined  by 
hypoblast,  will  become  later  the  urinary  bladder,  the  arteries  after  birth  are 
limited  to  the  supply  of  that  organ  and  are  known  as  the  hypogastric  vessels. 
At  first  the  chorion  and  decidua  are  everywhere  vascular,  but  later  the  villi 
with  their  vessels  disappear,  and  the  decidua  reflexa  becomes  gradually 
converted  into  a  yellow  membrane  except  at  a  disk-shaped  patch  where  the 


EMBRYOLOGY. 


955 


capsule  of  the  ovum  becomes  continuous  with  the  uterine  wall, — in  other 
words,  where  the  decidua  reflexa  joins  the  decidua  vera.  The  decidiia  at 
this  point  is  called  the  decidua  serotina.  Here  the  placenta  is  developed.  It 
consists  of  a  maternal  part,  the  thickened  mucous  membrane  of  the  uterus 
(the  decidua  serotina),  and  a  foetal  part  derived  from  the  chorion,  comprising 
the  greatly  developed  mesoblastic  allantois  and  the  epithelial  lay^r  of  the 
false  amnion,  or  subzonal  membrane.  The  zona  radiata  has  been  absorbed. 
The  villi  of  the  chorion  become  gradually  enlarged  to  form  tufts  (Fi^.  19), 
known  as  cotyledons,  which  project  into  great  blood-sinuses  formed  in  the 
decidua  serotina;  but,  as  the  outer- 
most epithelial  layers  of  the  foetal  and 
maternal  tissues  are  interposed,  the  ves- 
sels are  not  in  open  communication,  and 
interchange  of  materials  takes  place 
only  by  osmosis  (Fig.  19).  So  inti- 
mate is  the  connection  between  the  two 
parts  of  the  placenta  that  upon  birth 
the  placenta  as  a  whole,  including  por- 
tions of  maternal  tissue,  leaves  the 
uterine  wall,  and  is  therefore  classed 
as  deciduate.  In  many  mammals  this 
union  is  not  so  complete,  and  the  line 
of  separation  is  between  the  parts  of 
the  placenta,  the  foetal  portion  only 
being  cast  off,  the  maternal  remaining. 
Nor  is  the  placenta  always  a  compact 
structure,  but  in  some  animals  forms  a 
zone  around  the  ovum  and  in  others  is 
diffused,  the  villi  persisting  all  over 
the  chorion.     Or  the  cotyledons  may 

be  developed  in  patches,  the  decidua  reflexa  retaining  its  vascularity  at 
these  points.  The  amnion  has  now  grown  much  faster  than  the  embryo, 
and  occupies  all  the  space  within  the  chorion,  from  which  it  is  separated  by 
a  layer  of  gelatinous  substance,  and  further  covers  as  a  sheath  the  stalks 
of  both  allantois  and  umbilical  vesicle.  The  cord  thus  formed  is  known 
as  the  umbilical  cord,  and  comprises,  at  first,  splanchnic  mesoblast  contain- 
ing the  vessels  from  the  umbilical  sac  and  the  vessels  for  the  allantois,  and 
the  sheath  from  the  amnion,  which  is  made  up  within  of  somatic  mesoblast, 
and  without  of  epiblast.  Later  the  vessels  from  the  yolk-sac  and  one  allan- 
toic vein  disappear,  and  the  mesoblast  derived  from  the  amnion  becomes 
converted  into  the  jelly  of  Wharton,  binding  together  the  vein  and  the  two 
arteries  spirally  wound  around  it.  As  the  foetus  grows  and  the  amniotic  sac 
fills  the  entire  cavity  of  the  uterus,  the  space  between  the  decidua  reflexa 
and  the  decidua  vera  gradually  disappears  and  these  two  layers  become 
united. 


SXEUCTrRE  OF  HUMAN  PLACENTA.— i^*,  fCBtal, 

M,  the  maternal  placenta;  e',  epithelium  of 
maternal  placenta ;  d,  foetal  blood-vessels ;  d', 
maternal  blood-vessels;  ii,  villus;  ds,  ds,  repre- 
sents the  decidua  serotina  of  the  placenta ;  t,  t, 
trabeculse  of  serotina  passing  to  the  foetal  villi ; 
ca,  curling  arterj' ;  up,  utero-placental  vein;  x, 
a  prolongation  of  maternal  tissue  on  the  ex- 
terior of  the  villus  outside  the  cellular  layer  e', 
vphich  may  represent  either  the  endothelium 
of  the  maternal  blood-vessel  or  delicate  con- 
nective tissue  belonging  to  the  serotina,  or  both. 
The  layer  e'  represents  maternal  cells  derived 
from  the  serotina.  The  layer  of  fcetal  epithelium 
cannot  be  seen  on  the  villi  of  the  fully-formed 
human  placenta. 


THE  GENERAL  THERAPEUTICS  OF 
CHILDREN'S  DISEASES. 

By  EOBEETS  BAETHOLOW,  M.D.,  LL.D.       ' 


PRELIMINAEY. 


Remedies,  their  Preparation  and  Classification. — Nothing  can  be 
more  desirable  than  an  improvement  in  the  degree  of  certainty  with  which 
our  therapeutical  measures  are  employed.  That  greater  precision  in  the  use 
of  drugs  now  obtains  than  formerly,  is  because  of  advances  in  pharmaceu- 
tical chemistry,  whereby  more  powerful  agents,  whose  physiological  actions 
are  accurately  ascertained,  can  be  substituted  for  the  cruder  preparations, 
formerly  the  only  kind  available  for  use.  There  are  still  greater  changes 
in  the  armamentarium  for  children,  that  should  be  made.  Whatever  hold 
homoeoj)athy  has  acquired  is  due  for  the  most  part  to  the  sugar  pellets, 
tasteless  solutions,  and  other  contrivances  for  rendering  the  administration 
of  medicines  a  pleasure  rather  than  a  pain.  The  contests  with  children 
which  the  giving  of  nauseous  medicines  provokes  add  not  a  little  to  the 
hardships  of  parents.  Our  efforts  should  be  directed  to  the  preparation  of 
efficient  remedies  that  shall  be,  also,  without  disagreeable  qualities.  It  is 
not  by  "elegant  prescribing,"  so  called,  that  this  desirable  result  can  be 
reached.  In  elegant  prescribing,  the  power  of  a  given  combination  is 
usually  subordinated  to  the  question  of  a  pleasing  taste.  Attention  to  such 
details  may  make  a  good  medical  confectioner,  but  hardly  a  scientific  medi- 
cal practitioner.  Power  in  action  and  facility  in  administration  can  be 
combined  without  descending  to  such  trivialities. 

Keeping  in  view  the  necessity  of  the  case  as  above  outlined,  the  condi- 
tions to  be  complied  with  are — 

1.  The  use  of  concentrated  preparations  of  medicaments. 

2.  Their  arrangement  in  such  form  as  to  secure  facility  of  administra- 
tion and  precision  in  action. 

The  use  of  remedies  in  the  treatment  of  diseases  of  children  and  of 
adults,  to  have  system  and  coherence,  must  be  based  on  a  true  conception 
of  their  modes  of  acting.     Classification  becomes  necessary  if  the  facts 
956 


THE    GENERAL   THERAPEUTICS   OF   CHILDREN'S   DISEASES.  957 

ascertained  are  to  be  utilized  with  success.  Although  any  classification 
must  be  defective  because  of  our  incomplete  knowledge,  we  are  now  in  a 
position  to  arrange  remedies  with  some  degree  of  scientific  precision. 

The  obvious  differences  between  those  remedies  which  affect  only  the 
part  that  they  are  applied  to,  and  those  affecting  the  whole  system,  naturally 
divide  them  into  two  classes, — Local  Remedies  :  Systemic  Remedies. 

As  remedies  may  increase  or  lessen  function,  only,  and  not,  in  the 
normal  state  of  things,  change  its  character,  we  have  as  regards  systemic 
remedies  those  that  improve  and  those  that  retard  nutrition.  As  the  function 
of  nutrition  is  concerned  with  every  tissue  of  the  body,  the  classes  just 
given  are  general  in  scope.  The  condition  of  the  system  as  a  whole  organ- 
ism is  also  affected  by  certain  agencies  from  without,  especially  by  organic 
substances  and  micro-organisms.  Hence  of  general  remedies  we  have  three 
great  classes  : 

1.  Those  that  improve  nutrition  and  increase  tissue-metamorphosis  ; 

2.  Those  that  retard  nutrition  and  increase  waste  ; 

3.  Antiseptics, — remedies  destructive  of  micro-organisms. 

As  the  various  functions  may  be  affected  individually  by  certain  sys- 
temic medicines,  we  have  classes  thus  limited  to  the  function  or  functions 
of  organs. 

As  the  most  widely  connected,  the  diseases  of  the  nervous  system  should 
occupy  the  first  place.  Here  also  the  two  modes  of  acting  on  function 
possible  to  drugs  are  perfectly  well  exhibited.  One  group  increases,  another 
lessens  function  :  hence — 

Excito-motor  ; 

Depresso-motor  ; 

Increasing  action  in  the  sensory  area  ; 

Lessening  action  in  the  sensory  area. 

In  these  several  groups  or  classes  we  may  readily  include  all  remedies 
affecting  the  nervous  system,  and,  through  the  nerves,  other  functions.  But 
there  yet  remain  for  distribution  unassigned  remedies  affecting  some  other 
functions.  These  are  three:  the  intestinal  canal;  the  broncho-pulmonary 
mucous  membrane ;  and  the  genito-urinary  apparatus. 

Of  the  first,  or  the  intestinal  canal,  are — 

Emetics, 

Cathartics, 

Anthelmintics. 

Of  the  broncho-pulmonary  mucous  membrane,  are — 

Inhalations, 
Vapors, 
Spray, 

Douches,  etc. 

Of  the  genital  and  renal,  are — 

Diuretics, 

Emmenagogues. 


958  THE   GENERAL   THERAPEUTICS   OF   CHILDREN'S   DISEASES. 

When  we  come  to  inquire  whether  there  be  any  special  mode  in  which 
to  arrive  at  a  safe  conclusion  regarding  the  utility  of  any  remedy,  it  must 
be  said  that  it  can  be  based,  only,  on  its  physiological  actions.  Empiricism, 
or  the  information  obtained  by  observation  and  experience,  may  serve  until 
a  more  certain  guide — the  proper  study  of  physiological  actions — is  had. 
Clinical  experience  must  confirm  the  deductions  of  physiological  examina- 
tion, to  make  the  evidence  complete. 

In  the  absence  of  more  precise  data,  it  can  be  said  that  all  medicines 
acting  on  a  tissue,  an  organ,  or  a  system  of  the  body,  are  influential,  often 
curative,  in  the  maladies  affecting  these  several  parts  or  organs.  We  can 
formulate  a  law,  therefore,  that  has  an  enormous  experience  to  support  it : 
In  proportion  as  the  remedy  antagonizes  the  morbid  action  in  a  part  is  it  cura- 
tive ;  or,  stated  conversely,  The  more  nearly  the  action  of  the  remedy  harmo- 
nizes or  corresponds  to  the  morbid  action,  the  less  it  has  of  a  curative  action. 

We  may  illustrate  these  postulates  by  atropine  and  pilocarpine.  Pilo- 
carpine is  the  most  powerful  of  sudorifics,  or  sweat-producing  medicines,  we 
possess ;  but  in  the  treatment  of  morbid  sweating  it  increases  the  action 
of  the  sweat-glands,  or  it  opposes  it  feebly  and  inadequately,  or  it  has  no 
apparent  effect.  On  the  other  hand,  atropine,  which  most  directly  and 
powerfully  restrains  sweating,  is,  in  states  of  disease,  the  most  efficient  of 
remedies  to  stop  sweating.  Many  other  examples  could  be  quoted  if  it 
were  necessary  to  do  so. 

Unfortunately,  there  are  many  remedies  of  whose  curative  power  we  can 
have  no  prevision  except  such  deductions  as  may  be  derived  from  the  results 
of  observation  and  experience.  Of  such  we  are  compelled  to  base  our  thera- 
peutical conceptions  on  the  old  empirical  formula  :  A  remedy  that  has  cured 
one  case  must,  also,  cure  analogous  cases. 

There  are  many  reasons,  into  which  we  need  not  enter,  for  doubting  the 
general  applicability  of  such  a  formula,  but,  in  the  absence  of  all  other  aids 
to  a  right  conception,  it  may  serve  a  temporary  purpose. 

Many  approved  methods  of  treatment  which,  in  the  case  of  adults,  are 
much  employed,  cannot  be  in  children  because  of  difference  in  age,  insus- 
ceptibility to  impressions,  tenderness  of  the  tissues,  and  rapidity  of  the 
nutritive  processes. 

On  the  other  hand,  in  consequence  of  the  great  activity  of  tissue-meta- 
morphosis, some  modes  of  procuring  medicinal  action  not  effective  in  the 
case  of  adults  become  highly  so  in  children. 

As  an  example  of  the  greater  activity  of  a  tissue  in  children  that  in- 
creases the  proportionate  effects  of  medicinal  application,  the  skin  may  be 
mentioned.  Thus,  digitalis  moistened  and  enclosed  in  thin  muslin  and 
covered  with  oiled  silk  will,  after  ^some  hours,  begin  to  act  in  its  most 
characteristic  manner.  Other  medicaments  that  have  active  diffusion-power 
can  be  taken  into  the  system  in  the  same  way,  when  the  condition  of  the 
stomach  and  the  nature  of  the  remedy  may  make  such  a  mode  of  entering 
the  vessels  feasible,  in  the  maladies  of  early  life. 


THE   GENERAL   THERAPEUTICS   OF   CHILDREN'S   DISEASES.  959 

The  arrangement  of  the  facts  and  principles  of  general  therapeutics  as 
applicable  to  children  can  be  best  presented  under  the  head  of  the  various 
modes  in  which  medicaments  are  introduced  into  the  body.  The  relation 
of  the  facts  to  each  other,  and  to  the  scheme  of  classification  already  set 
forth,  will  be  stated  under  each. 

TKEATMENT   BY   THE   SKIN: 
Enepidermatie ;  Epidermatic  ;  Midennatic  ;  Hypodermatic. 

Inunctions. — In  suitable  cases  inunction  is  an  effective  mode  of  treat- 
ment. Careful  and  persevering  friction  with  oils  and  fats  will  improve  the 
body-weight  of  children,  sometimes  in  a  remarkable  degree.  This  practice 
is  the  more  eflPective  the  thinner  the  skin  and  the  more  active  the  circula- 
tion. The  absorption  of  fats  is  facilitated  by  a  preliminary  warm  bath. 
This  is  best  given  at  the  bed-hour.  The  child  should  sit  for  a  few  minutes 
in  the  bath,  the  water  at  90°  to  100°  F.  according  to  circumstances.  When 
taken  out  after  one  or  two  minutes,  the  skin  should  be  wiped  dry  and 
gently  rubbed  with  a  rough  towel.  The  inunction  of  the  fat  should  be- 
made  immediately.  The  whole  process  should  not  occupy  more  than  five- 
to  ten  minutes,  and  usually  five  will  suffice. 

The  fat  should  be  animal  fat,  and  not  cacao  butter,  olive  oil,  cotton-seed 
oil,  and  similar  vegetable  productions.  Benzoinated  lard  and  benzoinated 
mutton  suet  are  the  best  forms  of  fats  for  inunction,  the  addition  of  the  ben- 
zoin being  useful  in  improving  the  odor  and  preventing  decomposition  of 
the  fat.  By  systematic  application  of  fats,  very  great  improvement  in  the 
nutrition  of  children,  and  with  comparative  facility,  is  made.  Patience  and 
thoroughness  -are  necessary  qualifications  for  those  who  undertake  this  plan 
of  treatment ;  and,  if  the  operator  be  gifted  Avith  these  attributes,  results 
worthy  of  the  time  and  toil  expended  will  be  secured. 

When  the  body  is  wasted,  the  skin  dry  and  furfuraceous,  the  tempera- 
ture at  normal,  or  above,  inunctions  of  fats  contribute  to  the  removal  of  the 
morbid  state  causing  these  signs. 

Fat-inunctions  are  antipyretic  to  a  sensible  extent.  In  tlie  eruptive  fevers 
they  act  in  two  modes  :  allaying  the  irritation  in  the  skin,  and  lowering  the 
temperature.  It  is  probable  the  latter  is  chiefly  a  result  of  the  influence  of 
the  former  over  the  combustion-process.  For  if  the  irritation  of  the  skin 
is  removed,  it  follows  that  the  efi'ect  of  this  in  exciting  the  circulation  dis- 
appears. The  heart  acting  less  quickly,  the  vaso-motor  tone  is  increased, 
and  hence  less  blood  passes  through  the  tissues,  and  oxidation  declines,  in  a 
corresponding  ratio.  In  all  fevers  where  decline  in  heat  is  necessary  to 
safety,  this  procedure  may  be  employed  without  risk. 

In  using  fat-inunctions  in  fevers  it  is  implied  that  the  skin  is  kept  in 
good  condition  by  subsequent  sponging 'with  an  alkaline  solution, — sodium 
carbonate,  especially. 

Sponging  with  alkaline  solutions  is  a  highly  useful  measure  in  nervous 
diseases  of  irritation.     Children  in  high  fever,  with  twitching:  of  muscles 


960  THE   GENERAL   THEEAPEUTICS   OF   CHILDEEN's   DISEASES. 

and  tendons,  partial  or  general  convulsions  threatened,  are  suitable  subjects 
for  this  kind  of  medication.  A  saturated  solution  of  sodium  carbonate  in 
rain-water  or  clean  river-  or  spring-water  should  be  sponged  over  the  whole 
surface  of  the  body,  and  as  often  as  the  case  may  require, — for  a  case  of 
slow  progress  and  long  on  hand,  twice  a  day,  but  in  acute  cases  with  high 
fever,  every  two,  three,  or  four  hours,  pro  re  naia.  The  cooling  effect  of 
the  evaporation  of  water,  due  to  a  transferring  of  the  body-heat  into  another 
mode  of  motion,  is  an  antipyretic  action,  and  is  quite  apart  from  the  results 
of  the  alkaline  reaction  on  the  diffusion  process. 

Inunction  of  remedies  in  the  form  of  ointments  for  specific  effects  is  an 
old  method  that  has  l^een  recently  revived, — the  Vienna  school  having  been 
most  active  in  bringing  about  the  revival.  In  children  the  hereditary  or 
acquired  specific  lesions  are  most  readily  and  effectively  treated  in  this  way. 
The  preparation  most  uniformly  useful  is  the  oleate.  A  small  bolus  of  this, 
the  size  of  a  large  pea,  is  put  well  up  into  the  axilla,  and  the  movements 
of  the  arm  by  the  child  rub  it  into  the  skin.  ISIercurial  ointment  is  also 
rubbed  in  where  the  skin  is  thinnest.  Extemporaneous  formulae  of  other 
mercurial  salts  are  employed  in  the  same  way. 

Some  kinds  of  enlarged  glands  are  effectively  treated  by  topical  inunc- 
tions. The  ointment  of  the  red  iodide  of  mercury,  which  was  official  in 
the  Pharmacopoeia  of  1870,  is  a  suitable  combination  for  topical  use  in 
such  cases  as  goitre,  enlarged  spleen,  etc.  It  is  intended  to  be  applied  daily, 
until  the  skin  begins  to  show  signs  of  inflammation,  when  the  application 
is  suspended  until  it  may  be  made  with  safety. 

Baths. — The  most  important  of  applications  to  the  skin  to  effect  thera- 
peutical results  is  by  bathing.  It  must  also  be  considered  in  its  hygienic 
aspects,  so  far  as  these  are  utilized  in  the  treatment  of  diseases. 

In  children,  after  the  first  dentition  and  subsequently,  the  daily  morning 
sponge-bath  should  be  a  uniform  practice.  Children  susceptible  to  colds 
and  catarrhal  processes  in  general  are  rendered  less  susceptible  by  this  prac- 
tice. It  is  also  a  tonic  to  the  vascular  and  nervous  systems,  and  this  effect 
comes  by  an  impression  made  on  the  peripheral  nerves.  Warm  baths  at  or 
near  the  temperature  of  the  body,  and  washings  for  cleanliness,  cannot  be 
substituted  for  the  morning  cold  sponge-bath.  The  details  consist  in  a  tub 
large  enough  to  stand  in  and  catch  the  ovei'flowing  water ;  sufficient  water 
at  the  temperature  of  the  air  in  the  room ;  the  sponge  or  cloth  sufficiently 
large  to  carry  the  necessary  quantity  of  water ;  coarse  towels  for  friction 
of  the  skin. 

The  whole  body  is  gone  over  with  the  sponge;  the  coarse  towel  is 
used  to  dry  aud  to  make  the  necessary  friction  of  the  skin.  The  whole 
process  requires  no  more  than  five  minutes,  and  a  glow  of  a  very  grate- 
ful character  succeeds  to  the  first  chilliness  of  the  surface.  The  clothing 
should  then  be  put  on,  the  toilet  completed,  and  then  to  breakfast, — in 
these  details  assuming  the  state  of  fortune  permitting  such  attention  to  the 
person. 


THE    GEXEEAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  961 

Those  having-  sufficient  vigoi-  of  constitution — especially  boys — can  take 
a  morning  jjlunge-bath  if  the  circumstances  are  propitious ;  but  this  mode 
of  using  water  may  be  objectionable  for  these  reasons  :  the  heat  of  the  body 
is  more  rapidly  and  considerably  taken  up ;  the  shock  to  the  nervous  and 
vascular  apparatus  is  greater  ;  the  reaction  is  more  violent.  Hence  in  chil- 
dren of  weak,  as  in  most  of  those  of  vigorous  constitution  also,  the  method 
by  sponging  is  preferable. 

In  fevers  and  inflammations,  the  use  of  baths  has  attained  to  the  dignity 
of  a  highly  important  therapeutical  measure.  The  question  of  the  propriety 
or  need  of  the  measure  must  be  considered  in  connection  with  special  thera- 
peutics. Whether  sponging  of  the  surface  with  water  or  plunging  into 
baths  be  the  more  useful  expedient,  is  determined  by  the  character  of  the 
case  and  the  object  to  be  accomplished,  as  the  effects  of  these  modes  of 
application  are  not  the  same  in  kind  or  in  degree.  In  sponging  the  sur- 
face the  heat  is  reduced  by  evaporation  of  the  water :  in  other  words,  the 
heat  is  converted  into  another  mode  of  motion, — dissipated  in  the  vapor. 
In  a  bath,  the  heat  of  the  body  is  conveyed  to  the  water  by  conduction,  and 
the  amount  conveyed  is  considerable  according  to  the  distance  between  the 
heat-points  of  the  water  and  the  body.  Thus  it  is  that  an  expert  swimmer 
fails  at  a  distance  from  the  shore.  The  heat  of  the  body  is  so  rapidly  and 
largely  removed  that  the  muscles  at  length  pass  into  a  tetanic  state,  and 
are  no  longer  obedient  to  the  will. 

The  necessity  for  the  use  of  baths  for  antipyretic  effects  is  determined 
by  the  effect  of  heat-reduction  on  the  course  and  severity  of  the  fever.  In 
general  it  may  be  said  that  the  higher  the  fever,  the  more  injurious  the 
effects  of  the  heat  on  the  tissues  and  organs.  Granular  degeneration,  not 
long  since  supposed  to  be  due  to  the  fever-heat,  is  now  rather  referred  to 
the  original  cause :  to  the  morbid  influence  or  micro-organisms  setting  up 
the  febrile  movement.  This  fact  admitted,  the  necessity  for  antipyretic 
baths  is  limited  to  the  cases  in  which  discomfort,  restlessness,  deliriuna, 
and  so  forth  are  caused  by  the  heat  itself.  In  such  cases  sponging  the 
surface  affords  great  relief;  immersion  in  the  bath  is  still  more  effective. 

The  mode  of  applying  the  bath  in  children,  up  to  puberty,  consists  in 
immersion  in  water  at  or  about  80°  F.  Seated  in  the  tub,  not  covered 
above  the  lower  border  of  the  ribs,  the  water  is  gently  put  on  the  shoul- 
ders, arms,  neck,  and  chest,  so  that  complete  immersion  may  presently  be 
made  ^vit]l()ut  occasioning  shock  of  any  severity.  The  water  of  the  bath 
should  then  be  cooled  gradually  down  to  60°  F.,  or  about  that,  by  the 
addition  of  sufficient  cold  water,  or  some  ice.  If  evidences  of  faintness 
or  exhaustion  appear,  the  child  should  be  removed  from  the  bath,  given 
some  stimulant  if  necessary,  and  placed  between  blankets  if  sweating  be 
desired. 

The  general  cpiestion  of  the  utility  of  antipyretic  baths  in  the  treat- 
ment of   fever    remains    undetermined.     The    most  convincing   series  of 

figures,  based  on  careful  observations,  are  to  be  found  in  the  last  volume  of 
Vol.  I.— 61 


962  THE    GEXEEAL   THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

Guy's  Hospital  Reports  (xlv.  page  379,  "  Innominate  Fever  and  Antipy- 
retics," Dr.  James  F.  Goodliart).  In  summing  up,  Dr.  Goodhart  says, 
"  The  antipyretics  are  pretty  certain  in  their  antipyretic  action,  but  they  do 
not  cut  short  the  fever ;  I  cannot  say  they  influence  it  for  good  in  the 
majority  of  cases."  What  practical  physician  with  the  necessary  oppor- 
tunities for  making  clinical  observations  will  not  agree  heartily  with  Dr. 
Goodhart's  opinion  ?  In  children's  febrile  diseases,  the  treatment  by  anti- 
pyretics has  proved  to  be  specially  useful  and  effective  in  appropriate  cases ; 
and  of  these,  cold  baths,  easily,  take  the  first  place.  There  is,  however,  a 
growing  belief  that  the  lessening  of  fever  in  this  way  does  not  increase 
the  chances  of  recovery,  or  promote  improvement  in  the  course  and  dura- 
tion of  a  febrile  malady.  Further,  there  is  reason  to  believe,  indeed,  that 
the  effects  of  the  antipyretic  medicines  must  be  added  to  the  conditions 
imposed  by  the  disease,  and  thus  the  morbid  complexus  becomes  more 
complicated. 

The  immense  superiority  of  the  cold  bath  merely  as  an  antipyretic  is 
clear.  It  is  true  that  so  great  an  authority  as  Liebermeister  ^  says  that  if 
restricted  in  his  choice  of  antipyretics  to  one  he  would  select  quinine.  If 
this  dictum  be  assented  to  in  the  febrile  diseases  of  adults,  it  is  not  true  of 
those  occurring  in  children.  If  the  same  restriction  were  imposed  in  the 
fevers  of  children,  the  cold  bath  would  now  be  selected  as  the  single  and 
universal  antipjTetic. 

In  the  febrile  state  now  known  as  hyperpyrexia,  the  utility  of  the  cold 
bath  is  unquestionable.  Whenever  in  the  course  of  an  acute  inflammatory 
or  febrile  disease  the  temperature  rises  above  the  level  normal  under  the 
circumstances,  the  use  of  the  cold  bath  is  clearly  indicated.  On  the  other 
hand,  if  the  disease  pursues  the  regular  course  as  to  combustion  and  waste 
(which  is,  in  t^-pical  cases,  the  regular  course),  then  antipyretics  are  not 
necessary, — rather,  indeed,  they  are  hurtful.  When  the  cold  bath  is  not 
necessary  in  exacerbations  of  the  fever,  cold  sponging  without  changes  of 
posture  or  of  clothing  will  prove  grateful.  If  perfumes  are  pleasant  to  the 
senses,  a  little  cologne  can  be  added  to  the  water ;  but  a  general  bath  of 
alcohol,  diluted  or  undiluted,  should  never  be  used. 

Medicinal  Baths. — Several  kinds,  but  few  of  real  value,  are  applied  to 
the  skin  to  procure  systemic  effects.  It  is  only  by  diffusion  that  such  effects 
can  be  obtained,  and  this  merely  physical  process  is  much  hampered  by  the 
state  of  the  epidermic  layer. 

Diffusion  starts  two  movements, — one  in  the  terminal  nerves,  the  other 
in  the  blood-vessels.  The  double  action  may  be  illustrated  by  cocaine. 
When  the  outer  skin — the  epidermic  layer — is  taken  off,  the  sensory 
nerves  are  acted  on  and  deprived  of  sensibility  for  the  time  being ;  the 
general  system  is  affected  in  a  characteristic  manner  when  the  remedy  is 
distributed  by  the  blood,  into  which  it  diffuses. 

1  Handbuch  der  Palhologie  und  Therapie  dcs  Fiebers,  Vogel,  Leipzig,  1875,  p.  634. 


THE    GEXERAL    THERAPEUTICS    OF    CHILDREN'S   DLSEASES.  963 

In  the  diseases  of  early  life  the  skin  is  a  less  dense  diffusion-membrane 
than  it  afterwards  becomes,  and  hence  "absorption"  is  more  certain  and 
more  active ;  but  no  exactness  is  possible  in  such  a  mode  of  administration. 
The  quantity  admitted  to  the  blood  varies  with  the  state  of  the  skin,  the 
fulness  of  the  blood-veesels,  and  the  character  of  the  solutions.  As  the 
blood  is  an  alkaline  fluid,  it  is  obvious  that  a  medicinal  solution  having 
an  acid  reaction  will  diffuse  into  the  blood  more  quickly  than  neutral  or 
alkaline  substances.  Hence,  when  feasible,  this  fact  should  be  utilized  in 
preparing  a  solution. 

The  only  solutions  that  need  to  be  sjjoken  of  here  are  those  of  digitalis 
and  quinine.  The  application  of  the  former  has  been  referred  to  by  way 
of  illustration,  and  here  the  additional  details  are  given  only  in  a  general 
sense.  When  it  is  purposed  to  use  digitalis  or  other  similar  vegetable 
remedies,  the  leaves,  moistened  with  water  and  very  slightly  acidulated 
with  vinegar,  should  be  enclosed  in  a  flat  bag  of  thin  muslin,  but  suffi- 
ciently flexible  to  adapt  itself  to  the  inequalities  of  the  surface.  As  the 
action  of  digitalis  is  slow,  impatience  will  spoil  all,  for  if  removed  too  soon 
no  effect  can  be  had. 

Quinine  in  solution,  slightly  acidulated,  certainly  acts  with  considerable 
power.  I  am  informed  by  a  distinguished  physician  of  Orange,  Xew  Jer- 
sey, in  a  private  communication  with  which  he  has  favored  me,  that  quinine 
acts  efficiently  in  children  when  rubbed  into  the  skin.  He  makes  use  of  9i 
to  si  of  lard,  and  has  it  thoroughly  applied  where  the  skin  is  thinnest.  A 
slightly  acidulated  solution  will  probably  be  more  efficient,  and  the  quantity 
administered  might  be  much  larijer. 

The  pads  at  one  time  so  popular  in  this  country  and  sold  in  enormous 
numbers  must  have  had  some  effect,  or  the  lavish  advertisements  in  which 
they  were  kept  before  the  people  had  not  sufficed  to  maintain  their  position 
for  so  long  a  time.  The  Babcock  pad  had  a  strong  odor  of  fenugreek-seed, 
and  had  a  color  like  red  cinchona  bark.  No  doubt  some  Cjuinine  was  con- 
tained in  them  also.  After  a  few  days'  wear  the  skin  on  which  the  pad 
rested  (the  epigastric  region)  became  red,  and  numerous  papules  appeared. 
The  redness  and  moisture  favored  diffusion  of  the  quinine.  We  do  not  doubt 
that  physicians  practising  in  malarial  areas  might  utilize  this  expedient,  for 
rarely  children  can  take  quinine  without  a  struggle. 

Endermatic. — A  few  words  should  now  be  said  regarding  applications 
to  the  true  skin,  the  epidermis  having  been  removed. 

In  very  young  children  it  is  rarely  that  such  an  expedient  can  be  practised, 
for  the  pain  attending  the  removal  of  the  epidermis  is  too  great  and  per- 
sistent to  justify  the  practice.  In  the  older  and  more  self-controlled  children 
it  may  sometimes  be  employed.  To  raise  a  blister  is  the  first  step,  and  this 
is  most  easily  and  promptly  done  by  moistening  with  stronger  ammonia  the 
inside  of  a  watch-glass,  which  is  then  inverted  over  the  part  to  be  blistered. 
When  the  epidermis  is  removed,  the  medicament  can  then  be  put  on  the  raw 
surface.     Instead  of  water  of  ammonia  in  a  watch-glass,  pure  carbolic  acid 


964  THE    GENEEAL    THERAPEUTICS    OF    CHILDEEN's    DISEASES. 

can  be  brushed  over  the  part  to  be  blistered.  As  the  ansesthetic  eflPect  of 
phenol  is  considerable,  this  mode  of  endermatic  application  may  be  used  the 
more  readily  in  children. 

Hypodermatic  Injections. — The  real  inventor  of  the  hypodermatic 
method  was  Magendie,  and  so  long  ago  as  the  first  ten  years  of  this  century 
his  demonstration  was  made,  and  consisted  in  placing  the  medicament,  or  a 
solution  of  it,  under  the  skin  of  the  animal,  and  then  noting  the  time  and 
the  character  of  the  eifects  produced.  In  this  way  he  proved  that  dif- 
fusion into  the  blood  took  place,  and  that  the  action  was  the  same  in  kind 
as,  although  different  in  degree  from,  that  caused  by  the  same  medicine 
when  it  enters  the  system  by  the  stomach.  He  made  the  first  study  of  nux 
vomica,  and  the  publication  of  his  researches  led  to  the  use  of  the  remedy 
in  the  maladies  to  which  he  thought  it  adapted,  and  his  prescience  has  been 
confirmed  by  a  vast  experience. 

In  its  present  aspect,  as  introduced  by  Dr.  Wood,  of  Edinburgh,  the 
hypodermatic  method  consists  in  the  use  of  a  solution  of  a  medicament  which 
is  thrown  under  the  skin  by  means  of  a  small  syringe,  the  nozzle  of  which 
is  a  perforated  needle  armed  with  a  cutting-point  for  puncturing  the  skin. 
The  preparation  of  the  solutions  and  the  several  methods  and  precautions 
required  in  injecting,  the  special  dangers,  etc.,  have  been  so  copiously  treated, 
and  the  information  is  so  accessible,  that  further  discussion  of  these  points 
is  not  necessary. 

The  chief  objections  to  the  practice  of  hypodermatic  medication  in  chil- 
dren are :  the  danger,  the  pain,  the  subsequent  complications. 

When  the  injection  is  most  necessary,  the  little  patient  is  not  con- 
scious,— for  example,  in  ursemic  convulsions,  when  pilocarpine  is  used. 
TJie  dangers  are  idiosyncrasy,  power  and  quantity  of  medicament.  It  is 
unsafe  to  use  a  powerful  alkaloid  without  inquiry  into  the  peculiar  sus- 
ceptibility which  may  exist  in  an  adult  as  well  as  in  a  child.  With  suit- 
able care,  subcutaneous  injections  may  be  practised  in  the  case  of  children 
not  under  three  years  of  age.  An  inexperienced  practitioner  should  not 
attempt  this  procedure  except  under  experienced  direction  when  the  age 
is  less. 

The  pain  felt  at  the  insertion  of  the  needle  may  be  blunted,  or  pre- 
vented, in  several  ways : 

The  needle  should  be  small  in  size  and  sharp,  having  a  properly-shaped 
cutting-point. 

The  skin  may  be  benumbed  by  placing  on  it,  where  the  injection  is  to 
be  made,  a  pledget  of  absorbent  cotton  moistened  with  chloroform ;  by  rub- 
bing over  the  surface  the  cone  used  for  counter-irritation  and  for  the  relief 
of  pain  (chlor.  menthol,  camphor,  etc.) ;  by  applying  the  catliode  of  a  mild 
galvanic  current  for  several  minutes  to  the  skin.  If  the  injection  be  prac- 
tised at  once,  relief  will  be  nearly  complete. 

Tlie  remedies  used  hypodermatically,  chiefly,  in  the  diseases  of  children, 
are  the  followins : 


THE   GENERAL   THERAPEUTICS   OF   CHILDREN'S   DISEASES.  965 


Eseriue. 

Morphine  and  its  salts. 

Chloral  hydrate. 

Morphine  and  Atropine. 

Pilocarpine. 

Amyl  nitrite. 

Cocaine  and  its  salts. 

Apomorphine. 


Hyoscyamine  and  its  salts. 

Quinine. 

Duboisine  and  its  salts. 

Mercury. 

Urethan. 

Antipyrin. 

Antifebrin. 


The  most  eligible  preparation  for  the  hypodermatic  method  is  the  so- 
-called  "  soluble  hypodermic  pellet/' — a  flat,  circular,  pilular  body,  made  in 
this  form  by  compression  with  a  die.  The  advantages  of  such  a  preparation 
are,  convenience  in  preparing  a  solution,  safety  in  dosage,  and  accuracy  in 
amount  of  medicament. 

The  dose  for  administration  subcutaneously  is  determined  by  age  and 
body-weight.  The  rule  given  hereafter  for  apportioning  the  amount  of  a 
medicament  for  children  is  applicable  to  this  method,  with  the  exception 
that  its  power  is  about  three  times  greater. 

The  maladies  of  early  life  in  which  the  subcutaneous  method  is  applied 
are  the  painful,  the  spasmodic,  the  inflammatory,  and  the  specific.  They  may 
be  conveniently  grouped  in  this  way  for  consideration  here. 

Painful  Affections. — The  kinds  of  disease  meant  here  are  those  affect- 
ing the  sensory  apparatus  of  the  system,  apart  from  actual  changes  of 
structure  in  the  nerve-substance,  or  in  the  parts  to  which  nerves  of  sensa- 
tion are  distributed.  The  subcutaneous  method  should  not  be  used  in  con- 
<iitions  of  which  pain  is  the  chief  element,  unless  the  ordinary  means  of 
relief  prove  inadequate. 

Such  troubles  as  toothache  and  earache  do  not  justify  the  use  of  such  a 
powerful  remedy.  The  more  severe  and  exhausting  neuralgic  aflFections 
may  justify  or  even  require  its  administration.  Cocaine  is  less  dangerous 
than  any  other  anodyne  affording  as  much  relief;  and  the  curative  action  is 
greater ;  only,  however,  in  the  neuralgige  of  superficial  nerves.  It  should  be 
injected  at  or  about  the  area  the  seat  of  pain. 

In  the  convulsions  of  children  the  agent  employed  hypodermatically 
will  depend  on  the  cause :  if  ursemic,  pilocarpine  is  the  appropriate  agent, 
for  this  so  acts  on  the  skin  as  to  make  it  an  efficient  substitute  for  the 
kidneys.  The  depressing  effects  of  this  agent  can  be  readily  overcome  by 
using  its  physiological  antagonist,  atropine.  Therefore  whenever  symp- 
toms of  a  threatening  character  arise  from  cocaine,  its  antagonist  should  be 
given  without  delay.  As  idiosyncrasy  plays  so  large  a  part  in  the  actions 
of  pilocarpine  when  it  causes  toxic  effects,  the  physician  who  purposes  using 
it  in  any  subject  whose  reactions  to  it  are  unknown  should  always  be  pro- 
vided with  the  atropine ;  for  should  the  emergency  arise,  delay  may  be  fatal. 
In  convulsions  of  an  epilc})tiforni  cliaracter,  or  in  ursemic  convulsions 
not  amenable  to  the  action  of  pilocarpine,  hypodermatic  injections  of  mor- 


966  THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

phine  have  proved  remarkably  successful  in  some  cases.  When  convulsive 
seizures  are  due  to  inflammatory  action  of  the  meninges  or  of  the  brain- 
substance,  or  to  aural  troubles,  or  to  "  coarse  lesions"  of  a  subacute  or 
chronic  type,  the  morphine  injections  are  to  be  placed  first  among  the  most 
effective  remedies. 

I  must  repeat  my  warning  as  to  the  dose  and  mode  of  administering 
such  powerful  medicines  in  the  diseases  of  children.  Less  than  three  years 
is  a  contra-indication ;  for,  although  in  exceptional  conditions  this  limit 
may  not  be  regarded,  certainly  an  inexperienced  physician  should  not  take 
the  responsibility. 

The  hypodermatic  injection  of  ether  is  an  expedient  of  exceptional  value, 
as  I  have  seen  personally,  when  sudden  and  sev^ere  depression  of  the  vital 
powers  comes  on, — as  in  the  intestinal  hemorrhage  of  typhoid  fever,  in 
pneumonia,  both  fibrinous  and  catarrhal,  and  in  heart-failure  from  any 
cause.  The  injection  is  practised  at  any  point  where  the  subcutaneous  tissue 
is  sufficiently  extensible. 

Transfusion  and  Intravenous  Injection. — But  little  is  necessary  to- 
be  said  on  this  topic.  Rarely  is  there  need  to  transfuse  blood,  and  more 
rarely  to  inject  salines  into  the  veins. 

Transfusion  may  be  required  in  cases  of  the  bleeder  disease  (or  haemo- 
philia), when  bleeding  can  be  arrested  only  by  substituting  blood  capable  of 
coagulation.  For  this  purpose  blood  obtained  from  a  healthy  subject  (boy 
or  girl)  is  most  suitable ;  but  lamb's  blood  by  direct  transfusion  will  accom- 
plish the  object.  In  pernicious  anaemia,  if  no  other  remedy  can  succeed, 
and  the  functions  of  other  organs  are  in  a  good  state,  there  are  sound 
reasons  for  trying  this  expedient.  Also  when  the  blood  is  so  far  injured  by 
the  action  of  toxic  agents,  as  in  poisoning  by  phosphorus,  carbonic  oxide, 
chlorine,  and  other  gases,  the  substitution  of  blood  capable  of  functioning, 
becomes  imperative.^ 

The  details  of  the  operation  of  transfusion  belong  rather  to  surgery, 

and  hence  the  reader  is  referred  to  the  works  in  that  department  of  medical 

literature. 

BY   THE   GASTEO-INTESTINAL  CANAL. 

The  usual  route  to  introduce  medicines  into  the  system  is  by  the 
stomach.  The  form  of  medicament  and  the  manner  of  administration  be- 
come especially  important  in  the  treatment  of  children.  Attention  to  the 
preparation  of  such  medicaments  as  will  obviate  the  difficulties  arising  from 
the  quantity,  ill-taste,  and  generally  nauseating  character  of  our  medicines, 
cannot  be  too  strongly  insisted  on.  Besides  and  beyond  the  therapeutical 
knowledge  and  skill  which  should  be  constant  qualities,  a  wise  physician 
possesses  the  mother-wit,  in  prescribing,  to  avoid  the  anguish  of  children  and 
the  distress  of  parents  consequent  on  the  struggles  in  giving  nauseous  drugs. 

Of  the  liquids,  fluid  extracts,  simple  solutions,  and  concentrated  tine- 


1  Berliner  Klini.sche  Wochenschrift,  1871,  No.  21. 


THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  967 

tures  are  preferable.  Much  observation  has  made  it  clear  that  the  pleasing 
mixtures  in  which  these  forms  of  medicaments  are  put  by  "  medical  confec- 
tioners" disappoint  the  expectations  of  their  promoters.  If  the  child  can 
be  readily  induced  to  swallow  the  first  mouthful  or  two,  the  next  dose 
becomes  a  conflict,  or  prolonged  persuasion  is  necessary,  and  at  last  the  little 
one  triumphs.  On  the  other  hand,  a  concentrated  tincture  or  solution,  or 
a  fluid  extract,  can  be  given  readily  with  a  little  address.  Consideration 
must  be  given  to  the  character  of  the  case,  to  the  physical  and  mental  qual- 
ities of  the  child,  to  any  idiosyncrasy  known  to  exist,  to  the  mental  and 
moral  stamina  of  the  parents,  and  also  to  the  nature  of  the  medicament, 
the  physiological  effects  to  be  produced,  what  dose  is  necessar}^^  and  at 
what  interval  the  doses  must  be  given  to  secure  a  constant  impression.  For 
example :  aconite  in  inflammation,  which  for  a  child  of  three  or  five  can  be 
prepared  by  dropping  into  a  little  water,  at  the  time  required,  for  the  first 
dose,  two  drops,  and  subsequently,  every  hour,  or  every  two  or  three  hours 
as  the  case  may  be,  one  drop. 

Large  bottles  of  complicated  mixtures  or  solutions  are,  as  a  rule,  super- 
fluous. It  needs  no  diabolic  instinct  to  determine  the  physician's  perplexity 
and  indecision  by  the  number  and  variety  of  the  mixtures  that  cumber  the 
medicine-table  or  the  mantel-piece.  Such  practice  is  wasteful,  extravagant, 
costly,  and  should  not  be  added  to  the  other  burdens  occasioned  by  sickness. 
It  is  a  method  apt  to  engender  unpleasant  suspicions, — that  the  doctor  and 
the  druggist  divide  profits. 

There  are  now  so  many  fluid  extracts  from  which  to  choose,  that  the 
physician  can  always  avail  himself  of  a  concentrated  preparation  repre- 
senting the  full  powers  of  the  medicament.  Besides  these,  alkaloids,  neutral 
principles,  glucosides,  etc.,  are  also  available.  As  has  been  stated,  these 
active  principles  are,  as  a  rule,  more  certain,  and  more  manageable  when 
distinct  physiological  effects  are  to  be  produced.  Some  crude  agents  {e.g., 
pilocarpus)  are  less  exact,  and  more  apt  to  fail  under  certain  circumstances, 
than  are  their  alkaloids  {pilocarpine).  All  the  alkaloids,  or  nearly  all,  and 
their  salts,  dissolve  in  so  small  a  quantity  of  \vater  that  a  drop  or  two  of  a 
given  solution  can  contain  a  sufficient  quantity  to  act  as  strongly  as  may 
be  necessary. 

The  doses  of  medicaments  for  children  have  been  stated  in  various 
formulae ;  but  mathematical  devices  can  never  take  the  })lace  of  discretion 
and  knowledge.  An  arbitrary  quantity  of  any  medicament  can  never  have 
more  value  than  a  mere  suggestion.  For  the  most  part,  to  induce  physi- 
ological actions  within  controllable  limits  is  a  necessary  condition  to  effect 
curative  results  in  certain  states.  Idiosyncrasy  plays  so  large  a  part  in  the 
complex  of  disturbances  caused  by  medicines,  that  the  nature  and  limitations 
of  such  peculiarities  must  be  ascertained  before  their  therapeutical  powers 
can  be  brought  into  action  to  the  fullest  extent.  It  is  necessary,  however, 
to  have  some  guidance  in  fixing  on  the  dose  required  at  various  ages  as  a 
preliminary  step.      The  most  scientific  rule  is  that  which  determines  the 


968  THE    GEXEEAL    THERAPEUTICS    OF    CHILDEEX  S    DISEASES. 

dose  by  comparison  with  the  weight  of  the  subject.  Dr.  E.  H.  Clark,  of 
Boston,  proposed  the  following  : 

The  weight  of  the  adult  being  fixed  at  one  hundred  and  fifty  pounds  as 
the  standard,  this  must  be  regarded  as  unitii,  or  one.  Accordingly,  the  dose 
for  the  child  will  have  the  same  relation  to  one,  or  unity,  as  its  weight  has 
to  one  hundred  and  fifty  pounds.  If  the  weight  of  the  child  be  divided  by 
150,  the  resulting  fraction  is  the  proper  dose.  Assuming  the  child's  weight 
is  30,  the  proportion  is  30  :  150  : :  a; :  1.  Whence  we  have  i,  or  that  the 
amount  suitable  for  a  child  weighing  thirty  pounds  is  one-fifth  of  that  suit- 
able for  a  man  weighing  one  hundred  and  fifty  pounds.  Reduced  to  actual 
example,  it  may  be  stated  thus  : 

If  the  dose  for  an  adult  is  twenty  grains,  the  amount  suitable  for  a 
child  weighing  thirty  pounds  is  four  grains. 

Such  a  mode  of  arriving  at  the  proper  dose  can  be  approximative  only, 
yet  it  is  fau'ly  safe. 

Dr.  Cowling,  of  Louisville,  Kentucky,  has  added  to  the  list  of  formulae 
by  the  following  proposal :  Take  the  next  ensuing  birthday,  and  divide 
this  number  by  twenty-four.  If  the  child's  next  birthday  is  four,  and 
this  is  divided  by  twenty-four,  the  result  is  ^  =  ^.  Consequently  by  this 
rule  we  have  a  number  nearly  the  same  as  that  arrived  at  by  the  Clark 
formula. 

The  method  of  Dr.  Young,  which  has  been  long  known,  is  to  add 
twelve  to  the  age  of  the  child,  and  divide  the  product  by  the  figure  repre- 
senting the  age.  Thus,  if  the  age  of  the  child  is  four,  add  twelve,  which 
makes  sixteen,  and  this  divided  by  four  gives  J. 

It  were  easier  to  carry  the  fractions  in  memory  than  to  make  the  cal- 
culations. Any  one  will  serve  the  pui-pose,  if  the  resultant  dose  is  not  near 
the  lethal  one. 

When  we  come  to  consider  the  numerous  agents  used  to  affect  the  di- 
gestive apparatus,  it  is  clear  that  the  functions  are  acted  on  in  the  most 
diverse  manner ;  but  they  may  be  conveniently  arranged  in  several  groups  : 

ToiiiG  Bitters  ; 

Emetics  ; 

Cathartics  (including  Cholagogues)  ; 

Anthelmintics. 

At  present  our  concern  is  with  those  remedies  that  improve  appe- 
tite, that  increase  the  disposition  of  the  stomach  to  take  food  and  to  form 
peptones.  Beyond  this  are  the  systemic  states — as  fever,  inflammation, 
etc. — which  are  acted  on  by  agencies  that  enter  the  system  through  the 
stomach. 

The  morbid  state  by  the  French  writers  called  apepsia  is  one  of  the 
most  common  of  the  digestive  disorders  of  early  life.  A  condition  charac- 
terized by  slow  and  painful  digestion,  corresponding  to  nervous  dyspepsia 
as  it  occurs  in  adults,  is  far  from  uncommon.     In  these  disorders  pepsin  is 


THE    GEXERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  969 

said  by  its  promoters  to  be  curative ;  but  I  doubt  the  accuracy  of  their 
observations.  There  is  a  general  distrust  of  reports  made  by  physicians 
who  so  zealously  defend  some  particular  or  proprietary  preparation.  There 
are  numerous  pharmaceutical  combinations  now  "  manufactured  by  the  trade," 
containing  pepsin  and  bismuth,  pepsin  and  lime,  pepsin  and  cod-liver  oil, 
pepsin  and  lactic  acid,  etc.  The  number  and  variety  of  these  formulae  must 
appeal  to  the  average  doctor  and  sell  enormously ;  otherwise  their  repro- 
duction, together  with  the  additions  constantly  being  made  to  the  number, 
would  cease  to  be  profitable.  It  is  generally  believed,  by  those  competent 
to  form  a  correct  opinion,  that  all  wines  of  pepsin  are  without  ferment- 
power,  and  hence  that  the  alcoholic  solutions  are  inert.  From  this  conclu- 
sion the  pepsin  essence  of  Liebreich  may  be  excepted. 

In  considering  the  question  of  a  tonic  bitter  for  children  the  quantity 
and  disagreeable  taste  of  the  crude  jireparations  of  bitters  put  them  aside. 
The  most  generally  useful  is  the  tincture  of  nux  vomica,  of  which  a 
minim  or  two  will  suffice,  or  the  white  fluid  extract  of  hydrastis  prepared 
by  Lloyd  of  Cincinnati,  which  may  be  given  in  the  same  dose. 

The  routine  administration  of  quinine  when  a  tonic,  so  called,  is  re- 
quired, has  become  an  abuse  of  no  inconsiderable  proportions.  Giving  this 
for  every  trivial  purpose  has  an  ill  eifect  on  the  nervous  system,  and  may 
be  a  cause  of  chorea  and  other  nervous  diseases.  During  the  formative 
period  of  the  human  organism  it  appears  a  not  unreasonable  presumption 
that  permanent  disability  of  nerve-matter — an  excessive  mobility — may  be 
due  to  the  impression  made  by  quinine  on  the  cells  and  fibres  of  the  brain 
and  cord.  As  Dr.  Jacobi,  of  New  York,  has  shown,  children  bear  antipyretic 
doses  of  quinine  sufficiently  well,  but  such  circumstances  are  of  different 
character  from  the  low  state  of  the  nutrition  and  the  enfeeblement  of  con- 
stitution for  which  quinine  is  given  as  a  supposed  "  tonic."  No  remedy  is 
properly  a  tonic  that  does  not  supply  normal  material  in  which  the  organism 
is  supposed  to  be  deficient,  or  that  does  not  increase  the  amount  of  food 
which  may  be  received  and  properly  utilized.  Quinine  is  not  a  tonic  from 
either  point  of  view.  As  a  rule,  the  so-called  bitters  have  little  real  utility 
in  the  treatment  of  children's  diseases. 

The  medical  profession  has  been  singularly  neglectful  of  the  mineral 
acids  in  treating  children's  diseases.  Nitric  acid  is  the  first  in  value,  and 
the  diluted  acid  is  the  preparation  most  serviceable.  It  stimulates  the  secre- 
tions of  the  intestines,  of  the  mucous  glands,  and,  it  is  asserted,  of  the  liver 
and  pancreas ;  but  how  much  these  organs  are  really  influenced  by  the  acid, 
if  at  all,  is  not  known. 

In  the  treatment  of  the  stomachal  disorders  of  children,  when  acidity  is 
a  prominent  symptom,  diluted  nitric  acid  should  be  given  before  the  inges- 
tion of  food,  and  not  after.  One  or  two  drops  in  some  ice-water  or  cold 
water  is  a  dose  readily  taken  by  children.  In  cases  of  colliquative  diarrhoea 
attended  with  distinct  acidity,  the  mineral  acids — nitric  especially — are  very 
effective;  and  summer  diarrhcea  is  of  this  character. 


970  THE   GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

The  recent  discovery  of  tyrotoxicon^  a  product  of  the  pullulation  of 
germs  whose  habitat  is  milk,  has  thrown  much  hght  on  the  influences 
that  develop  catarrhal  affections  of  the  intestines.  The  remarkable  results 
that  have  been  obtained  by  the  administration  of  corrosive  sublimate  in 
some  of  these  maladies  would  now  seem  to  indicate  that  the  success  is 
due  to  the  germicide  power  of  the  remedy.  The  increasing  knowledge 
of  this  mode  of  setting  up  disease-processes  enlarges  the  scope  and  im- 
proves the  character  and  security  of  our  therapeutical  procedures.  Here- 
after this  mode  of  treating  diseases  of  the  digestive  tube  must  be  the  rule, 
and  other  modes  the  exception.  Two  points  especially  require  attention : 
the  first  is  to  destroy  the  parasite  ;  the  second  is  to  obviate  the  effects  of  the 
parasite  itself,  or  the  poison  produced  by  it,  on  the  organs  and  tissues  of  the 
body,  which  become  altered  to  a  greater  or  less  degree.  It  is  clear  that 
antiseptics  must  be  the  most  important  of  the  remedies  used  to  remove 
morbid  states  due  to  the  action  of  micro-organisms  in  the  gastro-intestinal 
canal.  Those  most  promising  in  catarrhal  and  related  affections  are  crea- 
sote,  carbolic  acid,  thymol,  resorcin,  naphthol,  corrosive  sublimate,  calomel, 
zinc,  copper,  and  lead  salts,  iodol,  iodoform,  salol,  etc. 

Instead  of  treating  merely  the  complex  of  symptoms,  the  real  cause  of 
the  disturbance  is  to  be  acted  on,  and  by  agents  whose  powers  have  a  con- 
stant relation  to  the  work  to  be  done.  Taking  into  consideration  the  man- 
ner in  which  tyrotoxicon  is  formed,  by  special  germs  acting  on  milk  mixed 
with  changing  organic  matters,  we  may  not  only  the  more  readily  bring 
about  decided  curative  results,  but  successful  prophylaxis  may  be  insti- 
tuted. As  it  is  always  more  desirable  to  prevent  a  disease  than  to  effect  a 
cure,  especially  when  the  cause  is  acting  vigorously,  it  follows  that  such 
prophylactic  measures  as  will  prevent  the  admission  of  micro-organisms  to 
the  canal  should  have  a  place  among  the  therapeutical  measures. 

The  application  of  remedies  to  the  treatment  of  obstructive  disorders 
affecting  the  intestinal  canal  should  be  based  on  a  proper  conception  of  the 
conditions  demanding  action.  Intussusception  is  a  more  common  affection 
than  faecal  impaction  in  children.  On  the  other  hand,  the  appendix  venni- 
formis  is  more  frequently  the  seat  of  inflammatory  and  ulcerative  disorders 
in  girls  and  young  women.  In  intussusception  the  effects  of  those  reme- 
dies which  have  a  selective  action  on  the  muscular  walls  of  the  bowel 
should  be  utilized, — for  example,  nicotine,  eserine,  atropine,  strychnine, 
picrotoxin,  etc.  More  effective  than  these  remedies,  in  some  instances,  are 
galvanism  and  faradism,  and,  as  the  application  of  either  or  both  involves 
no  present  injur}^  or  future  complication,  one  or  both  should  be  made  use 
of  before  the  inflammatory  exudations  and  adhesions  have  occurred.  The 
best  mode  of  utilizing  these  powers  is  to  place  the  negative  electrode  (a 
bulbous  insulated  sound)  in  the  rectum,  and  the  positive  (a  large,  well- 

1  Ptomaines  and  Leucomaines,  by  Vaughan  &  No.vy,  Lea  Brothers  &  Co.,  Philadelphia, 
1888,  p.  67,  et  seq. 


THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  971 

moistened  sponge  or  absorbent  cotton)  on  the  abdomen,  but  at  different 
points,  to  bring  the  several  parts  of  the  bowel  Avithin  the  circuit  in  turn. 
Galvanism  may  be  expected  to  act  most  efficiently  in  cases  of  intussuscep- 
tion ;  faradism  in  impaction.  It  should  also  be  known  that  a  mild  faradic 
current  has  in  many  instances  reduced  strangulated  hernia  when  the  taxis 
had  failed.  It  is,  in  fact,  the  most  efficient  means  of  reducing  hernia,  and 
should  be  resorted  to  so  that  the  taxis  may  be  avoided. 

Stimulants  are  well  borne  by  children,  and  in  the  treatment  of  diarrhoeal 
and  choleraic  diseases  brandy  (especially  cognac)  is  usually  a  highly  efficient 
remedy.  Alcohol  is  antiseptic,  and  also  tends  to  estalDlish  an  inward  diffu- 
sion, from  the  canal  into  the  vessels,  and  thus  checks  the  loss  of  the  blood- 
serum. 

The  jaundice  of  children  is  usually  catarrhal,  and  is  an  extension  of  the 
disease  affecting  the  duodenum.  Of  all  the  remedies  having  power  to  in- 
crease the  discharge  of  bile,  phosjDhate  and  sulphate  of  sodium  are  the  most 
efficient.  In  his  recent  original  and  excellent  work  on  the  liver,  Harley 
has  extolled  the  virtues  of  Glaubers  salt, — sulphate  of  sodium.  These  salts 
may  be  given  together,  and  are  probably  more  efficient  in  combination  than 
when  depended  on  singly. 

Mineral  waters  containing  alkalies  and  saline  constituents  are  also 
highly  useful  in  the  hepatic  troubles  of  early  life.  Children  are,  however, 
not  disposed  to  drink  those,  unless  the  taste  be  acquired.  Of  the  Saratoga 
waters.  Congress,  Hathorn,  and  Geyser  are  the  most  grateful,  and  the  taste 
for  them  is  usually  readily  cultivated. 

The  circumstances  under  which  hepatic  medicines  are  required  should 
be  clearly  defined  in  the  mind  of  every  practitioner.  It  is  to  be  regretted 
that  hepatic  torpor  (inactivity)  is  not  differentiated  sufficiently  from  irrita- 
tion of  the  liver  in  which  the  bile  is  in  excess.  Again,  when  there  is  a 
mechanical  obstruction  to  the  passage  of  the  bile  to  the  duodenum,  over- 
flow into  the  blood  takes  place.  So  nicely  balanced  is  the  function  that 
very  little  increased  pressure  in  front  suffices  to  cause  tlie  backward  flow 
of  the  bile  :  so  little  pressure  as  a  plug  of  mucus  just  filling  tlie  intestinal 
orifice  of  the  ductus  communis. 

When  increased  pressure  in  front  exists,  it  is  useless  to  force  the  pro- 
duction of  bile ;  for  such  attempts  can  only  increase  the  michief.  A\"hcn 
the  liver  is  in  a  condition  due  to  irritation,  and  the  state  of  the  system  is, 
in  common  language,  that  whicli  is  entitled  "  biliousness,"  calomel  or  gray 
powder  is  highly  efficient.  From  one-sixteenth  of  a  grain  to  one  grain 
of  calomel,  according  to  the  age  of  the  child,  is  the  amount  most  useful. 
Rarely  indeed — probably  never — is  more  than  one  grain  neccssai'}'.  It  has 
been  demonstrated  by  exjierimcnts  on  animals,  and  confii'iucd  by  o])serva- 
tions  on  man,  that  calomel  is  not  a  stimulant  ])ut  a  sedative  of  the  biliary 
function,  and  hence  its  remarkable  utility  in  some  cases  of  over-production 
of  bile.  Biliary  fistuhc  having  occurred  in  a  form  to  discharge  all  the  bile 
externally,  the  other  functions  of  the  body  being  in  a  normal  condition,  it 


972  THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

was  found  that  when  a  full  dose  of  calomel  was  given  the  quantity  of  bile 
produced  was  largely  diminished.  This  result  accords  entirely  with  the 
experiments  on  dogs  by  the  Edinburgh  committee.  These  experimental 
facts  render  it  clear  that  calomel  allays  hepatic  irritation,  and  explain  how 
it  effected  so  much  in  certain  kinds  of  diseases  during  the  period  when 
it  occupied  the  first  place  in  the  esteem  of  the  medical  profession.  It  should 
be  understood,  also,  that  the  color  of  the  stools  when  the  mercurial  has  had 
an  effect  is  no  doubt  due  to  the  influence  exerted  by  it  on  the  glands  of  the 
lower  ileum,  to  whose  secretion  the  characteristic  color  of  the  feeces  is  prob- 
ably due.  The  change  caused  by  mercury  in  the  character  of  the  evacuation 
would  therefore  seem  to  be  a  pathological  state  of  this  excretory  matter. 
It  has  been  said  that  children  do  not  experience  the  toxic  action  of  mer- 
cury as  manifested  in  salivation ;  but  it  is  not  less  true  that  other  parts 
are  affected  quite  severely,  the  spinach  stools  representing  serious  changes 
in  the  glands  of  the  ileum.  Notwithstanding  the  untoward  effects  of 
mercurials,  they  are  powerful  for  good  in  some  morbid  states  of  the  gastro- 
intestinal canal.  Vomiting  from  local  causes,  from  stomach-irritation 
especially,  is  relieved  by  the  frequent  administration  of  small  doses — such 
as  one-twentieth  to  one-twelfth  of  a  grain — of  calomel,  and  it  acts  more 
efficiently  if  subdivided  by  sugar  of  milk  as  minutely  as  possible.  In  the 
giving  of  small  doses,  frequency  of  administration  is  the  rule :  thus,  one- 
twentieth  of  a  grain  every  half-hour  when  vomiting  persists. 

Anthelmintics. — In  considering  this  subject,  the  remedies  should  be 
discussed  in  relation  to  the  form  of  intestinal  parasite  to  be  removed.  The 
round  worm  and  thread-worm  are  the  forms  that  are  most  frequently  en- 
countered. Children  of  the  most  tender  age  have  had  tape-worm,  and 
some  instances  of  their  congenital  presence  have  been  reported.  The  use 
of  raw  beef  and  other  uncooked  meats  and  meat-juices  explains  the  occur- 
rence of  the  tape-worm  in  children,  but  does  not  explain  the  congenital 
instances. 

The  anthelmintics  most  effective  in  the  case  of  round  worm  are  santonin, 
spigelia  (pink-root),  calomel  (three  to  five  grains),  calomel  and  hydrocyanic 
acid,  etc.  After  the  parasites  are  disposed  of,  the  catarrhal  state  of  the 
mucous  membrane  and  the  general  physical  and  mental  depression  require 
attention. 

The  most  annoying  of  parasites  in  children,  the  ascarides  vermicularis, 
have  their  habitat  in  the  rectum  and  adjacent  j)arts.  Inefficient  medication 
is  the  reason  that  the  thread- worms  so  often  recur  and  persist.  Besides  the 
immediate  destruction  of  the  worm  and  ova  infesting  the  rectum,  the  ova 
deposited  in  the  folds  of  the  mucous  membrane  and  skin,  and  neighboring 
parts,  must  be  disposed  of,  for  if  one  escapes  it  is  the  progenitor  of  millions 
soon  to  appear.  Such  remedies  as  quassia  and  aloes,  in  infusion,  are  effec- 
tive in  the  destruction  of  those  reached  ;  but,  as  they  pass  up  as  far  as  the 
ileo-csecal  valve,  inhabiting  thus  tlie  whole  of  the  large  intestine,  irrigation 
of  the  bowel  becomes  necessary.     Externally  parasiticide  solutions  should 


THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  973 

be  thoroughly  applied ;  but,  as  mauy  of  these  are  active  poisons,  discretion 
is  necessary.  Solutions  of  carbolic  acid,  corrosive  sublimate,  the  salts  of 
copper,  zinc,  and  lead,  are  the  most  generally  useful.  Salicylic  acid,  resor- 
cin,  and  other  antiseptics  and  germicides  of  the  same  class  will  not  cause 
toxic  effects  when  applied  to  the  skin,  if  judiciously  used. 

Tseniafuges  are  numerous.  Recently  chloroform  has  been  much  ex- 
tolled, but  such  a  remedy  is  not  suitable  for  the  treatment  of  children.  As 
the  tape-worm  is  composed  largely  of  albuminous  matter,  it  has  been  pro- 
posed to  cause  its  digestion  by  the  use  of  a  digestive  ferment,  as  pepsin,  or 
the  vegetable  digestive  agent,  papain,  or  pajjayotin.  It  is  reported  that 
tape-worm  has  been  completely  digested  by  the  free  use  of  this  ferment. 
As,  however,  when  the  parasite  is  digested  it  disappears  in  the  general  mass 
of  chyle  and  excretory  matters,  the  result  cannot  be  known  in  any  other 
way  than  by  the  disappearance  of  the  symptoms.  The  method  well  deserves 
attention. 

Remedies  to  promote  Nutrition. — As  the  remedies  used  to  increase 
the  vital  resources  enter  the  system  by  the  stomach,  it  becomes  necessary  to 
say  something  in  general  terms  as  to  the  agencies  required  for  this  purpose. 
The  use  of  bitters  and  digestive  ferments  to  increase  the  activity  of  the 
primary  assimilation  has  been  discussed ;  but  the  remedial  agents  used  to 
promote  nutrition,  to  increase  tissue-formation,  and  to  add  to  the  general 
resources,  yet  remain  for  discussion.  The  physical  forces,  heat,  light,  and 
electricity,  and  the  natifral  stimulant  and  great  vital  restorative,  oxygen, 
must  have  consideration  hereafter. 

First  of  the  agents  to  promote  constructive  metamorphosis  are  those 
utilized  by  nature  in  building  up  the  human  organism.  The  salts  of  iron 
and  lime,  phosphates,  and  phosphites,  are  the  chief  agents  employed  for  this 
purpose.  The  place  held  by  iron  is  partly  that  of  a  necessary  constituent, 
and  partly  that  of  an  agent  promoting  the  primary  assimilation.  Before 
the  salts  of  iron  can  accomplish  any  improvement  in  the  process  of  con- 
structive metamorphosis,  two  conditions  must  be  brought  about :  1,  the 
blood  must  be  supplied  by  a  due  quantity  of  suitable  aliment ;  2,  a  projier 
distribution  of  the  enriched  blood  must  be  effected. 

A  quarter  of  a  century  ago,  Brown-S^quard  asserted  (and  in  this  he 
echoed  French  opinion)  that  iron  was  reconstituent  by  virtue  of  its  power 
to  increase  the  activity  of  the  primary  assimilation,  and  not  by  contributing 
material  necessary  to  the  structure  and  functions  of  the  blood-globules.  It 
must  be  admitted  that  this  view  is  correct,  and  that  there  is  enough  iron  in 
the  ordinary  foods  to  sui)ply  the  small  deficiency  in  the  blood.  Another 
fact  deserves  consideration  in  tliis  connection, — that  the  astringent  salts 
of  iron,  sulphate,  nitrate,  chloride,  etc.,  are  more  efficient  as  chalybeate 
tonics,  and  often  agree  better,  than  the  salts  formed  with  tlie  vegetable 
acids. 

Preliminary  treatment  is  usually  necessary  to  obtain  the  best  results 
from  iron.     The  state  of  the  intestinal  mucous  membrane,  the  existence  of 


974  THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

consti23ation,  a  torpid  state  of  the  annexed  organs,  exert  an  untoward  effect, 
and  absorption  and  assimilation  are  thereby  prevented  or  greatly  retarded. 
Whether  well  or  ill  borne,  effective  or  not  effective,  it  is  clear  that  iron  is 
much  abused  when-  administered  without  preliminary  treatment  under  the 
conditions  named  above.  The  combination  of  arsenic  or  of  strychnine  with 
iron  contributes  greatly  to  the  curative  results  in  cases  of  ansemia  with 
special  complications  on  the  side  of  the  nervous  system.  When  the  nutri- 
tion is  low  from  the  domination  of  cachexia,  from  prolonged  suppuration, 
or  from  excess  of  waste  over  the  reparative  process,  the  combinations  of 
phosphorous  and  phosphoric  acids  with  lime  and  other  salts  are  more  useful 
than  iron  alone  or  than  a  mere  phosphate  ;  and  this  conception  is  given  form 
in  the  ofiicial  Syrupus  Hypophosphitum  cum  Ferro  of  the  Pharmacopoeia  of 
1880. 

Remedies  for  Inflammation  and  Fever. — In  deciding  on  the  use  of 
remedies  for  the  treatment  of  inflammation  and  its  products,  that  are  ad- 
mitted to  the  system  by  the  stomach,  the  stage  of  the  process  must  be  taken 
into  account,  so  far  as  our  present  means  of  ascertaining  the  fact  can  be 
applied.  Is  it  the  stage  of  congestion  ?  Is  it  the  stage  of  exudation  ?  Or 
do  both  processes  continue  in  the  same  area? 

The  remedies  that  prove  effective  in  the  condition  of  congestion  are  of 
different  powers  and  modes  of  acting  from  those  that  influence  the  exuda- 
tion stage.  The  former  are  acted  on  by  remedies  that  affect  the  calibre  of 
the  arterioles ;  but  w^hen  exudation  is  going  on,  the  remedies  that  liquefy 
and  promote  absorption  are  required. 

Of  the  remedies  used  to  influence  the  calibre  of  the  arterioles,  and  at  the 
same  time  to  slow  the  heart,  there  are  two  kinds  : 

1.  Those  reducing  congestion  by  acting  physiologically  on  the  vessels 
directly  and  by  reflex  action. 

2.  Antiseptics,  which  check  inflammation  by  destroying  or  inhibiting 
organisms  on  whose  presence  and  multiplication  depends  the  congestion  or 
inflammation. 

In  the  first  class  are — 
Aconite,  Veratrum  viride, 

Digitalis,  Quinine, 

Barium,  Ergot. 

These  remedies  are  not  equal  in  power  and  efficiency,  nor  do  they  agree 
in  the  rate  at  which  they  affect  the  functions  concerned.  They  do  agree  in 
the  manner  in  which  they  affect  the  organs  of  circulation,  respiration,  and 
calorification, — agree  in  kind,  not  in  extent  and  power  of  action. 

With  these  physiological  remedies  acting  directly,  so  to  speak,  we  include 
others  accomplishing  results  by  reflex  influence.  The  following  are  the 
remedies  in  question : 

Blood-letting  (Arteriotomy ;  Ven-         Counter-irritation, 

esection  ;  Cupping  ;  Leeching),  Low  Diet,  etc. 

Saline  Purgatives, 


THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  975 

The  febrile  state  due  to  an  inflammation  of  a  tissue  differs  in  many 
respects  from  that  of  an  essential  fever. 

The  stages  of  inflammation  in  a  given  tissue  decide  tlie  character  of  the 
remedies  to  be  used.  Those  affecting  the  amount  of  "blood  circulating  in 
the  area  of  inflammation  have  been  mentioned  above ;  but  for  the  exuda- 
tion stage  the  following  are  the  most  important : 

The  Alkalies,  Ammonia, 

Chloral,  Potash, 

Pilocarpine,  Soda, 

Picrotoxin,  Lithia, 

Saline  Laxatives,  Lime, 

Counter-irritants,  Renal  Stimulants,  or  Diuretics. 

The  remedies  for  removing  exudations  act  in  various  ways, — more 
variously,  indeed,  than  those  having  the  power  to  remove  congestion.  Only 
one  result  is  to  be  reached,  but  that  is  arrived  at  by  going  several  paths. 
Saline  laxatives  carry  off  sufiicient  serum  to  lessen  the  blood-pressure,  and 
this  in  turn  promotes  absorption.  Chloral  has  remarkable  power  to  check 
the  process  of  exudation,  to  liquefy  the  solid  exudates,  and  to  put  them  in  a 
form  most  suitable  for  excretion.  In  such  a  complex  as  is  furnished  by 
croupous  pneumonia,  with  cerebral  disturbance,  insomnia,  and  delirium,  it 
is  impossible  to  overestimate  the  value  of  this  remedy.  Pilocarpine  has 
extraordinary  powers  for  causing  absorption  and  excretion  of  inflammatory 
exudates,  and  these  powers  are  increased  by  combining  picrotoxin  wdth  it, 
unless  some  contra-indication  exist.  It  should  not  be  understood  that  pilo- 
carpine is  given  several  times  each  day,  but  one  dose  each  day,  or  on  alter- 
nate days  once,  or  once  or  twice  in  a  w^ek.  It  is  adapted  to  the  subacute, 
chronic  states,  rather  than  to  acute  cases.  The  manner  of  administering  it 
is  insisted  on  because  it  has  a  special  office  in  this  connection,  and  the 
desired  result  cannot  be  accomplished  by  frequent  administration  merely. 

The  use  of  antipyretics  in  the  treatment  of  fever,  and  the  nature  of  the 
functions  which  maintain  the  body-heat  at  the  normal,  are  perplexing  ques- 
tions, until  we  cease  to  regard  the  heat-function  of  the  body  as  something 
apart  from  heat-production  as  a  physical  process.  We  cannot  get  a  truer 
insight  into  its  real  nature  than  by  regarding  animal  heat  as  a  mode  of 
motion  and  correlative  with  the  other  physical  forces. 

Why  should  its  manifestations  in  the  human  body  be  studied  from  a 
different  stand-point  from  that  jMirsued  by  the  physicists?  We  learn  from 
the  highest  authorities  in  physical  science  that  li(>at  must  always  be  the 
product  of  burning, — of  combustion,  oxidation,  chemical  action,  etc., — aud 
that  there  is  a  constant  ratio  l^etween  tlie  amount  of  material  consumed  and 
the  result  in  foot-pounds  of  force  evolved.  In  tlie  human  body  the  same 
process  must  be  in  action  to  maintain  a  given  amount  of  lieat.  The  heat 
of  the  body  in  health  is  maintained  at  a  given  point  (98.5°  F.)  in  a  manner 
that  can  be  compared  to  the  boiling-point  of  water,  which  does  not  cxccckI 


976  THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

(at  the  sea-level)  212°  F.  The  body-heat  does  not  rise  above  98.5°  F. 
because  there  is  a  regulating  mechanism, — the  heat  continuing  to  be  pro- 
duced above  that  point  disappearing  in  the  vapor  of  the  perspiration,  as  the 
temperature  of  water  is  kept  at  the  one  rate  by  the  dispersion  of  the  water 
in  steam.  That  variations  in  the  amount  of  blood  will  change  the  rate  of 
combustion  going  on,  is  true,  and  the  conditions  favoring  heat-dissipation 
or  heat-retention  may  also  influence  febrile  temperature ;  but  in  these  cir- 
cumstances there  is  conformity  to  the  physical  laws  governing  heat  as  a 
mode  of  motion. 

As  it  is  clear  that  the  temperature  of  the  human  organism  is  affected 
by  the  same  conditions  as  heat  m  other  places,  the  treatment  of  the  febrile 
state  should  be  conducted  accordingly. 

In  fever  the  increased  heat  of  the  body  represents  increased  combustion 
or  oxidation,  or  the  regulating  function  by  which  the  normal  state  is  main- 
tained is  in  some  way  deranged.  In  heat-stroke  or  heat-fever,  the  tremen- 
dous rise  of  heat  is  accompanied  by  dry  skin,  so  that  the  heat  formed  is 
retained,  and  not  given  off  in  vapor.  In  typhoid  there  is  increased  com- 
bustion, shown  by  the  greater  excretion  of  urea  and  carbonic  acid.  Again, 
in  uraemia,  and  in  jaundice,  the  temperature  may  be  below  normal  because 
the  state  of  the  blood  in  the  first-named  lessens  oxidation,  and  the  lessened 
production  of  glycogen  affects  oxidation,  because  the  supply  is  insuffi- 
cient. Also,  febrile  heat  can  be  lessened  or  increased  by  certain  devices : 
lessened  by  measures  to  remove  heat  and  thus  prevent  any  accumulation ; 
increased  by  preventing  radiation  or  diffusion  from  the  surface  of  the 
body. 

These  physical  conceptions  of  the  heat-function  should  govern  the  use 
of  all  antipyretic  measures.  If  the  cause  of  increased  heat  cannot  be 
reached  by  the  means  employed,  it  may  be  asserted  with  confidence  that 
antipyretics  are  useless.  For  example  :  if  the  more  active  combustion  can- 
not be  moderated,  the  fever-heat  cannot  be  properly  controlled. 

Increased  body-heat  above  the  normal  is  a  more  common  incident  in 
children  than  in  adults, — for  the  reason  that  the  conditions  necessary  to 
combustion  are  more  active  :  the  circulation  is  more  rapid  and  hence  the 
materials  are  furnished  more  abundantly,  and  the  nervous  system  is  more 
quickly  responsive  to  impressions.  The  need  for  antipyretics  is  therefore 
a  more  acute  question  in  the  febrile  diseases  of  children  than  in  those  of 
adults.  It  is  evident  that  a  reformation  of  existing  methods  is  coming  near. 
The  antiseptics  that  now  play  so  large  a  part  in  the  treatment  of  the  specific 
fevers  will  be  less  employed  hereafter  as  juster  views  obtain.  It  is  now 
suspected  that  the  granular  degeneration  and  other  changes  which  were  sup- 
posed to  be  due  to  febrile  heat  are  really  the  effects  of  the  morbid  materials 
or  micro-organisms  causing  the  disease.  In  this  case  antipyretics  arc  less 
useful  than  they  were  supposed  to  be.  It  has  been  clearly  shown  also  that 
in  specific  fevers  and  in  the  fever  of  inflaniniation  the  reduction  of  fever- 
heat  does  not  modify  nor  shorten  the  course  of  the  disease.     In  a  paper  of 


THE   GEXERAL   THERAPEUTICS   OF   CHILDREN'S   DISEASES.  977 

high  practical  value  by  oue  of  the  physicians  of  Guy's  Hospital,^  it  has  been 
shown  in  a  collection  of  cases  attended  by  fever  and  in  specific  fevers  that 
antipyretics  are  of  limited — in  some  instances  of  doubtful — value,  in  that 
they  do  not  change  the  course  of  the  fevers  nor  shorten  their  duration. 

Cold  baths  are  easily  applied  in  the  fevers  of  children,  and  arc  effective. 
In  the  essential  fevers,  the  eruj)tive  and  specific  fevers,  it  may  be  said  that 
cold  water  is  the  most  useful  antipyretic.  When  the  temperature  exceeds 
103°  F.  the  cold  bath  may  be  utilized.  Below  that  temperature,  cold 
sponging  or  the  use  of  fat-inunctions  will  suffice  for  the  most  part. 

APPLICATIONS  TO  THE  BKONCHO-PIILMONAPvY  IVIUCOUS  MEMBEANE. 

Methods. — As  air  is  the  material  essential  to  the  functions  of  the  respira- 
tory apparatus,  so  air  may  be  made  the  vehicle  for  introducing  medicaments. 
Air  is  also  made  to  perform  a  curative  part.  Compressed  air  and  rarefied 
air  are  used  to  act  mechanically  on  the  pulmonary  tissues :  the  expansive 
force  of  the  compressed  air  inspired,  and  the  expansive  force  exerted  by 
suction  when  breathing  into  rarefied  air,  are  the  mechanical  forces  employed ; 
compressed  air  is  utilized  for  increasing  the  relative  proportion  of  oxygen, 
and  thus  takes  the  place  of  prepared  oxygen  breathed  in  certain  doses,  when 
the  lungs  are  so  affected  either  by  permanent  structural  alterations  or  by 
functional  disability  that  they  cannot  receive  sufficient  oxygen  to  carry  on 
respiration. 

Various  machines  have  been  constructed  to  compress  air  for  therapeuti- 
cal purposes.  In  places  having  a  water-supply  in  reservoirs  at  a  sufficient 
elevation,  large  metal  cylinders  are  used,  the  air  being  compressed  by  the 
inflowing  water.  Such  a  cylinder  may  be  employed  also  to  procure  rarefac- 
tion of  air  by  the  outflowing  water.  If  supplied  with  suitable  masks, 
flexible  tubes,  spray-tubes,  etc.,  such  an  instrument  can  be  utilized  in  many 
directions.  Air-pumps  whose  action  can  be  reversed,  and  provided  with 
suitable  reservoirs,  masks,  and  tubes,  are  now  made  for  every  kind  of 
service  in  respiratory  therapeutics. 

Pasteur  demonstrated,  not  long  since,  that  heat  has  a  remarkable  germi- 
cide power,  and  that  the  organism  of  alcoholic  fermentation  is  inhibited  or 
killed  below  the  point  at  which  heat  becomes  hurtful  to  wine  in  bottles, — at 
or  about  160°  F.,  and  that  in  this  way  it  is  possible  to  sterilize  wine.  Pas- 
teurized is  the  term  used. 

This  fact  has  been  turned  to  account  in  the  treatment  of  phthisis. 
Heated  air  is  now  j)roposed  as  a  substitute  for  air  filled  with  germicide 
vapors.  As  this  method  is  yet  on  trial,  it  will  suffice  to  say  of  it  now  that 
it  consists  in  the  inhalation  of  heated  air  which  is  also  washed  by  passing 
through  solutions  which  remove  organic  impurities.  The  amount  of  heat- 
used  depends  on  the  character  of  the  case,  on  the  condition  and  the  idiosyn- 
crasies of  the  patient,  and  also  on  the  forbearance  acquired  by  experience. 

'  Guy's  Hospital  Reports,  vol.  fur  1888. 
Vol.  i.— 02 


978  THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

Mechanical  appliances  of  the  most  complete  kind  have,  ho^vever,  but 
a  limited  scope,  partly  because  of  the  form  in  which  the  agents  are  applied, 
and  chiefly  because  of  the  limited  time  the  action  can  go  on.  There  is 
a  growing  conviction  that  the  length  of  time  during  which  the  action  of  the 
medicament  is  being  exerted  is  an  unportant  element  in  the  curative  effects. 
Hitherto  the  application,  by  spray,  or  vapor,  or  probang,  has  occupied  but 
few  minutes,  rarely  to  exceed  fifteen  minutes,  and  hence  the  curative  effects 
have  been  proportionally  short  in  duration.  In  the  application  of  some 
remedies  their  activity  may  render  it  necessary  to  use  them  briefly ;  on  the 
other  hand,  many  need  time  in  which  to  develop  their  best  powers.  During 
the  night  the  air  of  the  bedroom,  or  during  the  day  some  special  apartment, 
utilized  for  the  purpose,  can  be  filled  with  volatile  materials,  that  can  enter 
the  ultimate  air-sacs  with  the  air  breathed. 

Although  it  has  been  proved  that  spray  can  pass  the  chink  of  the  glottis, 
it  is  also  certain  that  a  small  amount  only  can  be  made  to  enter  the  bronchi, 
— too  little  to  be  eflective  in  diseases  of  the  luugs.  Young  and  timid  chil- 
dren can  rarely  be  induced  to  use  spray  effectively ;  but  vapors  in  the  air 
cannot  be  resisted.     Irrespirable  gases  are  exceptionally  employed. 

The  vapors  and  gases  most  worthy  of  consideration  as  remedies  are  the 
following : 

Gases.  Vapors. 

Oxygen.  Pyridin. 

Ozone.  Ethyl  Iodide. 

Compressed  Air.  Ethyl  Bromide. 

Rarefied  Air.  Iodine. 

Hot  Air.  Iodoform. 

Carbonic  Acid.  Bromine. 

Sulphuretted  Hydrogen.  Creasote  or  Carbolic  Acid 

Sulphurous  Acid,  etc.  Eucalyptus. 

Gaultheria. 

Turpentine,  etc. 

Some  of  the  vapors  diffuse  into  the  air  at  ordiuary  temperature,  others 
require  heat.  In  all  cases,  by  the  method  of  jjrotracted  inhalation,  there 
must  be  enough  of  the  medicament  present  to  be  recognized  by  the  senses 
and  to  cause  some  irritation  of  the  broncho-pulmonary  mucous  membrane. 
The  effect  of  some  of  them  on  the  system  is  prompt,  but  with  the  develop- 
ment of  the  action,  is  brief  in  duration ;  others,  whether  slow  or  quick  in 
producing  their  effects,  remain  long  in  the  system  and  keep  up  a  sustained 
impression. 

A  method  employed  with  success  during  an  epidemic  of  diphtheria  at 
the  Children's  Hospital  at  Rouen  consisted  in  the  volatilization  of  eucalyp- 
tus and  turpentine  on  a  common  heating-stove.  The  leaves  and  stems  of 
the  eucalyptus  were  put  in  a  vessel  of  water,  and  the  turpentine  added  as 
required. 


THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  979 

As  the  agents  used  by  inhalation  vary  thus  in  the  promptness  with  which 
the  action  begins,  and  in  the  duration  of  the  effects,  the  length  of  time 
employed  must  also  differ. 

A  small  room  or  large  closet  can  be  readily  filled  by  the  vapors  as  re- 
quired. A  spirit-  or  gas-lamp  or  a  small  stove,  a  vessel  containing  some 
hot  water,  kept  simmering  if  need  be,  and  the  medicament  -which  is  added 
to  the  hot  water  as  required  to  keep  the  air  of  the  apartment  saturated, 
are  the  appliances  needed  for  the  purpose.  Children  young  enough  to  enjoy 
play  can  carry  on  their  sports  as  in  an  ordinary  play-room.  Older  children 
can  read  or  study.  The  air  must  be  breathed,  and  hence  the  gases  or  vapors 
diffused  through  it  must  also  enter  the  air-passages  and  in  quantity  to  act 
on  the  micro-organisms. 

EXCRETION   AND   DEPURATION. 

The  need  of  recognizing  the  many  kinds  and  sources  of  metallic,  or- 
ganic, aud  organized  poisons  in  these  times  is  most  imperative,  and  we 
believe  that  physicians  are  not  sufficiently  attentive  to  the  indications  and 
methods  involved  in  the  necessary  therapeutic  processes.  The  large  group 
of  affections  in  the  treatment  of  which  the  remedies  called  alteratives  have 
been,  and  continue  to  be,  used  is  divisible  into  two  classes  :  1,  those  that 
increase  the  activity  of  the  organs  of  excretion, — for  example,  diuretics, 
cathartics,  cholagogues,  and  sudorifics ;  2,  those  that  act  on  the  morbid 
material, — for  example,  mercury  in  specific  deposits,  iodides  in  aneurism,  etc. 

The  definition  of  alterative  has  been  and  continues  to  be  difficult.  The 
vague  wandering  amid  the  clouds  which  formed  the  staple  of  the  thera- 
peutical conceptions  formerly  entertained,  cannot  now  be  accepted  in  the 
place  of  some  tolerably  distinct  facts,  and  there  are  two  in  regard  to  which 
there  can  be  no  doubt  or  misconception.  We  observe  under  the  action  of 
certain  remedies  that  deposits  of  a  morbid  kind  are  removed;  but  the 
tissues  in  which  or  on  which  these  deposits  are  found  are  not  necessarily 
changed  in  structure  or  disturbed  in  function  by  the  action  of  the  medica- 
ment. We  conclude,  therefore,  that  these  remedies  have  power  to  remove 
morbid  materials.  On  further  investigation,  it  is  ascertained  that  mineral 
substances  deposited  in  and  among  the  finest  subdivisions  of  the  tissues, 
and,  indeed,  chemically  combined  with  the  ultimate  form  of  the  organic 
structure, — with  protoplasm, — are,  also,  by  certain  remedies  sought  out  and 
put  into  a  soluble  form  for  excretion,  and  yet  the  tissue  may  remain 
unharmed  and  functionate  as  before.  Formerly  such  therapeutic  actions 
were  called  alterative,  but  now  they  are  more  api)ropriately  lield  to  be  an 
increase  of  the  destructive  metamorphosis,  or  an  increase  of  the  process  of 
waste.  The  products  called  "  waste"  are  in  part  the  materials  produced  in 
the  functioning  of  all  parts  of  the  system,  or  thrown  off  as  unused  material, 
or  the  result  of  gland-activity.  Such  waste  is  physiological.  Again,  the 
matters  that  result  from  the  action  of  medicines  or  morbid  deposits  are 
pathological  products.     In  the  complex  materials  that  constitute  the  urine 


980  THE    GENERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES. 

in  healthy  we  have  an  example  of  the  waste  that  comes  from  the  exercise  of 
the  normal  functions ;  but  in  the  urine  we  may  find  lead  and  other  poisons, 
representing  the  waste  caused  by  the  action  of  remedies. 

In  our  complex  modern  life  there  are  so  many  ways  in  which  various 
poisons  can  enter  the  human  system  that  much  disease  often  quite  inexpli- 
cable in  its  origin,  may  arise  in  this  way, — through  the  air  or  through  food 
and  water.  When  mysterious  and  complex  morbid  states  arise  in  children, 
sources  of  morbid  action  of  this  kind  should  be  taken  into  account.  It  is 
by  maintaining  activity  of  the  organs  of  excretion  that  much  may  be 
effected  in  the  way  of  curative  results. 

The  part  played  by  inherited  syphilis  is  too  little  considered.  The  late 
Prof.  Gross  propounded  the  theory,  in  1885,  that  inherited  syphilis  is  the 
real  source  of  most  of  the  morbid  action  now  afflicting  mankind.  Sir 
James  Paget  explains  the  high  estimation  in  ^^•hich  mercury  was  held  by 
the  physicians  of  fifty  years  ago — who  had  no  knowledge  of  visceral  syph- 
ilis— that  they  found  it  amazingly  successful  in  so  many  cases  of  inflam- 
matory action,  and  consequent  exudations,  liquid  and  solid,  that  the  results 
of  its  use  were  attributed  to  a  general  power  to  check  inflammation  and  to 
remove  its  products,  and  did  not  suspect  that  it  had  an  action  of  specificity. 

It  follows  from  the  foregoing  considerations  that  increasing  the  action 
of  the  excretory  organs  is  an  important  function  in  the  treatment  of  specific 
and  constitutional  maladies.  Although  these  rules  are  more  particularly 
a])plicable  to  patients  more  advanced  in  life,  yet  they  cannot  properly  be 
disregarded  in  the  treatment  of  children's  diseases. 

Besides  maintaining  action  of  the  excretory  organs  under  the  conditions 
described  above,  it  is  necessary  to  take  into  consideration  the  action  of  cer- 
tain remedies  directed  to  the  same  end.  I  refer  to  the  application  of  pilo- 
carpine, which,  causing  such  a  copious  discharge  of  sweat  and  saliva,  greatly 
increases  the  absorption  and  excretion  of  morbid  matters  in  consequence. 

Although  it  is  generally  known  that  this  agent,  more  than  any  other, 
has  power  to  increase  the  flow  of  sweat,  it  is  not  so  much  utilized  as  a  means 
to  dispose  of  morbid  products  as  it  ought  to  be.  Having  had  most  satis- 
fying results  from  this  use  of  pilocarpine,  I  can  properly  urge  the  matter 
on  the  attention  of  the  profession.  The  method  proposed  consists  in  the  use 
of  any  remedy  with  the  power  to  increase  waste,  as,  for  example,  mercurial, 
which  having  been  taken  in  the  usual  way  for  several  days,  pilocarpine  is 
then  given  once  a  clay,  or  on  alternate  days,  or  but  once  a  week,  to  secure 
the  extrusion  of  the  morbific  matters  which  had  been  softened,  disintegrated, 
and  thus  prepared  for  excretion. 

The  pilocarpine  should  be  given  in  such  dose  as  will  act  efficiently,  but 
there  is  no  justification  in  the  use  of  such  a  quantity  as  will  cause  after- 
depression  in  any  considerable  degree.  It  is  idiosyncrasy,  especially,  that 
must  be  provided  for  !  The  initial  dose  must  be  a  tentative  one.  When  it 
is  ascertained  that  the  child  is  not  unduly  impressionable,  then  sucli  doses 
should  be  prescribed  as  will  cause  decided  action  of  the  sweat-glands,  and 


THE    GEXERAL    THERAPEUTICS    OF    CHILDREN'S    DISEASES.  981 

at  such  intervals  as  may  be  necessary.  As  a  rule  the  best  time  for  giving 
the  remedy  is  at  night.  Provision  should  be  made  for  ridding  the  child's 
person  of  the  overflowing  secretions.  A  -warm  night-gown  should  be  in 
readiness  to  put  on  when  the  sweating  has  ended.  If  any  coldness  and 
depression  remain,  if  the  pulse  become  weak,  and  vomiting  with  approach- 
ing collapse  is  threatened,  a  minute  dose  of  atropine — from  ^^  to  -,r^  grain 
— will  promptly  arrest  the  symptoms.  It  should  be  a  constant  precaution 
to  have  some  atropine  at  hand  whenever  a  large  dose  of  pilocarpine  is  given 
or  the  idiosyncrasies  of  the  subject  are  unknown. 

COUNTER-IRKITATIOX. 

General  principles  only  are  to  be  considered  here.  The  forms  by  means 
of  w^hich  the  irritation  is  effected  must  be  stated  as  a  guide  for  the  applica- 
tion of  principles  to  the  actual  practice.  Rubefadion,  Vesication,  and  the 
action  called  Escharotic  are  the  general  results  of  the  impression  made. 
Rubefaction  is  a  making  red  of  the  skin, — red  without  changing  its  struc- 
ture. Vesication  consists  in  an  action  beyond  the  former,  for  the  skin  is 
not  only  reddened,  but  inflammation  occurs,  and  the  result  is  an  exudation 
of  serum,  which  constitutes  "■  blistering."  When  an  escharotic  completes  its 
action,  a  slough  is  formed,  and,  being  cast  off",  an  open  ulcer  is  left. 

In  children  any  irritation  beyond  rubefaction  is  rarely  necessary ;  in 
infants,  never,  for  the  skin  is  then  too  tender  and  the  nervous  system  too 
responsive  to  unpressions.  It  is,  indeed,  doubtful  whether,  at  any  age,  any 
counter-irritation  more  powerful  than  that  caused  by  a  mustard  plaster  is 
ever  necessary  or  beneficial.  To  understand  the  nature  of  the  action  and  to 
define  the  results  the  physiological  process  must  be  explained. 

When  an  irritant — a  mustard  plaster,  for  example — that  causes  rubefac- 
tion is  applied,  a  local  impression  occurs,  and  wider  systemic  effects  follow. 
Bv  the  local  action  we  find  dilated  and  fuller  vessels  and  the  end-oro-ans 
of  the  sensory  nerves  are  excited,  pain  is  transmitted  to  the  cord,  and  to  the 
brain,  where  it  is  translated  into  consciousness,  and  from  the  cord  an  excita- 
tion proceeds  to  the  vaso-motor  system.  As  a  result  of  the  reflex,  the  periph- 
eral vessels  contract,  and  in  this  we  have  an  explanation  of  what  utility 
soever  counter-irritation  has  in  inflammation.  The  results  may  be  stated 
in  two  separate  postulates  : 

jSIild  irritation  increases  the  vaso-motor  tonicity ; 

Severe  and  destructive  counter-irritation  causes  vaso-motor  depression, 
and  ultimately  vaso-motor  paresis. 

If  these  formuUe  become  the  guide  to  the  use  of  external  irritants,  the 
method  and  results  of  such  treatment  will  always  have  a  sound  basis. 


INDEX  TO  VOLUME  I. 


A. 

Abdomen,  the,  29. 

examination  of  the,  84. 
in  enteric  fever,  465,  467, 

489. 
prominent,  in  rachitis,  85. 
its  significance,  86. 
Abdominal  distention,  its   sig- 
nificance, 86. 
in   enteric   fever,  463, 
468,  489. 
dropsy,  86. 
obstruction,  970. 
organs  in  infancy,  3,  4,  33- 

37. 
phthisis,  88. 
pregnancy,  943. 
ring,  31. 
Abnormal  conditions    at  birth, 
244. 
position  of  the  limbs  after 
certain  cases  of   breech- 
presentation      at     birth, 
26U. 
Abnormalities    resulting    from 
maternal    imjiressions,     191- 
216. 
Abscesses   in  and  after  enteric 

fever,  474,  477. 
Absence  of  the  cry  and  of  tears, 

108. 
Absorption  by  the  skin,  963. 
Acid,  lactic,  bacillus  of,  153. 
perspiration     in     rheuma- 
tism, 797. 
sarcolactie,  as   a   cause   of 
the   sense  of  fatigue    in 
growing  children,  55. 
Acids,  mineral,  969. 
Aconite  in  fevers,  435. 
Acute  consumption,  404. 

phlegmonous       periostitis, 

126. 
rheumatism,  etc.  See  Rheu- 
matism, Acute,  etc. 
tuberculosis,  404. 

sometimes  mistaken  for 
enteric  fever,  480. 
A'lams,  Dr.  S.  S.,  on  diet  after 

weaning,  337. 
Addison's  disease,  106. 
Allusion,  cold,  in  enteric  fever, 

494. 
Agar-agar  flesh-peptone,  182. 
Age  as  a  factor  in  disease,  350. 
in    its    relation    to    height 
and  weight,  S9,  90. 
Agnathia,  935. 
Air  in  medication,  977. 


Albuminuria  of  diphtheria,  603, 
626,  628,  672. 
in  enteric  fever,  473. 
in   scarlet  fever,  564,  570, 

578. 
temporary,  433,  473. 
Alcohol,  ethylic,  produced  by  a 

bacillus,  153. 
Alcoholic  bath  condemned,  962. 
friction      after      relapsing 

fever,  513. 
solutions  in  practical  bac- 
teriology, 161. 
stimulants,  in  enteric  fever, 
485,  496. 
to   be  avoided   in  the 
d3'smenorrhoea       of 
puberty,  400. 
{See   also   Stimulants,  under 
the  names  of  different  dis- 
eases in  this  index.) 
Alcoholism  as  a  cause  of  tuber- 
culosis, 403. 
juvenile,  411. 
Alimentary  canal,  its  develop- 
ment, 34. 
its  peculiarities  in  infancy, 
4,  34,  41. 
Alkaline  solutions  in  practical 

bacteriology.  161. 
Alkaloids,     poisonous     animal. 

^e  Ptomaines. 
AUantois,  954. 
Alteratives,  979. 
Amenorrhoea,  399. 
Ammoniacal    fermentation,  ba- 
cillus of,  152. 
Amnion,  952. 

false,  952. 
Amniotic  Huid,  234. 
A  m  I  )ut  ations,         intra-uterine, 

224. 
Anadidymous  monsters,  932. 
Anaerobic  bacteria,  181. 
Anakatadidymous        monsters, 

936. 
Analvsis  of  foods,  311,  313. 

of  milk,  275,  279,280,282, 
283,  284,  288,  289,  290, 
306,  307,  308,  309,  310. 
An.asarca  of  the  foetus,  231. 
Anatomy  of  children,  3-S,  11-50. 
of  jiiined  twins,  9:'.8. 
pathological.     ^SVe  Pathol- 
ogy, under  the  head  of 
the      ])rinci|>al     diseases 
nained  in  tliis  index. 
Angina  of  scarlet  fever,  568. 
Anglo-Swiss    condensed    milk, 
315. 


Aniline  dyes  for  the  demonstra- 
tion of  bacteria,  161. 
Animal  culture-media,  186. 
Ankle,  50. 

Ankylosis  in  the  uterus,  231. 
Ante-natul  fractures,  231. 
Anthelmintics,  972. 
Autlirax,  the  microbes  of,  153, 

154. 
Antifebrin,  436. 

iu  dengue,  898. 
Antipyretics,  434,  962,  975. 

in  typhoid,  492. 
Antipyrin,  435. 

in  cerebro-spinal  fever,  553. 
in  dengue,  898. 
in  malaiial  neuralgia,  852. 
in  scarlet  fever,  576. 
Antiseptic  medicines,  970. 
Autisyphilitic  remedies,  225. 
Aorta,  (i,  7,  26,  64. 
Apepsia,  968. 
Aphasia,  117. 

from  typhoid,  472. 
in  cerebro-spinal  fever,  529. 
Aphthous  stomatitis,  128. 
Apoplectic   condition   at  birth, 
247. 
causes  of,  247,  248. 
treatment  of,  248. 
Apoplexy,  pulmonarj',  in  diph- 
theria, 61  6 
Apparatus    for    bacteriological 
investigations,  171. 
for    sterilizing    food,    299, 
371. 
Apparent  still-birth,  247. 
Ajuiendagcs,  foetal,  diseases  of 

the,  233. 
Appendix  vermiformis,  970. 
Ai){)etite,  niedicines  which  af- 
fect, 968. 
Arch  of  the  palate,  20. 
Area  gcrminativa,  946. 
opaca,  948,  953. 
pellucida,  948. 
vasculosa,  953. 
Arms  in  infancy,  47. 

lifting  children  by  the,  47. 
Arnold's  nerve,  16. 
Arsoninted  mineral  waters,  their 
use  in  chlorotic  and  strumous 
disorders,  106. 
Arsenic  in  malaria,  861. 
Arterial    pressure    in    infancy, 

5,  6. 
Arteries,  hypogastric,  their  pe- 
culiarities, 255. 
and     umbilical,    their 
closure,  252-257. 
983 


984 


INDEX    TO    VOLUME    I. 


Arteries  in  rachitis,  5. 

in  relation  with  the  tonsils, 
20. 
Artery,   pulmonary,   7,   26,   27, 
64,  253. 
the     sujierior     vesical,    its 
peculiar       development, 
256,  257. 
Arthritis,  rheumatic.  795. 

rheumatoid,      822.         See 
Rheumatoid  Arthritis. 
Artificial  feeding,  291. 
foods,  311,  319. 
immunity   from    infectious 

diseases,  188. 
respiration   for  the  newly- 
born,  249. 
Ascarides,  129,  972. 
Asphyxia  at  birth,  247,  250. 
Asses'  milk,  290. 
Asthenia,  infantile,  245. 
Asymmetric  janieeps,  935. 
Atavism,  111. 
Ataxia,  heredi+ary.  111. 
Atelectasis  puimonum    in   per- 
tussis, 709. 
Athetosis,  116. 

Atomizer  in  diphtheria,  664, 671. 
Auscultation,  82,  123. 
of  the  back,  83. 
of  the  head,  95. 

in  rachitic  children,  5. 
Authorities,  lists    of,  on    diph- 
theria, 583,  584. 
Autumnal  fever,  443. 
Averages  in  height  and  weight, 

53,  88,  89,  90,  91. 
Axial  mesoblast,  948. 
Axilla,  temperature  of  the,  100. 


Bacilli,  multiplication  of,  157. 
Bacillus,  153. 

how  to  stain  for  observa- 
tion, 160-169. 

of    ammoniaeal    fermenta- 
tion, 152. 

of  anthrax,  153,  154. 

of  blue  milk,  153. 

of  butyric   acid   fermenta- 
tion, 154. 

of  cholera,  900,  910. 

of  cholera  nostras,  186. 

of  dengue,  833. 

of    diphtheria,    152,    154, 
687. 

of  enteric  fever,  154,  164, 
446,  461. 

of  ethyl  alcohol,  153. 

of  glanders,  168. 

of  Klebs  and  LoeiHer,  587. 

of  lactic  acid,  153. 

of  leprosy,  153,  167. 

of  malignant  oedema,  15  i. 

of  splenic  fever,  153. 

of  syphilis,  167. 

of  tuberculosis,  163,  165. 

of  yellow  milk,  152. 

the  genus,  153. 
(^ee    also   Bacteria,  and    the 

names  of  various  diseases.) 
Back,  examinations  of,  97. 

topography  of,  28,  36. 
Bacteria,  classification  of,  148. 

counting  of,  186. 


Bacteria,  culture   of,   158,  169, 
186. 
definition  of,  150. 
examination  of,  158. 
fgecal,  69,  301. 
in    alimentary  canal,  302- 

305. 
in  cerebro-spinal  fever,  517. 
in  enteric  fever,   154,   164, 

445,  451. 
in  fevers,  422. 
in  foods,  301. 
in  pertussis,  706. 
in   typhoid,  154,  164,  445, 

451. 
isolation  of,  169. 
morphology  of,  156. 
multiplication  of,  157. 
of  diphtheria,  154. 
of  fowl-cholera,  154. 
of  pebrine,  152. 
of  small-pox,  724. 
of  yellow  milk,  152. 
pathological    properties  of, 

188. 
preparation  of,  for  the  mi- 
croscope, 159. 
projjagaiion  of,  158. 
proper,  described,  156. 
ptomaines     developed    by, 
189,   190,  422,  451,   586, 
588,  900. 
staining  of,  160,  162,  168. 
transmission  of,  to  the  foe- 
tus, 225. 
{See   also    Bacillus,  and    the 
names  of  the  various  dis- 
eases.) 
Bacteriaceae,  153. 
Bacteriology,  147. 

apparatus  and  instruments 
used  in  studying,  171. 
Bacterium  (the  genus),  152. 

multi[ilieation  of  the,  157. 
Bard,  Dr.  S  ,  his   observations 

on  diphtheria,  583. 
Barley,  Robinson's,  310. 
Barley-water,  311. 
Bartholow,  Dr.  Roberts,  on  the 
general  therapeutics  of  chil- 
dren's diseases,  956. 
Bath,    hot,    in    apparent    still- 
birth, 248. 
in  typhoid,  494. 
medicated,  962. 
Bathing,  357,  366,  960. 
in  fevers,  436,  961. 
sea-,  367. 

the  new-born  child,  241. 
Beading   of    the    ribs,    its    sig- 
nificance, 86,  94. 
Bed,  the,  358. 

Bed-sores,  prevention  of,  362. 
ill  typhoid,  491. 
in  t3'phus,  502. 
Beef-broih,  338. 

tea,  338. 
Beggiatoa  (the  genus),  153. 
Belly.     Sec  Abdomen. 
Benzoate    of    sodium    in    diph- 
theria, 669. 
Biedert's   cream    mixture,  311, 

321. 
Bilateral  hemiplegia,  115. 
Bile    as    an    antilerinent    and 
germicide,  303,  304. 
in  children,  68. 


Bilious  temperament,  106. 

typhoid  of  Lebert,  509. 
Biliousness,  971 . 
Bill  of  fare,  a  child's,  340,  344. 
Biniodide  of  mercury  in  scarla- 
tina, 574. 
Birth,  abnormal   conditions   at, 
244. 
debility  at,  245. 
Birth-marks,  193,  218. 

{See  also  Naevus.) 
Black  measles,  678. 

vomit,  867. 
Blackader,  Dr.  A.  D.,  on  variola, 

722. 
Blackleg,  the  microbe  of,  154. 
Bladder,  38. 

and   uterus,   their   relative 
position   in   the    infant, 
18,  42. 
stone  in  the,  130. 
Blastodermic    membrane,     945, 

947. 
Blastosphere,  945. 
Bleeder-disease.       See     Haemo- 
philia. 
Blindness     following     cerebro- 

sjjinal  fever,  638. 
Blisters,  352,  981. 
Blood  in   diphtheria,  the,  612, 
650. 
in    infancy,    the,   5-7,    64— 

66. 
tumor,  97. 
Blood-poisoning  in  diphtheria, 

602,  6U3,  612,  651. 
Blood-poisons  taken  up  by  the 

foetus,  219. 
Blood-pressure,  eflfects  of,  upon 
the  foetus,  219. 
in  early  infancy,  6,  6. 
Blood-serum     for     culture-pur- 
poses, 175. 
Eluod-transfusion,  966. 
Blood-vessels  in  early  infancy, 

5-7. 
Blue  milk,  bacillus  of,  162. 
Blush,  the  febrile,  429. 
Body,  section  of  the,  20. 
Boiled  milk,  271,  299,  301. 
Bones,  formation  of,  45. 

fractured     in    the    uterus, 

231. 
injuries   of,  at  birth,  263- 

269. 
of  the  head,  injuries  of,  263. 
syphilitic    affections  of,  in 

the  fojtus,  223. 
the,  in  typhoid,  475. 
Wormian,  12. 
Bottle-feeding,  364. 
Bottles,  nursing,  371. 
Bovine  virus,  747. 
Bowels,  35. 

constipation    of    the,    341, 

433,  467.  488. 
in  enteric  fever,  467,  488, 
489. 
{See  also  Intestine.) 
Boys,  average  height  and  weight 

(if,  89,  90. 
Brain,  development  of,  13. 

in  infancy,  3,  12-14. 
Bread-jelly,  338. 
Break-bone  fever,  878. 

{See  Dengue.) 
Breast  of  the  wet-nurse,  334. 


INDEX    TO    VOLUME    I. 


985 


Breast-milk,  275,  279,  28n,  282, 
2S3,  284,  289,  290,  303,  306, 
308,  310. 

Breathing.     See  Respiration. 

Brefeld's  methods  in  bacterio- 
logical investigation,  171. 

Bright's  disease,  129. 

Bromides  in  cerebro-spinal 
fever,  552. 

Bronchial  phthisis,  124. 
its  diagnosis,  124. 

Bronchitis,  124. 

and  teething,  3S3. 
capillary,      in      whooping- 
cougli,  70S. 

Broncho-pneumonia,  124. 

Bronzing,  its  significance,  106. 

Broths,  338. 

as  culture-media  in  bacte- 
riological stud}',  177. 

Browne,  Sir  Crichton,  his  re- 
port on  overpressure  in 
schools,  410. 

Bruit  skodique,  123. 

Bursa;  of  the  knee,  49. 

Busey,  Dr.  S.  C,  on  scarlet 
fever,  555. 

Butyric  acid  fermentation,  ba- 
cillus of,  154. 

Byers,  Dr.  J.  AV.,  on  the  influ- 
ence of  race  and  nationality 
upon  disease,  132. 


C. 

Cachexia,  malarial,  845. 
Cadaver,  the,  after  enteric  fever, 

452. 
Caecum,  35. 

Calcification  of  the  ligamentum 
arteriosum,  254. 
of  the  teeth,  374,  375,  376. 
Calculus,  vesical,  130. 
Callahan,  Fla.,  yellow  fever  at^, 

861. 
Calomel  as  a  remedy,  971. 

in  diphtheria,  666. 
Campbell,   C.  F.,  on   the    com- 
parative death-rates  in  North- 
ern and  Southern  States,  134. 
Canada   balsam    for    mounting 
bacteriological    preparations, 
163. 
Canal,  inguinal,  31,  32. 

medullary  or  neural,  948. 
of  Nuck,  32,  33. 
Cancer,  111. 

of  the  kidney,  130. 
Capacity  of  the  stomach,  295. 
Capillary  bronchitis  in  whoop- 
ing-cough, 709. 
Capsules,  suprarenal,  38. 
Caput  succeilancum,   251,    258, 
259, -260,  261. 
causes  of,  259. 
diagnosis  of,  261. 
position  of,  26(1. 
treatment  of,  261. 
Cardiac  diagnosis,  122,  125. 

system,  122. 
Care  of  the  child  at  birth,  236- 
251. 
in     abnormal     conditions, 
244. 
Carnrick's  food,  311,  315,  318, 
320,  322. 


Carpal  bones,  48. 
Carpo-pedal  spasms,  121. 
Carrageen  as  an  article  of  food 
and  as  a  remedial  agent,  405. 
Cartilage,  cricoid,  21. 
Catamenial  milk,  281. 

period.     See  Menstruation. 
Cataphora,  398. 
Causes  of  fever,  423. 

{See   also   Causation    or  Eti- 
ology, under  the  names  of 

diseases  in  this  index.) 
Cells,  mastoid,  15. 

of   the   spermatic    tubules, 
942. 

polar,  941. 
Cellular   tissue,    induration    of, 

109. 
Cephalhaamatoma,  97,  261. 

blood  m,  4. 

causes  of,  261,  262. 

spurious,  251,  258,  259,  260, 
261. 

treatment  of,  262. 
(<S'ee  Caput  Succedaneum.) 
Cephalothoracopagus,  935. 
Cerebellum  at  birth,  14. 
Cerebral  paralysis  of  the  newly- 
born,  266,  267. 

symptoms    in    fever,    428, 
431. 
Cerebro-spinal  fever,  514. 

age  of  patients,  523. 

anatomical    characters    of, 
540. 

antipyrin  in,  553. 

bacteria  in,  617. 

blindness  following,  537. 

blood-changes  in,  541. 

bromides  in,  552. 

causes  of,  517,  521. 

cerebral  efi'ects  of,  514,  541, 
542,  643,  545. 

chloral  in,  653. 

choreic  movements  in,  531. 

coma  of,  546. 

commencement  of,  525. 

complications  of,  522,  532, 
535,  546. 

conditions    favoring,    518, 
521. 

contagiousness  of,  618. 

convulsions  in,  530. 

cutaneous  surface  in,  635. 

deafness  following,  537. 

deaths  from,  540. 

definition  of,  514. 

diagnosis  of,  524,  539,  546. 

diet  in,  554. 

digestive  system  in,  532. 

drowsiness  in,  631. 

ear  in,  638. 

eclampsia  in,  531. 

endemic,  516,  539,  540. 

ejiidemic   quality    of,   515, 
519,  620,  524. 

ergot  in,  553. 

eru])tion  of,  536. 

etiology  of,  517,  521. 

external     applications     in, 
551. 

exudation  of,  517,  542,  543. 

eye  in,  5."0,  537. 

geographic   range  of,   137, 
515. 

headache  in.  553. 

history  of,  514. 


Cerebro-spinal    fever,    hygiene 

of,  518. 
hyperajsthesia  in,  528. 
in  the  lower  animals,  520. 
influence  of   race  and  cli- 
mate in,  137. 
influence  of  sex  in,  522. 
joints  in,  536. 
kidneys  in,  544,  545,  546. 
lotions  in,  651. 
lower  animals,  in  the,  620. 
maculaj  of,  536,  545. 
medication  in,  551,  552. 
meningitis    in,    514,    541, 

543,  547. 
mental  state  in,  528. 
microbe  of,  517. 
mortality  from,  540. 
muscular    contractions    in, 

628. 
names  of,  514. 
naturalized,  539. 
nature  of,  539. 
nephritis  in,  544,  545,  646. 
nervous  system  in,  527. 
nomenclature  of,  514. 
non-contagiousness  of,  618. 
nursing  in,  654. 
nutrition  in,  564. 
onset  of,  525. 
ojjium  in,  553. 
origin  of,  514,  617. 
pain  in,  625,  527. 
paralj'sis  in,  529. 
pathological    anatomy    of, 

540. 
predisposing  causes  of,  521. 
prevention  of,  547,  552. 
prognosis  in,  544. 
pulse  in,  533. 
pupil  in,  537. 
respiratory  system  in,  535, 

646. 
retraction  of  the  head  in, 

529. 
seasons    of    the    vear    in, 

518. 
secondary,  522. 
sex  as  a  factor  in,  522. 
skin  in,  535. 
special  remedies  in,  552. 

senses  in,  537. 
spots  in,  536,  545. 
strabismus  in,  530,537. 
stujior  of,  531. 
symptoms  of,  524,  525,  527, 

539. 
synonymes  of,  514. 
temj)erature  in,  533. 
treatment     of,     547,     548, 

552. 
urinarj'  organs  in,  536. 
use  of  lotions  in,  551. 
venesection  in,  549. 
vomiting  in,  526. 
Cerebro-spinal   meningitis,  514. 

(.SV''  Cerebro-Spinal  Fever.) 
Cerebrum  and  eciebullum,  their 

relative  size,  14. 
Chalybeate   mineral    waters   in 
chronic  strumous  and  tuber- 
cular diseases  of  the  voung, 
406. 
Chamber,  moist,  in  bacteriologi- 
cal observation,  172. 
Chamberland's  filter.  189. 
Charb-m,  bacillus  of,  153,  154. 


986 


INDEX    TO    VOLUME    I. 


Chart  of  temperatures  for  en- 
teric fever,  460,  462, 
476. 
for  tyi^hus  fever,  498. 
for   yellow  fever,  854, 
856,864,  871.  ' 
of  weekly  gains  in  weight, 
272. 
Cheadle,   Dr.  W.  B.,  on    rheu- 
matism, 785. 
Cheap  foods  not  to  be  tolerated, 

293. 
Cheeks  in  infancy,  17. 
Chest,  examination  of  the,  86, 
87. 
its  size  at  birth,  55. 
Chest-diameter,  its  ratio  to  head- 
diameter,  55,  94. 
Chest-diseases,  74,  87. 
Cheyne  Stokes    breathing,  118, 
12:i 
rhythm,  67. 
Chicken  jelly,  .342. 
Chicken-pox,  754. 
{See  Varicella.) 
Child  in  health,  the,  236. 
the  sick,  349. 
the  spoiled,  348. 
Childhood,   death-rate  in,  134, 

135. 
Children,  79-131. 

the  term  defined,  497. 
Children's  clinic,  9. 
hospitals,  347. 
Chills  and  fever.    See  Malaria. 
Chinese  measles,  141. 
Chinking  percussion,  123. 
Chloral  in  cerebro-spinal  fever, 

553. 
ChloranEemia,  7,  400. 

{See  Chlorosis.) 
Chlorate  of  potassium  in  diph- 
theria, 661. 
Chloride  of  iron  in  diph;heria, 

659. 
Chlorosis,  7,  400. 
causes  of,  400. 
symptoms  of,  400. 
treatment  of,  401 . 
Cholera,  Asiatic,  900. 

bacillus  of,  155,   900,   905, 

910-914. 
bowels  in,  904. 
cleanliness  in,  902,  904. 
dejections  in,  902,905,915. 
diagnosis  of,  917. 
disinfection   in,    902,    905, 

907. 
dry,  915. 

effects  on  the  foetus,  229. 
enteroclysis  in,  917,  918. 
foetal,  229. 
food  in,  903. 
foudrovante,  916. 
hygiene  during,  902,  904. 
hypodermoclysis    in,    917, 

920. 
infantum,  geographic  range 

of,  142. 
infectiosa,  900. 
infectious  quality  of,  900. 
microbe,  165,  900,  905,  910- 

914. 
milk  a  vehicle  of,  901. 
mortality  from,  921. 
nostras,  bacillus  of,  186. 
of  fowls,  bacterium  of,  151, 


Cholera,  premonitory  signs  of, 
914,  915. 
prevention     of,    902,    904, 

906. 
prognosis  in,  921. 
profihj'hixis    against,    902, 

905-909. 
ptomaine  of,  900. 
quarantine     against,     905, 

907-909. 
rice-water     discharges    in, 

910,  913. 
sicca,  915. 

stages  of,  914-916,  921. 
symptomatology  of,  914. 
tannic    acid    enteroclysters 

in,  918. 
temperature  in,  916. 
toxica,  917. 
treatment  of,  917. 
walking  attacks  of,  906. 
Cholera    infantum,    its    range, 

etc.,  142. 
Cholerine,  916. 

Chondrus  crispus,  its  value  as  a 
food  and  as  a  remedial  agent, 
405. 
Chorea,  113,  115,  123. 
in  rheumatism,  803. 
its  heredity,  1 13. 
Choreic  movements  in  cerebro- 
spinal fever,  531. 
Circulation,  foetal,   27,   28,    64, 
253,  256. 
infantile,  64. 
Circulatory  system  in  typhoid, 

463. 
Circumcision,  40. 
Class,  its   influence  on  disease, 

135. 
Classification  of  bacteria,   148, 
149,  150,  151-156. 
of  remedies,  957. 
Clavicle  in  infancy,  46. 

fracture  of,  268. 
Cleanliness,  356. 
Cleft  palate,  20. 

as  a  consequence  of  mater- 
nal impressions,  203. 
Climate,  133. 

change  of,   as   a    remedial 
measure    for    tubercular 
disease,  406. 
in    treatment    of    chronic 
strumous  and  tubercular 
disorders  of  puberty,  405. 
its  effects  on  puberty,  390. 
on  typhoid,  443. 
Climatic  influences,  133. 
Clinical  instruction,  9,  10. 
Clostridium  (the  genus),  154. 
Closure  of  ductus  arteriosus,  252. 
of  hypogastric  and  umbili- 
cal arteries,  252. 
Clothing  in  sickness,  358. 

{See  also  Dress.) 
Coagulum,  308. 
Coecnceas,  151. 
Cocci,  156. 
Cohn's  classification  of  bacteria, 

148,  149. 
Cold  pack  in  typhoid,  493. 

water  treatment  of  scarla- 
tina, 576. 
wet  pack,  437. 
Golden,  Dr.  Cadwallader,  his  ob- 
servations on  diphtheria,  582. 


Colicky  pains  in  young  infants, 

242. 
Collapse  in  enteric  fever,  464. 
of  lung,  125. 

of  lungs  in  pertussis,  709. 
temperature  of,  103. 
Collar-bone,  46. 

Collie,  Dr.  Alex.,  on  typhus,  497. 
Colloredo,  Lazaro,  a  double  mon- 
ster, 937. 
Colon,  35. 

rupture   of,  in    the   foetus, 

232. 

Colored     races,     cerebro-spinal 

fever  in  the.  137, 138. 

cholera     infantum    in 

the,  143. 
diphtheria  in  the,  141. 
measles  in  the,  140. 
scarlet    fever    in    the, 

139. 
small-pox  in  the,  144. 
syphilis  in  the,  145. 
whooping-cough       in 
the,  137. 
Colors,  recognition  of,  62. 

used  in  preparing  bacteria 
for  observation,  160. 
Colostrum,  276. 

Coma   in    cerebro-spinal   fever, 
531. 

{See  also  Stupor.) 
Comma  bacillus,  155,  186,  900, 
Complexion,  106. 
Complications  of  enteric  fever, 
476. 

{See   also    under   the   names 
of  the  various  diseases  de- 
scribed in  this  volume.) 
Compressed  air,  its  therapeutic 

uses,  977. 
Compresses  in  tj'phoid,  493. 

use  of,  436. 
Compulsory  education,  evils  of, 

409. 
Condensed  milk,  315,  339. 
Condition,   social,  as    afi'ecting 

disease,  135. 
Confluent  small-pox,  729,  731. 
Congenital  hernia,  33. 

movements,  56. 
Congestive    asphyxia   at  birth, 

247. 
Conjtinctivitis     and     teething, 

382. 
Consanguineous  marriages.  111. 
Constipation,  341. 

in  enteric  fever,  467,  488. 
in  fever,  433. 
Continued  fever,  438. 
Contracted  pupil,  118. 
Contractions,  muscular,  22. 
Convalescence      from      enterio 

fever,  495. 
Convolutions  of  the  brain,  14. 
Convulsions  and  teething,  382. 
causes  of,  385. 
in  cerebro-spinal  fever,  530. 
in  fevers,  428. 
in    tubercular    meningitis, 

428. 
malarial,  835. 
nodding,  121. 
salaam,  121. 
Convulsive  diseases,  119,  120. 
Cooling  a]iparntus   in  bacterio- 
logical work,  172. 


INDEX    TO    VOLUME    I. 


987 


Co-ordinating  power,  61. 
Corban,  Mrs.  (a    monstrosity), 

933. 
Cord,  cutting  the,  236-238. 
dressing  the,  241, 
ligation  of  the,  237. 
umbilical,  237. 
Corrosive  sublimate  in  diphthe- 
ria, 664. 
Cortical  laj'er  of  the  ovary,  939. 
Cost  of  infant-foods  not  to  be 

considered,  293. 
Cotyledons  of  the  placenta,  955. 
Cough,  122. 

absence    of,    in    chest-dis- 
eases, 122. 
Counter-irritation,  981. 
Counting  of  biieteria,  186. 
Cover-glass  preparations,  162. 
Cow-pox.     /See  Vaccination. 
Coxalgia,  48. 
Cracked-pot  sound,  123. 
Cradle,  the,  243. 
Cranial  injuries,  263. 
Criiniopagus,  935. 
Craniotabes,  its  significance,  95. 
Cranium,  the  h3'drocephalic,  12. 

the  infantile,  12. 
Cravings,  maternal,  their   pos- 
sible ill  efl'ects  on   offspring, 
214. 
Cream,  323. 

mixture,  Biedert's,  311. 
mixtures,  321. 
Creeping,  61. 
Crenothrix  (a  genus  of  bacteria), 

155. 
Cricoid  cartilage,  21. 
Crookshank's    classitication    of 

the  bacteria,  151-156. 
Croup,  122. 

Crucifixion  attitude,  121. 
Cry,  107. 

absence  of,  108. 
hydrencephalic,  108. 
significance  of  the,  107. 
Cultivations    of    bacteria    from 

animal  tissues,  186. 
Culture  at  puberty,  407,  412. 

of  bacteria,  169. 
Culture-media,  animal,  186. 
bacteriological,  177. 
fluid,  177. 
opaque,  184. 
solid,  178. 
oven,  176. 
plates,  18.3,  184. 
tubes,  184. 
Curtin,  Dr.  R.  G.,  on  relapsing 

fever,  504. 
Curvatures    of    spinal    column, 
abnormal,  97,  98. 
normal,  43,  44, 
Curve    of    temperature,    dailj', 

102. 
Cutaneous  disorders  and  teeth- 
ing, 385. 
reflexes    in    enteric    fever, 

473. 
surface.     .S'c-c  Skin. 


Dabney,  Dr.  W.  C,  on  maternal 

impre.ssions,  191. 
Daily  curve  of  temperature,  102. 


D'Aquin,  Dr.,  his  observations 

on  dengue,  888,  note. 
Deafness     from     cerebro-spinal 

fever,  538. 
Death-rate  of  children,  135. 
Death-rates    as    influenced    by 

climates,  134. 
Deaths  from  diphtheria,  650. 
(.S'ee  also  Mortality,  under  the 
names  of   various   diseases 
in  this  index.) 
Debility  in  the  uewly-born,  245. 
Decidua,  ^Jbb. 
Deciduous  teeth,  375. 
Deckschicht,  945. 
Defecation,  a  regular  habit  of, 

369. 
Defective    nutrition,    its    effect 

on  the  fcetus,  219. 
Defects  due  to  maternal  impres- 
sions, 191,  207. 
Definition  of  an  infectious  dis- 
ease, 451. 
of  the  term  "children,"  497. 
{See  also  under  the  names  of 
different    diseases    in    this 
index.) 
Deformity  of  the  head,  tempo- 
rarj',  251. 
unilateral,  97. 
Degenerative    cUanges    associ- 
ated wiih  fever,  424. 
Dejections  in  enteric  fever,  482. 
Delay  in  walking,  92. 
Delayed  dentition,  92,  376. 
menstruation,  390. 
walking,  92. 
Delirium  in  enteric  fever,  471, 
487. 
its  significance,  431. 
Dengue,  878. 

antifebrin  in,  898. 
antipyrin  in,  898. 
bacteria  of,  883. 
causes  of,  881. 
clinical  history  of,  886. 
complications  of,  890,  891. 
conditions  favoring,  881. 
convalescence  from,  899. 
course  of,  891. 
defined,  878. 

derivation  of  the  name,  879. 

differences    from    malaria, 

893. 

from  yellow  fever,  893. 

differential     diagnosis     of, 

S93. 
duration  of,  891. 
ejjideinics  of,  879. 
eruption  of,  888,  899. 
etiology  of,  888. 
etj-niology  of  the  word,  879. 
geographv     of,     879,     880, 

881. 
headache  in,  889. 
history  of,  879,  885. 
incubiition  of,  887. 
inva.<ion  of,  887. 
liniments  in,  899. 
malaria     compared     with, 

S94. 
McLaughlin's     discoveries 

concerning,  S82-886. 
micrococci  in,  883. 
names  of,  878,  879. 
pathological   anatomy  and 
pathology  of,  895. 


Dengue,  prognosis  in,  892. 
pulse  in,  888. 
relapses  in,  892. 
sequels  of,  890. 
stages  of,  887-890. 
symptomatology    of,    886- 

890. 
synonymes  of,  878,  879. 
temperatures  in,  887,  888. 
treatment  of,  896. 
urine  in,  889. 
yellow  fever  and,  893-895. 
Dental  groove,  18. 
Dentition,  373. 

alleged   disorders    of,    350, 

379. 
anomalies  of,  376. 
dangers  of,  75. 
delayed,  92,  376. 
historj',  69. 
in  rachitis,  382. 
irregular,  377. 
multiple,  377. 
precocious,  376. 
retarded,  92,  376. 
second,  disorders  of,  385. 
symptomatology  of,  379. 
Depressions   of    cranial   bones, 

263. 
Depurative  medication,  979. 
Development,  its  diagnostic  im- 
port, 87. 
of   the   abdominal  organs, 

33,  34. 
of  the  teeth,  373. 
Diabetes,  130. 

saccharine,  114. 
Diagnosis,  cardiac,  122,  125. 
general  principles  of,  73. 
methods  of,  79. 
{See  also  under  the  names  of 
different    diseases    in    this 
index.) 
Diapers,  369. 
Diaphragm,  the,  29. 
Diarrha;a  during  dentition,  383. 
from  improper  food,  341. 
in  typhoid,  467,  489. 
of  cholera,  915. 
Dieephalus,  927. 
Dicranus,  926. 
Dicrotic  pulse,  105. 
Diet  after  weaning,  337. 
in  di]>litheria,  657. 
in  fever,  433. 
in  typhoid.  -184. 
Differences     between    infantile 

and  adult  life,  3-5. 
Differential  diagnosis.     See  Di- 
agnosis  under  the  names  of 
different  diseases  in  this  in- 
dex. 
Differentiation  of  sex,  41. 
DifiicuU  labor  as  a  cause  of  in- 
fantile j)araly8is,  idiocy,  etc., 
266,  267. 
Digestion  in  infancj-,  67,  68.     . 

of  milk,  68. 
Digestive    functions    in    fever, 
429. 
system,     its      peculiarities 
during  the  infantile  pe- 
riod, 3,  67,  126. 
Diphtheria,  580. 

ago  of  patients,  595. 
albuminuria   in,   603,   626, 
672. 


988 


INDEX    TO    VOLUME    I. 


Diphtheria,  anatomical  charac- 
ters of,  589,  608,  625,  639. 
animals  as  afi'ected  by,  592. 
antiseptics  in,  663. 
apoplex3-,    pulmonary,    in, 

616. 
atomizer  in,  664,  671. 
authorities    on,    583,    584, 

631. 
bacillus  of,  154,  585-591. 
bacteria  of,  152,  585. 
benign  type  of,  612,  618. 
blood  in,'6u2,  612,  620,  650, 

651. 
brain  in,  613. 
calomel  in,  666. 
causes  of,  585. 
chlorate   of  potassium    in, 

661. 
chloride  of  iron  in,  659. 
clinical  history  of,  618-621. 
communication  of,  592. 
conditions  favoring,  591. 
congestion  of  lungs  in,  650. 
constitutioniil  disease,  602. 
corrosive  sublimate  in,  664. 
death  from,  650. 
diagnosis  of,  128,  605. 
diet  in,  6,57. 

disinfectants  in,  651-656. 
ear  in,  623. 

emphysema  from,  615. 
epidemic  nature  of,  581. 
epiglottis  in,  614. 
eruptions  in,  625. 
etiology  of,  585. 
eye  in,"  622. 

fauces  in,  606,  613,  619. 
follicular  tonsillitis  in,  606. 
food  in,  657. 
fowls  affected  by,  592. 
gangrenous  pharyngitis  in, 

60S,  621. 
genito-urinary   organs    in, 

624. 
geographical  range  of,  etc., 

140,  581,  584. 
germicides  in,  663. 
glands  in,  616. 
heart-failure  in,  616,  637- 

643,  650. 
hemorrhage  in,  621. 
herpetic    pharyngitis     in, 

608. 
history  of,  580. 
hygiene  of,  656. 
incubation  of,  598. 
inflammation  of,  609,  610. 
influf-nce  of  age  in,  595. 
intestines  in,  612,  617,  623. 
in  the  newly-born,  596. 
iron  as  a  remedy  for,  659. 
isolation  of  patients,  651- 

655. 
kidneys  in,  60.3,  618,  626, 

628. 
laryngo-tracheal,  606. 
lists  of  authorities  on,  583, 

584. 
literature  of,  582,  583,  631. 
liver  in,  617. 
local  remedies  in,  670. 
localities  of,  584. 
lower  animals  affected  by, 

592. 
lungs  in,  614,  616,  650. 
lymphatic  glands  in,  616. 


Diphtheria,  membrane  of,  601, 

605,  610. 
mercurials  in,  664,  666. 
mild  type  of,  612,  618. 
milk  as  a  vehicle  of,  594. 
mortality  from,  650. 
mouth  in,  617,  623. 
mucous  membranes  in,  610. 
nares  in,  605,  611,  621. 
nature  of,  600. 
nursing  in.  355. 
oedema  jjulmonum  in,  616, 

650. 
Oertel's  views  on,  589,  613. 
oesophagus  in,  623. 
ordinary  type  of,  619. 
papayotin  in,  671. 
paralysis  of.    See  Diphthe- 
ritic Paral.ysis. 
pathogeuy  of,  585. 
pathology  of,  589,  608. 
pepsin  in,  671. 
pharyngitis  in,  607,  608. 
pilocarpine  in,  669. 
pleurisy  in,  615. 
pneumonia  in,  615. 
potiissium  chloride  in,  661. 
prevention  of,  651. 
primary,  600. 
prognosis  of,  649-651. 
propagation  of,  591. 
pseudo-membranes  of,  601, 

610,  611,  621. 
ptomaines  of,  649. 
pulmonary     apoplexy     in, 
616. 
oedema  in,  616,  650. 
pultaceous  pharyngitis  in, 

607. 
quinine  in,  659. 
range,  etc.,  of,  141. 
scarlatinal,   564,   568,   569, 

574.  600,  6(17. 
secondary  form  of,  600. 
septic  poisoning  in,  650. 
severe  type  of,  61  9. 
sewer-gas    as    a    cause    or 

vehicle  of,  591. 
skin  ii],  625. 
sodium  benzoate  in,  669. 
solvents  in,  670. 
sjjinal  cord  in,  613. 
spleen  in,  617. 
stimulants  in,  658. 
stomach  in,  611,  617,  623. 
strychnine  in,  673. 
sulphur-fumigation  in,  652. 
Taylor,    Dr.    W.    M.,    his 

opinions  concerning,  590. 
temperature  in,  620. 
tongue  in,  6!  7,  620. 
tonsils  in,  606,  61M. 
toxaemia  from,  603. 
transmission    of,    in   milk, 

594. 
treatment  of,  602,  651,  656, 

672.     ■ 
turpentine  in,  655,  667. 
ulcero-uierabranous     phar- 
yngitis in,  608. 
urajmia  in,  650. 
urinary  organs  in,  603,  618, 

624,  626. 
uvula  in,  613,  614. 
vesicular    emphysema,    in, 

615. 
virus  of,  585,  589. 


Diphtheria,  vomiting  in,  620. 
vulvitis  in,  625. 
wounds  as  the  seat  of,  624. 
Diphtheritic  inflammation,  672. 
nephritis,    603,    618,    626- 

629,  672. 
paralysis,  629,  635,  672. 
authorities  on,  631. 
cardiac,  637. 
causes  of,  643. 
clinical  history  of,  631 . 
commencement  of,  631. 
dysphagia  in,  636. 
etiology  of,-643. 
facial,  636. 
heart -failure  in,  637- 

643. 
history  of,  629. 
knee-jerk    absent    in, 

633. 
multiple,  635. 
mutations  of,  635,  647. 
palatal,  635. 
pathology  of,  639,  644, 

645. 
strychnine  in,  673. 
tendon  reflexes  absent, 

633. 
treatment  of,  672. 
stomatitis         complicating 

measles,  679. 
toxsemia,  603. 
vulvitis,  625. 
Diphtheroid  symptoms  in  small- 
pox, 725,  736. 
Diprosopus,  926. 
Dipygus,  932. 
Discrete  small-pox,  729. 
Discus  proligerus,  940. 
Diseases   of  the   foetal    appen- 
dages, 233. 
of  the  Icetus,  217. 
Disinfectants  in  diphtheria,  651- 

656, 
Disinfection,  355,  365. 
Disk,  germinal,  946. 
proligerous.  940. 
Dislocations    of    cranial   bones, 
263. 
of  the  hip  at  birth,  269. 
spontaneous,  475. 
Disorders  of  dentition,  379. 

of  female  puberty,  396,  399, 
402,  415. 
Distortions  of  the  head  at  birth, 

251,  258. 
Diverticulum,  Meckel's,  30. 
Doming,    Dr.   John,  on  denti- 
tion, 378. 
Dorsal  lamina;,  948. 
Double  monsters,  922. 
{See  Joined  Twins.) 
Dress,  hygiene  of,  386,  414. 
of  children,  367-370. 
of  young  women,  414. 
Drinking-water,  372. 
Drooling,  380. 
Drop  cultures  in  bacteriological 

investigation,  178. 
Dropsy,  108. 

abdominal,  86. 
of  the  foetus,  231. 
scarlatinous,  571. 
Drouin  twins  (a    monstrosity), 

930. 
Drowsiness     in     cerebro-spinal 
fever,  631. 


IXDEX    TO    VOLUME    I. 


989 


Drowsiness  in  enteric  fever,  48". 
Dry  cholprii,  915. 
Dry-beat  sterilizer,  17o. 
Dryness  of  climate,  its  influence 

on  enteric  fever,  443. 
Duct,  otnphalo-mesenteric,  952. 

vitello-intestinal,  952. 
Ducts,  Muellerian,  41. 
Ductus    arteriosus,    closure    of, 
252-257. 
structure  of,  252. 
venosus,  28. 
Dysmenorrhoea,  399. 


E. 

Ear,  defects  of,  due  to  maternal 
impressions,  207. 
in  childhood,  15. 
in  diphtheria,  623. 
in  malaria,  842. 
in  scarlatina,  570. 
in  typhoid,  475. 
Earache  and  teething,  382. 
Early  puberty,  93,  392. 

and  premature  decay, 
134,  .392. 
Eclampsia,  343. 

in  cerebro-spinal  fever,  531. 
nutans,  121. 
Eczema,  hove  distinguished  from 

small-pox,  738. 
Eczema  rulirum  and  erysipelas, 

780. 
Education,     compulsory,     409, 
410. 
medical,    with    respect    to 

pediatrics,  9,  10. 
of  youth,  409. 
Edwards,  Dr.  W.  A.,  on  rubella, 

684. 
Effects  of  fever,  424. 
Ekiund's    compilations    on   the 

death-rate  of  children,  135. 
Elbow,  the,  47. 
Electric     reactions     in    enteric 

fever,  472. 
Electricity   in    abdominal    ob- 
structions, 970. 
Embolism    as    a   cause    of    en- 
larged spleen,  85. 
in  rheumatism,  805. 
Embryo,  30. 
Embryology,  939. 
Embryonic  fowl,  949. 
Emphysema,  subcutaneous,  109. 
vesicular,     in     diphtheria, 
615. 
Encephalocele,   how   diagnosti- 
cated   from    spurious  kepha- 
lohasinatoina,  261. 
Endcrmatic  medication,  963. 
Endocarditis,  rheumatic,  797. 
Endometrium,  diseases  of   the, 
their  efTects  upon  the  foetus, 
219. 
Enemata,  353. 

of  cold  or  iced  water  in  en- 
teric fever.  495. 
Enlarged  head,  95. 

pupil,  its  significance,  118. 
Enteric  fever,  441. 

abscesses  in  and  after,  474, 

477. 
age  as  cause  of,  444. 
albuminuria  in,  473. 


Enteric  fever,  alcoholic  stimu- 
lants in,  485,  496. 
analysis   of   symptoms   of, 

462. 
anatomical  lesions  in,  452, 
475. 
groups  of,  452. 
of  central  nervous  sys- 
tem, 458. 
antipyretics  in,  492. 
aphasia  fioiii,  472. 
bacilli  of,  446. 

entrance    of,   into    the 

organism,  450. 
e.xperiments    of   culti- 
vation of  spores  in, 
446. 
not     developed      from 
other     micro-organ- 
isms, 447. 
production  of  a  chemi- 
cal poison  by,  451. 
tendency  to  collect  in 
particular       organs, 
449. 
bacteria  in,  445. 
bath  in,  488,  494,  495. 
bed-sores,  474,  491. 
belly  in,  467. 
bones  in,  475. 
bowels  in,  453,  467. 
cadaver  after,  452. 
causes  of,  442. 

drinking-water  as  one 

of  the,  447. 
exciting,  445. 
predisposing,  442. 
charts   of  temperature    in, 

460,  462. 
chest-troubles  in,  491. 
cicatrization   of  ulcers    in, 

454. 
circulatory  system  in,  463. 
climatic  influences  in,  443. 
clinical  course  of,  in  child- 
hood, 459.    ' 
coils  for  the  head  in,  493. 
cold  affusion  in,  494. 
pack  in,  493. 
sponging  in,  492, 
collapse  in,  464. 
complications  of,  458,  464, 
465,  469,  471,  474,   476, 
485. 
compresses  in,  493. 
constant  lesion  of,  453. 
constipation  in,  467,  488. 
constitutional  symptoms  in, 

451. 
consumption,    acute,    and, 

480. 
contagiousness  of,  449. 
convalescence     from,    463, 

464,  495. 
course  of,  458-463. 
cutaneous  reflexes  in,  473. 
defervescence  in,  462. 
definition  of,  441. 
dejections  in,  482. 
ilc-liiiuiii  in,  459,471,  487. 
derivation  of  name,  441. 
diagnosis  of,  478. 
diarrhoea  in,  467,489,496. 
dietetics  of,  357,  483. 
difl'erentiatcd     from     acute 
consumption,  480. 
from  remittent,  479. 


Enteric      fever      difl'erentiated 
from  trichinosis,  481. 

digestion  in,  452,  466. 

direct  causes  of,  442. 

disinfectants  in,  482. 

dislocations  in,  475. 

drinks  in,  484. 

duration  of,  441,  463. 

ear  in,  475. 

effects  of,  upon  the  foetus, 
229. 

electric  reactions  in,  472. 

enemata  in,  cold,  495. 

epidemics  of,  447,  449,  482. 

epistaxis  in,  466. 

eruption  of,  460,  474. 

etiological     treatment     of, 
495. 

etiology  of,  442. 

exciting  causes  of,  445. 

expectancy  in,  486. 

eyes  in,  470. 

fastigiuin  of,  463. 

floccitation  in,  471. 

fojtal,  229. 

geography  of,  443. 

glands  in,  453,  455. 

hair  after,  474. 

headache  in,  486. 

heart  in,  456,  464,  491. 

hemorrhage    in,   466,    468, 
490. 

history  of,  442. 

house  epidemics  of,  449. 

hypostatic    jint-umonia    in, 
465. 

ice  in,  493. 

incubation  of,  449. 

inoculation  of,  446. 

intestinal    hemorrhage   in, 
468,490. 
perforation  in,  468. 
symptoms  of,  how  pro- 
duced, 451. 

invagination    of    intestine 
in,  453. 

kidneys  in,  456. 

knee-jerk  in,  472. 

Iar3'n.\  in,  457,  466. 

lesions  of,  452. 
bones  in,  475. 

liver  in,  455. 

lobar  pneumonia  as  compli- 
cation of,  458,  465. 

lungs  in,  457,  465. 

lysis  of,  462. 

macula:  of,  460,  474. 

management  of,  483. 

meningitis  in,  471,  488. 
simulating,  119. 

menstruation  in,  473. 

mesenteric  glands  in,  455. 

mode  of  life  as  cause,  445. 

moisture  of  soil  as  aflfect- 
ing,  444. 

mouth  in,  488. 

muscles  in,  456,  457. 

names  of,  441,  443. 

nervous  system  in,  470. 

neuralgia  in,  472. 

ndmonclature  of,  441,  443. 

nosebleed  in,  466. 

nurse's  duties  in,  484. 

oedema  of  the  limbs  in  or 
alter,  464. 

onset  of,  459,  460. 

osseous  system  in,  475. 


990 


INDEX    TO    VOLUME    I. 


Enteric  fever,  pain  in,  468,  470, 
472,  475. 
pathological    anatomy    of, 

451. 
pathology  of,  450. 
perforation    of    bowel    in, 

454,  468,  491. 
peritonitis  in,  469,  491. 
Peyer's    patches    in,    45.3, 

454. 
pneumonia  in,  465. 
privy-vaults  in,  482. 
prodromes  of,  459. 
prognosis  in,  481. 
prophylaxis  against,  481. 
ptomaine  of,  451. 
pulse  in,  464. 
rash  in,  460,  473. 
reflexes  in,  472,  473. 
relapses  of,  461. 
remittents       differentiated 

from,  479. 
respiratory  system  in,  465. 
seasons    of    the    year    in, 

444. 
sequels  of,  476. 
sex  in,  444. 
simulated  by  other  diseases, 

479. 
skin  in,  473. 
sleeplessness  in,  487. 
soil-moisture  as  predispos- 
ing towards,  444. 
sordes  in,  488. 
sjiecific  treatment  of,  495. 
spleen  in,  455,  470. 
sponging  in,  492. 
spots  of,  460,  473. 
stages  of,  in  childhood,  458. 
of  intestinal  ulceration 
in,  453,  454. 
stimulants  in,  485,  496. 
stupor  of,  487. 
subsequent  attacks  of,  461. 
sudden  death  from,  464. 
symptoms  of,  458,  462. 
synonymes  of,  441,  443. 
taches  bleuatres  in,  474. 
temperature   in,    459,   460, 
462,  476. 
during   convalescence, 

463. 
height    of,    in    child- 
hood, 462,  463. 
of  room,  484. 
thoracic  troubles  in,  491. 
tongue  in,  466,  470,  488. 
trachea  in,  457. 
treatment  of,  481,  485,  495. 
tremor  in,  487. 
trichinosis,      how      distin- 
guished from,  481. 
tubercular  meningitis,  how 
distinguished  from,  119. 
tympany  in,  453,  468,  489. 
cause  of,  453,  468. 
form  of,  454. 
type  of,  in  childhood,  451, 

458,  460,  462. 
ulceration  of  the  bowels  in, 
453,  454. 
of  larynx  and  epiglot- 
tis in,  457. 
of  vocal  cords,  466. 
unrecognized,  462. 
urine  in.  4fi0.  473. 
use  of  disinfectants  in,  482. 


Enteric    fever,  voluntary  mus- 
cles in,  457. 

vomiting  in,  466. 
Enteritis     simulating     typhoid 

fever,  480. 
Enteroclyses  in  cholera,  918. 
Enumeration  of  bacteria,  186. 
Enuresis,  130. 
Envelope,  the  serous,  952. 
Epiblast,  945. 
Epiblastic  ridges,  948. 
Epidemics.  »S'ee  under  the  names 

of  contagious  diseases. 
Epigastrius.  937. 
Epilepsy,  diagnosis  of,  120. 

hysterical,  397. 

hystero-,  121. 

in  the  wet-nurse,  333. 
Epispadias,  defined,  40. 

in  typhoid,  466. 
Epistaxis  in  enteric  fever,  466. 

in  relapsing  fever,  607. 
Eiiithelial  pearls,  3. 
Epithelium,  the  germinal,  940. 
Ergot  in    cerebro-spinal   fever, 

553. 
Erotic  literature,  evil  effects  of, 

413. 
Erotomania,  413. 
Eruption  in  tvphoid,  474. 

of  the  teeth,  375,  377. 
Eruptions,  cutaneous,  385. 

(/S'ee  Skin  Diseases.) 
Eruptive  diseases,   nursing  in, 

355. 
Erysipelas,  771. 

age  in,  773. 

ambulatory,  780. 

aniitomical    characters    of, 
778. 

anod3fne     applications    in, 
782. 

aniiphlogistics  in,  782. 

antiseptics  in,  783. 

astringents  in,  782. 

bacteria'  of,  772. 

carbolic  acid  in,  783. 

causes  of,  771. 

cerebral  symptoms,  776. 

chill  before,  774. 

commencement  of,  775. 

complications  of,  778,  781. 

contagion  of,  773. 

counter-irritation  for,  782. 

cour.=e  of,  777. 

definition  of,  771. 

derivation  of  the  word,  771. 

diagnosis  of,  779. 

digestive  organs  in,  776. 

eczema    confounded    with, 
780. 

epidemics  of,  773. 

etiology  of,  771. 

etymology    of    the    name, 
771. 

exclusion  of  other  diseases 
by,  772. 

external     applications    in, 
781. 

fever  of,  777. 

historj'  of,  771. 

in  foetal  life,  228. 

in  the  new-horn,  777. 

integument  in,  775. 

iodine  in,  783. 

kidneys  in,  776. 

local  treatment  of,  781. 


Erysipelas,    lymphangitis,  how 
diagnosticated  from,  780. 
micrococci  of,  772. 
mucous  membranes  in,  776, 

780. 
nomenclature  of,  771. 
nourishment  in,  784. 
pathological  anatomy,  778. 
prevention  of,  781. 
prodromes  of,  774. 
prognosis  of,  780. 
prophylaxis  of,  781. 
pseudo-,  780. 

respiratory  organs  in,  779. 
sarcoma  banished  by,  772. 
sclerema,  how  distinguished 

from,  780. 
season  of  the  year  as  affect- 
ing, 773. 
seat  of,  at  commencement, 

775. 
sequelae  of,  778. 
sex  in,  773. 
skin  in,  775. 
spleen  in,  779. 
stimulants  in,  784. 
symptoms  of,  774,  776,  777. 
synonymes  of,  771. 
treatment  of,  781. 
turpentine  in,  783. 
vaccination  as  a  cause,  751, 

774. 
varieties  of.  771. 
Erythema    distinguished    from 

erysipelas,  780. 
Escharotics,  981. 
Escherich's  studies' on  the  diges- 
tion of  milk,  68. 
Esmarch  tubes,  183. 
Ethyl  alcohol,  bacillus  of,  153. 
Etiology,  497. 

{See  under  names  of  special 
diseases.) 
Eustachian   tube   in   childhood, 
16. 
in  tonsillar  disease,  20. 
Evacuations    in    sickness,    353, 

365. 
Examination  of  back,  97. 
of  head,  93. 
of  mouth,  127. 
of  sick  children,  16,  73,  75, 

79,  93,  97. 
of  thront,  128. 
of  wet-nurses,  330-336. 
Excretions,    the    regulation    of 

the,  979. 
Exercise,  372. 

for  chlorotic  girls,  401. 
Expectoration,  infantile,  74. 
Expense  not  a  matter  to  be  con- 
sidered in  selecting  artificial 
food  for  infants,  293. 
Experiments  on  sterilized  milk. 
.     29». 
Extremities,  lower,  48. 

upper,  46. 
Eye,  1-4,  60. 

and  orbit,  14. 
foetal,  14. 

in  diphtheria,  622. 
in  disease,  116. 
in  malaria,  842. 
movements  of,  60. 
Eyes,  defects  of,  due  to  maternal 
impressions,  208. 
half-open,  107. 


INDEX   TO   VOLUME   I. 


991 


Faeces,  68,  94. 

Face   in    disease,    16,    17,    105, 
106. 
in  infancy,  16. 
in  yellow  fever,  866. 
wounds  of  the,  262. 
Facial  paralysis,  26;^. 

diphtheritic,  636. 
reflex  movements,  69,  60. 
signs  of  disease,  16,  17, 105, 
106. 
Fall  fever,  443. 

{See  Enteric  Fever.) 
Family  histoi}',  110. 
Fashionable  dress,  its  ill  effects, 

414,  415. 
Fat,  its  use  in  inunctions,  959. 
Father,  influence  of,  upon    the 

health  of  his  off^^pring,  220. 
Fatigue  in  children,  causes  of, 

55. 
Fauces  in  diphtheria,  613. 
Febricula,  438. 
Febrile  blush,  the  significance 

of,  429. 
Feeding,  270. 

artificial,  288-329. 
in  sickness,  356. 
intervals  between,  273. 
rules  for,  273. 
through  the  nose,  357. 
Feeding-bottle,  354. 
Feeding-cup,  Haven's,  371. 
Feeding-tubes,    294,    296,   297, 

298. 
Fellows's    sj'rup    of  the    hypo- 
phosphites,  405. 
Female  dress,  errors  in  regard 

to,  414,  415. 
Female   puberty,   disorders   of, 
396,  399,  402,  415. 
hygiene  of,  412. 
Femur,  development  of  the,  49. 

fracture  of  the,  269. 
Feruiented  drinks  for  children, 
345. 
for  wet-nurses,  336. 
Fertilization,  943. 
Fever,  417. 

(<S'ee  also  Pyrexia.) 
antipyretics  in,  434.    i 
bacteria  in,  422. 
bathing  in,  436. 
blush  of,  429. 
causes  of,  421. 
cerebral  symptoms  in,  431. 
cerebro-spinal,  514. 

{See   Cerebro-spinal  Fe- 
ver.) 
cold  applications  in,  436. 
compresses  in,  436. 
constipation  in,  433. 
continued,  438. 
convulsions  in,  428. 
definition  and  nature,  417. 
delirium  in,  431. 
diet  in,  433. 

digestive  functions  in,  429. 
efl'ects  of,  424,  433. 
enteric,  441. 

{See  Enteric  Fever.) 
heat-production  and  heat- 
loss  in,  417,  418. 
hectic.  427. 
lips  in,  429,  430, 
nature  of,  417. 


Fever,  neerosial,  110. 
of  diphtheria,  777. 
pack  in,  432,  437. 
paludal.     See  Malaria, 
poisons  of,  422,  423. 
pulse  in,  429. 
rapid     growth     associated 

with,  54. 
relapsing.     See    Relapsing 

Fever, 
remedies  for,  974. 
remittent,  478. 
respiration  in,  431. 
scarlet.    See  Scarlet  Fever, 
senses  in,  431. 
significance  of,  425. 
simple  coniinued,  438. 
skin  in,  419,  429. 
sponging  in,  436. 
spotted.      .S'ee  Cerebro-spi- 
nal Fever, 
stages  of,  427. 
stimulants  in,  437. 
symptoms,  427. 
thermic,  439. 
tongue  in,  429. 
treatment  of,  433,  974. 
types  of,  427. 
typhoid.  ^ee      Enteric 

Fever, 
typhus.    See  Typhus  Fever, 
urine  in,  4:)2. 
vomiting  in,  429. 
Fevers  and  miasmatic  diseases, 

417. 
Fever-type  of  typhoid  in  chil- 
dren, 451,  458,  460,  462. 
Fibrous  nodules  in  rheumatism, 

801. 
Fibula,  development  of  the,  49. 
Filter,  Chamberland's,  189. 
Finlayson,  Dr.  James,  on  diag- 
nosis, 73. 
Fireplace,  the,  362. 
Fission,  monstrosities  by,  924. 
Fissure  of  Rolando,  13,  14. 

of  Sylvius,  13. 
Fistulas  at  navel,  30. 
Fits,  maniacal,  121. 

{See  also  Convulsions.) 
Fleck-typhus,  497. 
Flesh-peptone,  agar-agar,  182. 

gelatin,  180. 
Flexure,  sigmoid,  35. 
Floccitation    in   typhoid    fever, 
471. 
its  significance,  431. 
Fluid  culture-media,  bacterial, 

177. 
Flushing   of   the  face,    febrile, 

429. 
Foetal   appendages,  diseases  of 
the,  233, 
circulation,  27,  28,  64,  253, 

256. 
diseases,  infectious,  217. 
non-infectious,  230. 
heart,  26. 
membranes,  951. 
syphilis,  221-225. 

diagnosis  of,  222. 
liver  in,  224. 
origin  of,  221. 
osteochondritis  in,  223. 
patlu.logy  of,  223. 
jirognosis  of,  225. 
signs  of,  223. 


Foetal  syphilis,  spleen  in,  224. 
treatment  of,  225. 
tissues,  254,  255. 
traumatism,  232. 
Fcetus,  diseases  of  the,  217,  230. 
invasion     of,    bj'    tj'phoid 

microbes,  449. 
papj-raceus,  923. 
Fontanels,  12. 

auscultation  of,  95. 
closure  of,  55. 
h^'drocephalic        murmurs 

over,  95. 
rachitical    murmurs    over, 

5,  95. 
size  of,  55. 
Food  of  sick  children,  345. 

the  care  of,  370. 
Foods,  4. 

artificial,  310,  311,  315,318, 

321,340. 
household    preparation    of, 

326-329. 
infant's,  so  called,  340. 
patent,  310,  311,  315,  318, 
321. 
Foot,  development  of  the,  50. 
Foramen  of  Magendie,  13. 

of  Winslow,  34. 
Forchheimer,  Dr.  F.,  on  mala- 
ria, 825. 
Foreign  bodies  in  trachea,  24. 
Fore-milk,  its  inferior   quality 
as  compared  with  other  milk, 
289,  290. 
Forster  on  the  source  of  bodily 

heat,  418. 
Fowl,  the  emliryonic,  949. 
Fowls,  transmission  of  diphthe- 
ria by,  592. 
Fractures.     See  Injuries, 
of  cranial  bones,  263. 
of  the  clavicle,  268. 
of  the  femur,  209. 
of  the  humerus,  267. 
in  utero,  231. 
Frecnum  linguae,  19. 

in  whooping-cough,  711. 
Freckles   as   a  diagnostic  sign, 

106. 
French  measles,  684. 
Friedreich's  disease.  111. 
Frog-spawn  fungus,  152. 
Frolowski's    investigations    on 
the    infantile    stomach,    273, 
295. 
Fruit  as   a  cause  of   digestive 

troubles,  345. 
Funicular  process,  33. 
Furrows  of  the  face  in  disease, 

17,  105. 
Fusion,  monstrosities  by,  923. 


Gain  in  weight,  normal,  5,  52, 
271-273.- 

Gall-bladder,  36. 

Gallojiing  consumption,  404. 

mistaken    for    enteric 
fever,  480. 

Gangrenous  pharyngitis,  608. 

Gardner,  J.  J.,  on  the  compli- 
cations of  small-pox,  734-736. 

Garments,   infantile,    367,   370, 
414. 


992 


INDEX    TO    VOLUME   I. 


Gases,  therapeutic  use  of,  978. 
Gastric  capacity,  295. 
Gastro-intestinal      medication, 

966. 
Gelatin  flesh-peptone,  179,  180. 
how  kept  solid  at  high 
temperatures,  177. 
General  development,  its  diag- 
nostic import,  87. 
rules  of  feeding,  273. 
Generation,  development  of  the 

organs  of,  41. 
Genital  precocity,  93,  390,  410. 
Genito-urinary  system,  129. 
Geograjjhy  of  diseases,  132. 
(See  also  under  the  names  of 
various  diseases  in  this  in- 
dex.) 
German  measles,  684. 
Germinal  disk,  946. 
epithelium,  940. 
vesicle,  940. 
Germinative  area,  946. 
Germs  of  disease,  organic.     See 
Bacteria, 
of  the  teeth,  18. 
Gingivitis,  383. 
Girls,  average  weight  of,  89. 
GlaBOgenes,  148. 
Glanders,  bacillus  of,  153,  168. 
Glands,  lymphatic,  22. 
Glandular  swellings,  110. 

system,  4. 
Glycogen,  54. 
Gonorrhoea    in    the   wet-nurse, 

333. 
Gout,  inherited,  114. 
Graafian  vesicles,  939. 
Gram's  method  of  staining  ba- 
cilli, 168. 
Gravel,  130. 

Green-sickness.     See  Chlorosis. 
Green-stick  fracture,  45,  47. 
Grinding  of  the  teeth,  129,  381. 

in  typhoid,  471. 
Groin,  31. 
Groove,  dental,  18. 
Grosvenor's  system  of  dress  for 

children,  368. 
Growing-pains,  54,  110,  113. 
Growth  of  the  child,  5,  7,  51,  52. 
its   relation  to  weight,  53, 
54,  88,  89,  90. 
Guiteras,  Dr.  John,  on  yellow 

fever,  853. 
Gums,  18. 

in  teething,  382. 
lancing  the,  388. 


H. 

TTajnintoma,  97. 
Ilpematoxylin  solutions,  162. 
Useniopbiiia,  112,  986. 
Hair,  care  of  the,  367. 

after  enteric  fever,  474. 
Half-open  eyes,  107. 
Hand-fed  infant  compared  with 

the  breast-fed,  55. 
Hand-feeding,  270,  354. 
Hanging  drop  cultures,  178. 
Hardness  of  water,  372. 
Hare-lip,  20. 

and  cleft  palate,  203. 

as  a  consequence  of  mater- 
nal impressions,  203. 


Haven's  feeding-cup,  371. 
Hay-bacillus,  153. 
Head,  anatomy  of,  11. 

auscultation  of  the,  5,  95. 
defects  of,  due  to  maternal 

impressions,  209. 
distortions  of,  in  labor,  251, 

258. 
enlarged,  95. 
examinations  of,  93. 
injuries    of    the,   in    labor, 

258-267. 
percussion  of  the,  95,  96. 
rachitic,  12. 
sections  of  the,  14,  16. 
size  of,  at  birth,  55. 
smallness  of  the,  96. 
unilateral  deformity  of  the, 
97. 
Headache  in  enteric  fever,  486. 
Head  -  diameter,     its     ratio    to 

chest-diameter,  55,  94. 
Health  an  inheritance,  244. 

resorts,  406. 
Hearing,  development  of,  63. 
Heart,  embryonic,  950. 

foetal  and  infantile,  5-7,  26- 

29. 
its  normal  weight  as  com- 
pared  with   that  of   the 
lungs,  5. 
the,  in  the  newly-born,  5. 
Heart-diseases,     diagnosis     of, 

125. 
Heart-failure  in  diphtheria,  637. 
Heat,  dissipation  of,  419. 

of  fevers,  its  origin,  418. 

[See  Pyrexia.) 
of  the  body,  its  source,  418. 
Heat-stroke,  439. 
Heated  air  for  phthisis,  977. 
Hectic  fever,  427. 
Height,  ratios  of  weight  to,  53, 
54,  88-90. 
and  weight,  89,  90. 
Heightened  temperature,  425. 
Helen  and  Judith  (pygopagous 

twins),  931. 
Hemiplegia,  1 15. 
Hemorrhage  in  typhoid,  490. 
in  yellow  fever,  869. 
meningeal,  266,  267. 
Hemorrhagic    small-pox,     729, 

732. 
Hendon  disease,  the,  557. 
Henoch's    observations    on   the 
duration    of    typhoid    fever, 
463. 
Hepatic  remedies,  971. 
Hereditary  ataxia.  111. 
Heredity,  110. 

in  disease,  220. 
Hernia,  32,  33. 
Herpetic  pharyngitis,  608. 
Hesselbacli's  triangle,  33. 
Hiccoui;h,  59. 
Hide-bound,  109. 
High  temperature,  its  effect  on 

the  foetus,  218. 
Highmore,  antrum  of,  16. 
Hip-joint,  48. 

disease,  48. 
Hippocrates,    his    observations 
on    the   disorders   of    female 
puberty,  396. 
Hirsehfeider,  Dr.  J.  0.,  on  ery- 
sipelas, 771. 


Hirst,  Dr.  B.  C,  on  diseases  of 

the  foetus,  217. 
History,  family,  110. 
Hoffmann,  E.,  his  observations 
on   arterial  pressure   in  very 
young  animals,  5. 
Hooping-cough.    See  Pertussis. 
Hot-bath     for    apparent     still- 
birth. 248. 
Human  milk,  275,  279,  280,  282, 
283,  284,  289,  290,  303,  306, 
308,  310,  336. 
Humerus,  47. 

fracture  of  the,  during  la- 
bor, 267. 
Hunger-pest.       See     Relapsing 

Fever. 
Hutchinson  teeth,  379. 
Hyaline  degeneration  of  the  foe- 
tal tissues  after  birth,  254. 
Hydramnion,  234. 
Hydrencephaloid  diseases,  119. 
Hydrocephalic  skull,  12,  95. 
Hydrocephalus   as   a  sequel  of 
cerebro-spinal  fever,  554. 
diagnosis  of,  95. 
Hydronephrosis,  130. 
Hygiene,  360. 

of  dress,  367-370,  414. 
of  female  puberty,  412. 
of  food,  370-372. 

{See  also  Food.) 
of  pubert.y,  407. 
Hypera3Sthesia,  109. 
Hyperpyrexia,  421,  432. 
Hypoblast,  945. 

Hypodermatic  medication,  964. 
Hypodermoolj'ses     in     cholera, 

919. 
Hypogastric  artery,  closure  of, 
252. 
peculiarities  of,  255. 
Hypophosphites   of  iron,  lime, 
and    potash,    their   remedial 
value,  405. 
Hypospadias,  defined,  40. 
Hysteria,  121. 

causes  of,  414. 
the  voice  in,  396. 
Hysterical  epilepsy,  397. 
insanity,  397. 
paralysis,  398. 
trance,  397. 
Hystero-epilepsy,  121. 


Ice  in  typhoid,  493. 
Ice-bags,  437. 
Ice-water,  372. 
Idiocy,  121. 

as  a  supposed  result  of  in- 
jury at  birth,  267. 
microcephalic,  96. 
Illness,  general  signs  of,  350. 
Imbecility,  121. 
Imitative  movements,  57. 
Immunity  from  infectious   dis- 
eases, artificial,  188. 
Imperial  Granum,  310,  311,  318, 

319. 

Impressions,  channels  of,  their 

influence    on    the    child, 

213. 

character  of,  most  liable  to 

produce  defects,  214.      / 


INDEX    TO    VOLUME    I. 


993 


Impressions,     duration    of,    in 
cases  followed  by  defects, 
213. 
expectation   not   always   a 
forerunner      of      defects 
after,  212. 
maternal,  191,  218. 
proportion  of  cases  followed 
by  defects  in  the  child, 
211. 
value  of   expectations  and 
statements  of  the  mother 
regarding,  212. 
Impulsive  movements,  57. 
Induration    of    cellular    tissue, 

109. 
Infant-feeding,  270. 
Infant-foods,  340. 
Infantile  development,  3. 
Infectious  disease  defined,  451. 
artificial    immunity    from, 
188. 
Infectious  diseases,  foetal,  225. 

nursing  in,  355. 
Infiltration,    sero-sanguineous, 

258. 
Inflammation,  croupous,  609. 
diphtheritic,  609. 
remedies  for,  974. 
Influenza     resembling     enteric 

fever,  480. 
Inheritance    of    good    or    bad 

health,  244. 
Iniodymus,  926. 
Iniops,  935. 

Initial  weight  of  infants,  273. 
Injections,  hypodermatic,  964. 
in  cholera,  018. 
intravenous,  906. 
of    iced    water    in    enteric 
fever,  495. 
Injuries,  ante-natal,  231. 
intra-eranial,  266. 
of  the  arms,  267. 
of  the  bones  of  the  head, 

263. 
of  the  lower  limbs,  269. 
of  the  neck,  265. 
of  the  trunk  in  labor,  267. 
Inoculation  with  ptomaines  as  a 
preventive    of  infection, 
188-191). 
with  small-pox,  744. 
Insanity,  hysterical,  397. 
Insolation,  439. 
Instinctive  movements,  56. 
Instruction     in     pediatrics,    9, 

10. 
In'^truments  for  bacteriological 

investigations,  171. 
Intermittent    fever,    825,    833. 
{S':k  Malaria.) 
pulse,  1  05. 
Intervals  of  feeding,  273. 
Intestinal  obstruction,  127. 

perforation,  ante-natal,  232. 

in  enteric  fever,  491. 
troubles    wrongly    ascribe  1 
to  teething,  384. 
Intestine,  35. 

Intolerance    of    light,    its    sig- 
nificance, 118. 
Intoxication,  ill  efi'ccts  of,  upon 

the  fo;tup,  218,  220,  221. 
Intra-cranial  injuries,  260. 
Intra-uterine  amputations,  232. 
^    life,  13. 
/        Vol.  I.— 63 


Introduction,  1. 
Inunctions,  959. 
Involuntary  movements,  58. 
ludide  of  potassium  after  cere- 

bro-spinal  fever,  554. 
Iodine  in  tuberculosis,  405. 
Irish  moss,  its  value  as  a  food- 

niedieine,  405. 
Iron  as  a  remedy,  973. 

chloride  of,  in   diphtheria, 
659. 
Ischiopagus,  931. 
Isolation  of  bacteria,  169,  183. 
Itching  at  anus,  129. 
at  nose,  129. 


Jaborandi    (pilocarpine)    as    a 
depurative  agent,  980. 
in  diphtheria,  669. 
in      scarlntinal     nephritis, 
579. 
Jacobi,  Dr.  Abraham,  introduc- 
tory chapter,  1. 
Jadelot's  lines,  17,  107. 
J.aggard,  Dr.  W.  W.,  on  joined 

twins,  922. 
Janiceps,  925,  935. 
Jaundice,  its  significance,  106. 
of  yellow  fever,  866. 
remedies  for,  971. 
Jaw,  the  lower,  19. 
Jaws  and  teeth,  17. 
Jayne,  Dr.  Horace,  on  embry- 
ology, 939. 
Jeffries,  Dr.  J.  A.,  his  papers  on 
the  sterilization  of  food, 
301,  305. 
his  views  on  sugar  in  the 
digestive  tract,  325. 
Jelly,  bread,  338. 
chicken,  342. 
of  Wharton,  955. 
Jenner,  Dr.  Edward,  his  illus- 
trious discovery,  744,  745. 
Jennings,   Dr.   C.   G.,  on   vari- 
cella, 754. 
Johnson,  Dr.  James,  his  obser- 
vations  on    the    dangers    of 
puberty,  408. 
Joined  twins,  922. 

anadidymous,  932. 
anakatadidymous,  936. 
anatomy  of,  927,  938. 
by  fission,  924. 
by  fusion,  923. 
by  radiation,  924. 
causation  of,  924. 
circulatory  system  of,  928. 
classification  of,  925. 
cranio]iagous,  935. 
dicephalous,  927,  929. 
dicranous,  926. 
digestive  system  in,  929. 
diprosopous,  926. 
dijiygous,  932. 
epigastrious,  937. 
genesis  of,  922. 
genito-urinary    system    in. 

929. 
ischiopagous,  931. 
katadidymous,     925,     920. 

932. 
literature  of,  938. 
monocranous,  926. 


.Joined    twins,    nervous    svstem 
in,  929. 
nomenclature  of,  925. 
omphalopagous,  926,  937. 
prosopo-thoracopagous,93f.. 
pygopagous,  931. 
radiation,  924. 
respirator}'  system  of,  928. 
skeleton  of,  927. 
sternopngous,  937. 
syncephalous,  932. 
thoracopagous,  937. 
xiphopagous,  936. 


K. 

Karyokinesis,  944. 
Katadidymous    monsters,    925, 

926,  932. 
Kephalohffimatoma,  261. 
{See  Cephalhematoma.) 

spurium,  258. 
[See  Caput  Succednneum.) 
Key  West,  Florida,    death-rate 

at,  865,  856. 
Kidney-disease,  130. 
Kidneys,  37. 

in     diphtheria,     603.     618, 

626-629,  672. 
in  enteric  fever,  456. 
in  pertussis,  711. 
in    scarlet  fever,  122,  564, 

570,  678. 
passage  of  microbes  through 
the,  228. 
Kindergarten,  410. 
Klebs-Loeffler  bacillus,  587. 
Klcbs's  method   with    bacteria, 

170. 
Knapp's    observations    on    the 
eye-complications  of  cerebro- 
spinal fever,  538. 
Knee-jerk  in  diphtheritic  paral- 
ysis, 633. 
in  typhoid,  472. 
Knee-joint,  49. 
Knock-knee,  49. 
Koch,  Prof.  R.,  his  discoveries, 
147. 
his  methods  with  bacteria, 
169,  170. 


double 


on    the 
impres- 


Labial  line,  17,  107. 

Lactation,  270. 

Laloo    (a    stcrnopagous 

monster),  937. 
Laminas  dorsales,  948. 
Lancing  the  gums,  388 
Lanugo,  72. 
Large  intestine,  35. 
Larrey's    observations 

efiects    of    maternal 

sions,  192. 
Larynx,  anatomj'  of  the,  21. 
Leeching,  352,  353. 
Leiter's  head-coils,  493. 
Lcnion-juiee  in  malaria,  862. 
Lens,  Zeiss's  apochromatic,  158. 
Leprosy,  bacillus  of,  153,  107. 
Lcptothricheaj,  155. 
Lethargy,  398. 
Lcuconostoc,  152. 
Lifting   children   by  the  arm;-, 

47. 


994 


IXDEX    TO    VOLUME    I, 


Ligainentum  urteriosum,  2.33. 
Ligation  of  the  cord,  237. 
Light,  artificial,  in  the  nursery, 
364. 
intolerance  of,   its   signifi- 
cance, lis, 
perception  of,  62. 
Liuibs,  development  of,  44. 
Linea  alba,  29. 
Lines,  Jadelot's,  17,  107. 
Lips  in  fever,  429. 
in  infancy,  17. 
Literature  of  teratology,  938. 
Liver,  36. 

in  enteric  fever,  455. 

its  peculiarities  in  infancy, 

68. 
its    peculiarities    in    mon- 
sters, 938. 
Liver-pad,  963. 

Lobar  pneumonia  in  enteric  fe- 
ver, 458. 
Lceffler's  method  with  bacteria, 

168. 
Loeflaud's  sterilized  milk,  317. 
Longings,  maternal,  their  possi- 
ble ill  etfeets,  214. 
Lordosis,  98. 
Love-sickness,  413. 
Lovrer   extremities    as    affected 
by  maternal  impressions, 
207. 
extremity,  the,  48. 
Lungs,  25. 

in  diphtheria,  614. 
in  double  monsters,  938. 
in  enteric  fever,  457. 
Lustgarten's  method   in  bacte- 
rial study,  167. 
Luxations.     See  Dislocations. 

in  utero,  231. 
Lymphangitis,  how  distinguish- 
able from  erysipelas,  780. 
Lymphatic  glands  in  diphtheria, 
616. 
of  the  neck,  23. 
vessels    of    the    head    and 
neck,  40. 


M. 

MacAlister   on   the    origin    of 

bodily  heat,  418. 
MacLaughlin,  J.  W.,  his  inves- 
tigations   regarding   dengue, 
882-886. 
Maculas  of  cerebro-spinal  fever, 
636,  545. 
of  enteric  fever,  460,  474. 
of  typhus,  499,  500. 
Madden,  Dr.  T.  M.,  on  puberty, 
its   pathology    and    hygiene, 
380. 
Malaria,  825. 

age  as  affecting,  832. 
alimentary  tract  in,  839. 
anatomical    characters    of, 

832. 
arsenic  in,  851. 
bacteria  of,  479,  826-831. 
benign  type  of,  834. 
blood- corpuscles   in,    829, 

833. 
brain-complications  in,  836. 
bronchial    tubes    in,    833, 


Malaria,  cachexia  of,  845. 
causation  of,  825. 
cerebro-spinal    nerves     in, 

837. 
change    of    residence    for, 

851. 
changes   in  its   geographic 

range,  825,  831. 
chill  from,  835. 
chronic,  845. 

circulatory  system  in,  840. 
complications  in,  836,  846. 
definition,  826. 
dengue  compared  with,  894. 
diabetic  symptoms  in,  841. 
diarrhoea  from,  840. 
effect    of    the    seasons    in, 

830. 
etiology  of,  826. 
foetal,  228. 
gl^'cosuria  in,  841. 
how     distinguished      from 

dengue,  894. 
infant-mortality  from,  832. 
intermittent,  833. 
intestinal       complications, 

840. 
lemon-juice  for,  852. 
medication  for,  848. 
mental  disturbances  of^  837. 
microbes  in,  826. 
miscarriage  due  to,  831. 
moisture  as  a  factor  in,  831. 
morbidity  from,  831. 
nervous  system  in,  836. 
neuralgia  from,  837,  844. 
night-air  in,  831. 
organs  of  special  sense  in, 

842. 
pathological    anatomy    of, 

832. 
pathology  of,  826. 
peculiarities  of,  in  children, 

835. 
pernicious        intermittent, 

834. 
Plasmodium  of,  828. 
pneumonia,  its  relation  to, 

839. 
poison  of,  826,  830. 
prognosis,  847. 
prophylaxis,  847. 
quartan,  833. 
quinine  in,  848. 
quotidian  type,  833. 
remittent  type,  842. 
continuous,  844. 
forms  of,  843. 
thermometric  range  of, 
844. 
respiratory    apparatus    in, 

838. 
season  of  the  year  in,  830. 
skin  in,  842. 
spleen  in,  840,  846,  851. 
stages  of,  835. 
syni|)tomatology  of,  833. 
tertian  type,  833. 
thermometry  of,  844. 
treatment  of,  847. 
typhoidal  forms  of,  842. 
urinary  organs  in,  841. 
vaso-motor  disturbances  in, 

838. 
Malarial  cachexia,  815. 

disense  in  the  foetus,  228. 
Malformations  of  the  teeth,  378. 


Malignant  disease  of   the  kid- 
ney, 130. 
Malpighi,  pyramids  of,  37. 
Malposition  of  teeth,  378. 
Mammals,  ovary  of,  940. 
[  Management  of  sickness,  354. 
I  of  teething,  386. 

Maniacal  fits,  121. 
Marie  and  Rose  (joined  twins), 

930. 
Marks,  mother's,  17,  193,  211, 
218. 

{See   Maternal  Impressions; 
also  Na3vus.) 
Mastoid  cells  and  antrum,  15. 
Masturbation,  93,  131. 
Matas,  Dr.  Rudolph,  on  dengue, 

878. 
Maternal  impressions,  191,216, 
217,  218. 
as  affecting  the  ears,  207. 
eyes,  208. 
hair,  210. 

lower  extremities,  207. 
skin,  210. 
trunk,  209. 

upper  extremities,  205. 
as    producing   defects,    de- 
formities, or  marks,  196- 
216. 
Maturation  of  the  ovum,  941. 
Maxillary  bones,  17. 
McClellan,  Dr.  George,  on  tho 

anatomy  of  children,  11. 
Meals,  344. 

time  of,  343. 
Measles,  675. 

anatomical    characters    of, 

676. 
atypical  courses  of,  678. 
black,  678. 
bronchitis  in,  680. 
causation  of,  675. 
Chinese,  141. 

complications  of,  677,  679. 
conjunctivitis  in,  679. 
contagion  of,  675. 
convalescence  from,  682. 
convulsions  in,  681. 
decline,  stage  of,  677. 
definition  of,  675. 
diagnosis  of,  678. 
diet  in,  355. 
diphtheritic   symptoms  in, 

679,  680. 
disinfection  in,  355. 
distinction  from  rubella  and 
from    scarlet    fever, 
699. 
from  small-pox,  738. 
epidemic  characters  of,  680. 
eru])tive  stage  of,  677. 
etiology  of,  675. 
eye-troubles  in,  679. 
foetal,  228. 
geographical    range,    etc., 

140. 
German  or  French,  684. 
hemorrluigie,  (i78. 
history  of,  675. 
hot  drinks  in,  681. 
hygienic  conditions  in,  681. 
in  foetal  life,  228. 
intestinal  troubles  in,  680. 
invasion  of,  676. 
malignant  types  of,  678. 
mouth  in,  679. 


INDEX    TO    VOLUME    I. 


995 


Measles,  names  of,  675. 
nursing  in,  355. 
pathological    anatomy    of, 

676. 
pneumonia  in,  680. 
prevention  of,  681. 
prognosis  of,  680. 
stage  of  decline  in,  677. 
stimulants  in,  6S2. 
stomatitis  in,  679. 
symptomatology  of,  676. 
synonymes  of,  675. 
treatment  of,  681. 
Meckel's  diverticulum,  30. 
Meconium,  69. 

Media  aortas,  its  relations  with 
the    ligamentum   arteriosum, 
253,  254. 
Media  for   the  culture  of  bac- 
teria, 177. 
Medullary  plates,  948. 

substance,  the  ovarian,  940. 
Meigs's  mixture,  322. 
Mellin's  food,  310,  311,  319. 
Meuibrana  granulosa,  940. 
Membrane,  subzonal,  954. 
Membranes  of  the  brain,  12. 

foetal,  951. 
Meningeal     hemorrhage,     266, 

267. 
Meningitis,  109. 

cerebro-spinal,     116,     137, 
547. 

(<S'ee  also   Cerebro-spinal 
Fever.) 
in  typhoid  fever,  471. 
its    alleged     frequency    at 

Havana,  857. 
rheumatic,  805. 
simulating  typhoid,  480. 
sporadic,  its  discrimination 
from    cerebro-spinal    fe- 
ver, 547. 
tubercular,  119. 
{See  Tubercular  Meningitis.) 
Menstrual  disorders  of  puberty, 

399. 
Menstruation,     commencement 
of,  391. 
delayed,  390. 
in  typhoid,  473. 
premature,  390. 
return  of,  281. 
Mental  defects  due  to  maternal 
impressions,  191. 
training  of  youth,  409,  413, 
414. 
Mercurials  in  diphtheria,  664. 

in  foetal  syphilis,  225. 
Mercuric   iodide    in  scarlatina, 

574. 
Merismopcdia  (the  genus),  152. 
Alesobhist,  947. 
Mi'tabolisui    a   source  of    heat, 

4  IS. 
Metacarpal  bones,  48. 
Metatarsal  bones,  50. 
Method     in     bacterial      study, 
Klebs's,  170. 
Koch's,  169,  170. 
Lreffler's,  168. 
Methods  of  staining  in   bacte- 

rian  study,  100,  162,  168. 
Miasmatic  diseases,  417. 

(Sec  also  Malaria.) 
Microbes.     See  IJacteria. 
Microcephalic  idiocj',  96. 


Micrococcus  (the  genus),  151. 

diphtheriticus,  585. 
Microkinesis,  56. 
Micro-organisms.    See  Bacterin. 
Microscopy  of  the  bacteria,  158. 
Micturition,  70,  130. 
Miliary  tubercle,  404. 
Milk,  abnormal,  276. 

analyses  of,  275,  279,  280, 
282,  283,  284,  289,  290, 

306,  307,  310. 

as    a   food    after    weaning, 

337,  338. 
as  a   vehicle   of   infection, 

557,  594,  901. 
asses',  290. 
bacillus  of  blue,  153. 
bacterium  of  yellow,  152. 
boiled,  299,  301. 
catauienial,  281. 
chemical   analysis  of,  288, 

307,  360. 
condensed,  315,  339. 
cow's,   290,   306,  308,    309, 

310,  339. 
digestion  of,  68. 
human,   its   analyses,   etc., 
275,   279,   280,    282, 
283,   284,   289,    290, 
303,  306,  308,  310. 
its  characters,  335. 
of  the  wet-nurse,  279,  280, 

282,  283,  284,  335,  336. 
one  cow's,  338. 
peptonized,  317,  340. 
secretion  of,  277. 
sterilized,  317. 
variations  of,  280. 
yellow,  its  bacterium,  152. 
Milk-sugar,  325. 
Milk-teeth,  374. 
Milzbrand,  bacillus  of,  153. 
Mineral  acids,  969. 

waters  in  infantile  hepatic 
troubles,  971. 
in  strumous  and  tuber- 
cular disease,  4  06. 
Miscarriages    due    to    malaria, 

831. 
Mitchell,  Dr.  A.,  on  the  results 
of  maternal  impressions,  193. 
Mixed  foods,  322,  327. 
Moist  chamber,  its  use  in  bncte- 
riological  investigations,  172. 
Moisture   in   the  air,  its  thera- 
peutic uses,  354. 
Mole,  blastoderm  of  the,  947. 
Money,  Dr.  Angel,  on  the  physi- 
ology of  infancy,  51. 
his  observations  on  certain 
complications  in  enteric 
fever,  472. 
Monocranus,  926. 
Monoplegia,  115. 
Monsters,  anadidymous,  932. 

double,  922. 
Monstrosity,  moral,  217. 
Monthly  nurse,  240. 
Moral  abnormity  as  a  result  of 

miiteinal  impressions,  217. 
Jloral    qualities    requisite  in  a 

wot-iuirse,  330. 
Moral  training  of  youth,  408, 

409. 
Morbid   anatomy.      .^ee    under 
names  of  individual  diseases. 
Morbilli.     S:'e  Measles. 


Morphology  of  bacteria,  156. 

Morula,  944. 

Mother's    marks,   17,   193,  211, 

218. 
Mountain  health-resorts,  evil  as 
well  as  good  results  from  vis- 
iting, 407. 
Mounting     of      bacteriological 

preparations,  163. 
Mouth,  examinations  of,  127. 

in  enteric  fever,  488. 
Movements  classified,  57. 

congenital,  reflex,  instinc- 
tive, and  volitional,  56. 
of  the  newlv-born,  57. 
Muguet,  128. 
Multiple  dentition,  377. 

paralysis,  diphtheritic,  635. 
Multiplication  of  bacilli  and  of 

the  bacterium,  157. 
Mumps,  767. 

{See  Parotitis.) 
Murmurs    over  rachitic   fonta- 
nels, 5. 
Muscles,  heat-producing   func- 
tion of  the,  418. 
Muscular  coutractions,  22. 

paralysis,       pseudo-hyper- 
trophic,  98,  112,  118. 
sense,  62. 
Music,    excessive    devotion    to. 
413. 

N. 

Najvus,  facial,  17. 
Napkins,  infants',  369. 
Nares  in  diphtheria,  611,  621. 
Nasal  line,  17,  107. 
Nationality,    its    influence    on 

disease,  132. 
Neck,  anatomy  of  the,  21-24. 
injuries  during  labor,  265. 
Necrosial  fever,  110. 
Negroes.     .S'ee    Kace    and    Na- 
tionality. 
Nematogenes,  148. 
Nephritis,     diphtheritic,     603, 
618,  626-«29,  672. 
in     ecrebro  -  spinal     fever, 

544,  545,  546. 
scarlatinous,  564,  570,  571, 
578. 
pleural     effusions     in, 
122. 
Nerves,  their  course  as  a  guide 

in  diagnosis,  31. 
Nerve-sedatives,    their    use    in 
the  di.sorders   of  female   pu- 
berty, 4 1 6. 
Nervous  disorders  of  females  .at 
))uberty,    treatment     of, 
415. 
system  in  disease,  115. 
in  typhoid,  470. 
its  peculiarities  in   in- 
fancy, 3,  51. 
its  relations  to  thermo- 
genesis  and  thermo- 
Ivsis,  420. 
Nestld's  food  :'.I1,  315. 
Neural  canal,  918. 
Neuralgia  after  typhoid,  472. 

from  malaria,  837. 
Neurotic  diseases,  113. 
Newly-born  child,  care  of  the, 
236,  238,  214. 


996 


INDEX    TO    VOLUME    I. 


Newly-born    child,    movements 
of  the,  57. 
senses  of  the,  62. 

Nightingale,    the    two-headed, 
930. 

Night-light,  364. 

Night-tenors,  121,  343. 

Nocturnal  terrors,  121. 

Nodding  convulsions,  121. 

Nodules,  rheumatic,  800,  801. 

Non-infectious    foetal    diseases, 
230. 

Normal  gain  in  weight,  273. 

Nose  in  diphtheria,  611,  621. 
in  infancy,  16. 

Nosebleed  in  enteric  fever,  466. 
in  relapsing  fever,  507. 

Notch  of  Rivinus,  15. 

Notochord,  948. 

Nourishment.     See  Food. 

Novel-reading,  excessive  devo- 
tion to,  413. 

Nuck,  canal  of,  33. 

Nucleolus,  940. 

Nucleus,  940. 

Numbering  of  bacteria,  186. 

Nurse,  wet-,  286,  330. 

Nurse's  duties  at  childbirth,  240. 
in  cerebro-spinal  fever,  554. 
in  general,  347-359. 

Nursery,  the,  351,  361. 
hj'giene,  360. 

Nursing  of  sick  children,  345, 
347-359. 

Nursing-bottles,  371. 

Nutrition   of   the  foetus,   defec- 
tive, 219. 

Nutritive  remedies,  973. 

Nycturia,  130. 


O. 

Oatmeal  bath,  358. 
Obstruction    of    the    intestine, 

diagnosis  of,  127. 
Occipito-atlantoid  disense,  98. 
Occupation    in    its  relations  to 
female  health  nt  puberty,  415. 
Oculo-zygomatic  line,  17,  107. 
0'Dw_yer,  his  discoveries  in  the 
treatment  of  diphtheria,  584. 
(Edema,  1(19. 

of  the  extremities  after  en- 
teric fever,  464. 
pulmnnum    in   diphtheria, 
616,  650. 
Oertel's    views    on    diphtheria, 

589,  613. 
Oesophagus,  the,  24. 

in  diphtheria,  623. 
Ointments,  960. 
Oleates,  960. 
Omphalo-mesenteric  duct,  952. 

veins,  953. 
Omphalopagus,  926,  937. 
One  cow's  milk,  338. 
One-sided  paralysis,  115. 
Oosperm,  591. 
Opaque  area,  948,  953. 

culture-media,  184. 
Opium  in  cerebro-spinal  fever, 
553. 
in  rheumatism,  819. 
Opodymus,  926. 
Optic  nerve,  1 18. 
Orbit  of  the  eye,  14. 


Oscillation  of  the  pupil,  118. 
Osseous     system     in     typhoid, 

475. 
Osteoblasts,  45. 
Osteochondritis,  syphilitic.  223, 

224. 
Otalgia  during  teething,  382. 
Otitis  after  scarlatina,  670. 
Out-door  exercise,  372. 
Ova,  the  primordial,  940. 
Ovarian  tumor  in  a  child,  93. 
Ovaries,  42,  939. 
Ovarj',  cortical  layer  of,  939. 

follicles  of,  940. 

germinal      ejji:  helium     of, 
840. 

mammalian,  940. 

medullary      substance     of, 
939,  940. 

membrana     granulosa     of, 
940. 

section  of,  939,  940. 

structure  of,  939. 

vesicles  of,  939. 
Overwork  in  schools,  410. 
Ovum,  940. 

of  the  cat,  940. 

of  the  mammal,  940. 

of  the  rabbit,  945-949. 

the  fertilization  of  the,  943, 
944. 

the  maturation  of  the,  941. 
O.xyuris  vermicularis,  129. 


Pack,  437. 

dangers  of,  432. 
Pain  as   elicited  by  diagnostic 
manipulations,    its    sig- 
niiicance,  84. 
in  enteric  fever,  468,  470, 

472,  475. 
in  general,  109. 
Painful  affections,  the  relief  of, 

965.     . 
Pains,  growing,  54,  110,  113. 

in  general,  109. 
Palatal  paralysis,  diphtheritic, 

635. 
Palate,  cleft,  20. 

in  infancy,  20. 
Pallor,  its  significance,  106. 
Palpation  in  diagnosis,  84. 
Pancreas,  37. 
Pancreatic  secretion,  67. 
Papain,  or  papayotin,  973. 

in  diphtheria,  671. 
Papyraceous    foetus     described, 

923. 
Paralysis,  116,  117. 

cerebral,  in  the  newly-born, 

266,  267. 
facial,  263. 
hysterical,  398. 
in      cerebro-spinal      fever, 

529. 
in  enteric  fever,  472. 
infantile,  115. 
one-sided,  115. 
of  the  aim   in  the  newly- 
born,  268. 
pseudo-hypcrtrophic,       98, 
112,  117. 
Parish,    Dr.    W.    H.,    on     wet- 
nurses,  330. 


Parotitis,  767. 

abscess  in,  770. 
causes  of.  768. 
defined,  767. 
diagnosis  of,  769. 
epidemic,  768. 
etiology  of,  768. 
idiopathic,  768. 
local  effects  of,  768. 
metastasis  in,  767,  769. 
names  of,  767. 
pathological    anatomy     of, 

768. 
prognosis  of,  770. 
symptomatology  of,  768. 
synonymes  of,  767. 
treatment  of,  770, 
varieties  of,  767. 
Parvin,  Dr.  Theophilus,  on  in- 
juries of  the  new-born  child, 
258. 
Passage   of    bacteria    into    the 

foetal  circulation,  225-230. 
Pasteur,    Dr.    Wm.,    on    fever, 

417. 
Pasteur,    Louis,    his    illustrious 

discoveries,  147. 
Pasteurization,  977. 
Patent  foods,  311,  315,  318,  321, 

340. 
Paternal  influence  in  producing 

diseased  ofl'spring,  220. 
Pathogenetic  qualities   of  bac- 
teria,' 188. 
Pathology.     ^S'ee  the  names  of 
various  diseases  in  this  index. 
Pearls,  epithelial,  3. 
Pediatrics  as  a  specialty,  1,  2. 

the  study  of,  9. 
Peligot  and  Reiset  on  milk,  289, 

290. 
Peliosis  rheumatica,  802. 
Pellucid  area,  948. 
Pelvis,  38. 
Penis,  40. 

Penrose,  Dr.  R.  A.  F.,  on  the 
care  of  newly-born  children, 
236. 
Pepsin,  968. 

for  tape-worm,  973. 
in  diphtheria,  671. 
Peptonized  milk,  317,  340. 
Ptptonum   siceum   in   bacterio- 
logical culture-media,  177. 
Percussion  of  the  head,  95. 
Perforation  of  the  intestine  in 
enteric    fever,    454, 
468,  491. 
in  the  foetus,  232. 
Pericarditis,  125. 

from  periostitis,  126. 
pyajuiic,  126. 
rheumatic,  126,  798. 
Perichondritis  of  the  arytenoid 
cartilages  in  or  after  enteric 
fever,  460. 
Pericr.anium,  11. 
Perineum,  43. 
Periosteum,  45,  110. 
Periostitis,  110. 
Peritoneum,  33. 
Peritonitis  in  enteric  fever,  469, 
491. 
tubercular,  85,  86,  127. 
Perity]>hlitis,  its  scat,  35. 
Permanent  teeth,  375. 
Pernicious  intermittent,  834. 


INDEX    TO   VOLUME    I. 


997 


Pertussis,  atomizer  in,  719. 

bacteria  in,  70(5. 

belladonna  in,  720. 

brain  and  membranes,  70S. 

bronchi  in,  708,  709. 

capillary  bronchitis  in,  709. 

causes  of,  703,  713. 

collapse  of  lungs  in,  709. 

complications  of,  708,   711, 
721. 

contagion     of,     704,     706, 
713. 

convulsive    stage    of,    715, 
720. 

cough  in,  711. 

curative  measures  in,  719. 

definition  of,  703. 

diagnosis  of,  71a. 

diet  in,  721. 

disinfection  in,  717. 

emphysema  in,  709,  712. 

etiology  of,  703,  713. 

eyes  in,  708. 

■frsenum  linguas  in,  711. 

geography  of,  136. 

glands  in,  710. 

heart  in,  710. 

history  of,  703. 

hygiene  of,  717. 

in  public  institutions,  718. 

isolation  of,  716. 

kidneys  in,  711. 

kink  of,  711. 

lungs  in,  70S,  712,  713. 

mortality  from,  705. 

mucous  membrane  in,  708. 

names  of,  703. 

nose  in,  708. 

palliative  treatment  of,  719. 

pathology  of,  706,  713. 

pneumonia  in,  710. 

prevention  of,  715. 

prodromes  of,  713. 

prognosis  in,  715. 

prophylaxis  of,  715. 

pulmonary  collapse  in,  709. 

quarantine  of,  716. 

race    and    nationality    in, 
136. 

sanitation  in,  717. 

stages  of,  713,  719,  720. 

stomach  in,  708. 

symptoms  of,  713. 

synonymes,  703. 

tracheo-bronchial      glands 
in,  710. 

treatment  of,  715,  719. 

virus  of,  704,  706. 

whoop  of,  712. 
Pestilential  diseases,  their  ori- 
gin, 5S1. 
Potccliiic  of  typhus,  499. 
Petechial  fever,  497. 
Peycr's  patches,  453,  454. 
Phalanges,  48,  50. 
Pharyngitis,  gangrenous,  608. 

heri)ctic,  608. 

in  (liphihei-ia,  607,  608. 

pultacoous,  607. 

scarlatinous,  607. 

ulcero-membranous,  608. 
Pharynx,  anatomy  of,  20. 
Phimosis,  131. 

Phlegmonous  inflammation, 

how  distinguishable  from  ery- 
sipelas, 780. 
Photophobia,  118. 


Phragmidiotherix  (a  genus  of 

bacteria),  157. 
Phthisis,  123. 

abdominal,  88. 
therapeutics  of,  977. 
wasting  in,  88. 
Physical  signs    of    disease,  17, 
74,  107. 
in  the  wet-nurse,  333. 
training  of  youth,  409. 
Physiognomy,  17,  105. 
Physiology  of  infancy,  51. 
Pigeon-breast,  24,  86,  230. 
Pigmentation,   its  significance, 

106. 
Pilocarpine  as  a  depurative,  980. 
in  diphtheria,  669. 
in      scarlatinal     nephritis, 
579. 
Pin-worms,  129,  972. 
Pitting  in  small-pox,  740. 
Placenta,  28,  955. 
diseases  of,  233. 
separation  of  the,  236. 
Placental  cotyledons,  955. 
Plant,  Dr.  W.  T.,  on  vaccina- 
tion, 743. 
Plasmodium  of  malaria,  828. 
Plate-cultures,  182,  184. 
Plates,  medullary,  948. 
Pleurae,  25. 
Pleurisy,  125. 

in  diphtheria,  615. 
in  rheumatism,  799. 
Plumbing,  365. 
Pneumonia,  124. 
foetal,  230. 
in  diphtheria,  615. 
in  malaria,  839. 
in  rheumatism,  799. 
in  whooping-cough,  710. 
of  foetal  life,  230. 
Poisons  in  the  maternal  blood, 
219. 
pathogenic,  189,  190,  422, 
900. 
Polar  cells,  941. 
Polyuria,  130. 

Pomeroy,  Jesse,  a  possible  cause 
of  his  abnormal  moral  char- 
acter, 217. 
Porcher  on  the  distinction  be- 
tween    dengue    and     yellow 
fever,  893. 
Position  of  the  viscera,  24,  85. 
in  the  foetus,  27. 
{See  also  Topography.) 
Potassium  chlorate  in  diphthe- 
ria, 661. 
Potato-culture  (bacterial),  184, 

185. 
Pott's  disease,  31. 
Poupart's  ligament,  32. 
Poverty   and   wealth,  their  in- 
fluence on  disease,  etc.,  135. 
Precocity,  sexual,  93,  390,  392, 

410. 
Prcdigestiou.      See   Peptonized 

Foods. 
Pregnancy     during      lactation, 

283. 
Premature  decay,  134. 
ossification,  2. 
puberty,  93,  390,  .S92,  410. 
Prevention  of  disease  by  inocu- 
lation, 188-190. 
{Sec  also  Inoculation.) 


Primitive  streak  and  trace,  946. 
Primordial  ova,  940. 
Privy-vaults    in    enteric    fever, 

482. 
Prodigium        AVillinghamense, 

393. 
Proeotia,  93,  390,  410. 
Prognosis  in  typhoid,  481. 
{See  also  under  the  heads  of 
diseases  named  in  this  in- 
dex.) 
Proligerous  disk,  940. 
Prominent    belly,    its     signifi- 
cance, 86. 
Pronucleus,  female,  942. 

male,  943. 
Properties  of  bacteria,  188. 
Prosopo-thoracopagus,  936. 
Prostate  gland,  40. 
Protoveitebrce,  948. 
Pseudo-erysipelas,  780. 
Pseudo-hy  pel  trophic    muscular 

paralysis,  98,  112,  118. 
Pseudo-membranes,       diphthe- 
ritic, 601,  610. 
Ptomaines,  189,  190. 

as  a  cause  of  disease,  422. 
inoculation  with,  190. 
of  cholera,  900. 
of  diphtheria,  586,  588. 
of  enteric  fever,  451. 
Puberty,  389. 

age  of,  390,  392,  410. 
changes  in  the  mastoid  at, 

15. 
chloransemia  at^  400. 
diseases  of,  393. 

in  the  female,  394. 
evolution  of,  389,  391. 
hygiene  of,  389,407,  412. 
hysterical  disorders  of,  395. 
epilepsy  in,  397. 
insanity  in,  397. 
paralj'sis  in,  398. 
trance  in,  397. 
in  females,  390. 
menstrual  disorders  of,  399. 
nervous   disorders  of,  395, 

415. 
occupation    in    its  relation 

to  health  at,  415. 
of  males,  392. 
physical  and  moral  culture 

at,  407,  412. 
premature,  93,  392,  410. 
regimen  at,  345. 
signs  of.  392.  394. 
special  disorders  of,  394. 
strumous  disorders  of,  402. 
treatment   of  nervous    dis- 
orders of,  4' 5. 
tuberculosis  of,  402. 
Puerile  breathing,  125. 
Pulmonary  oedema  in  diphthe- 
ria, 616.  650. 
system,  122. 
Pulse,  dicrotic,  105. 
in  diagnosis,  104. 
in  fever,  10-1,  424. 
in  relapsing  fever,  507. 
intermittent,  105. 
normal,  66. 
slowness  of,  101. 
PuUaceous  pliaryngitis,  607. 
Pupil,  contracted,  IIS. 
enlarged.  IIS.  119. 
oscillating,  IIS. 


998 


IXDEX    TO    VOLUME    I. 


Purposeless  movements,  infan- 
tile, 57,  58. 
Purpuric  erythema  in  rheuma- 
tism, 802. 
PyEemia,    how    distinguishable 

from  rheumatism,  810. 
Pyelitis,  i;^0. 
Pygopagus,  931. 
Pyramids  of  Malpighi,  37. 
Pyrexia,  417,  976. 

its    significance,   425,    426, 

427. 
its  stages  and  types,  427. 
its  treatment,  9(il,  976. 
of     childhood      contrasted 
with  that  of  adult   life, 
425. 
symptoms  of,  427. 
Pyrogenesis,  421. 


Qualifications  of  a  nurse,  347- 
359. 
of  a  wet-nurse,  330. 
Quality  of  food,  275-329. 
Quarantine  in  }>ertussis,  716. 

in  yellow  fever,  876. 
Quinine  in  dengue,  898. 
in  diphtlieria,  659. 
in  enteric  fever,  486.' 
in  malaria,  848. 

dose  of,  849. 
in  scarlatina,  575. 
its  routine  administration, 

969. 
its   uselcssness  in  cerebro- 
spinal fever,  554. 
rectal     administration     of, 
850. 


R. 


Rabbit's  ovum,  945,  949. 
Rabenhorsfs    classification     of 

the  bacteria,  150. 
Race,  its  influence  on   disease. 

1.32,  146. 
Rachitic    oedema,    how    distin- 
guishable from  rlieuma- 
tism,  810. 
pelvis,  38. 
rosary,  86. 
Rachitis,  5,  24,  64,  112,  123. 
as  a  cause   of   various  ob- 
scure symptoms,  381. 
blood-vessels  in,  5. 
dentition  in,  382. 
in  the  wet-nurse,  332. 
of  the  foetus,  230. 
signs  of,  85. 
Radiation,      monstrosities     by, 

924. 
Radius,  its  development,  48. 
Ratio  of  chest  to  head  in  size, 
55. 
of  heart  to  aorta,  64. 
Ratios  of  growth  to  weight,  53, 

54,  88,  89,  90. 
Rectum,  41. 

thermometry  of  the,  101. 
Recurrent      fever,     congenital, 
229. 
typhus.       See      Relapsing 
Fever. 
Reflex  movements,  56,  5S. 


Reflexes,  cutaneous,  in  enteric 
fever,  473. 
tendon,    in    enteric    fever, 
472. 
in  diphtheritic  paraly- 
sis, 633. 
Regimen  of  the  sick,  345. 
Reisot    and    Peligot    on    milk, 

289,  290. 
Relapsing  fever,  504. 
appetite  in,  507. 
bacteria  of,  505,  509. 
bilious  form  of,  509. 
causes  of,  605. 
complications  in,  507,  509, 

512. 
contagion  of,  505. 
convalescence  from,  513. 
definition  of,  504. 
delirium  in,  608. 
diagnosis  of,  509,  510. 
diarrhoea  in,  509. 
disinfection  in,  511. 
epistaxis  in,  507. 
eruptions  in,  510. 
etiolo£ty  of,  505. 
heada'ehe  in,  508,  512. 
heart  in,  508,  512. 
history  of,  504. 
hygiene  in,  511. 
jaundice  in,  507,  513. 
joints  in,  508. 
liver  in, '506.  507,  610. 
medication  in,  512. 
mortality  from,  509,  511. 
nervous  system  in,  508. 
nosebleed  in,  607. 
nourishment  in,  511. 
pain  in,  508,  513. 
pathology  of,  505. 
prognosis  in,  511. 
pulse  in,  507. 
relapses  of,  506. 
sleeplessness  in,  512. 
spleen  in,  606,  507,  510. 
symptoms  of,  506. 
synunymes  of,  504. 
temperature    in,    607,   509, 

512. 
tongue  in,  507. 
treatment  of,  511. 
types  of,  509. 
vomiting  in,  513. 
Remedies,     administration     of, 
967. 
classification  of,  957. 
in  general,  956. 
Remittent  fever,  479,  842. 
(Sec  Malaria.) 
how  distinguished  from  en- 
teric fever,  479. 
Renal  disease,  6,  129. 

in    diphtheria,     603,     618, 

626. 
in  scarlet  fever,  571,  578. 
Reprise,    the,    in    the    cry  and 

breathing,  107. 
Respiration,  25,  26,  66,  66,  67. 
[See  also  Breathing  and 
C'heyne-Stokes.) 
artificial,  249. 
establishment  of,  236,  248. 
in  fever,  431. 
Respiratory  organs,  medication 

of  the,  977. 
Resjiiratory  system,  122, 
in  typhoid,  465. 


Retarded  dentition,  92,  376. 
menstruation,  390. 
walking,  92. 
Revaccination,  753. 
Rex,    Dr.   0.  P.,   on    parotitis, 

767. 
Rheumatism,  110,  785. 
acute,  785. 
age  in,  791. 

alkalies  in,  817,  818,  819. 
an£emia  of,  806,  820. 
anatomical    characters    of, 

792,  793. 
ankylosis  following,  814. 
arthritis  in,  788,  795. 

{See     also     Rheumatoid 
Arthritis.) 
articular,  of  the  foetus,  229. 
bacilli  of,  793. 
causes  of,  787. 
childhood,  its  peculiarities 

in,  785. 
chill    as    a   cause    of,   787, 

792. 
chorea  in,  803,  814. 
chronic,  821. 
definition  of,  785,  787. 
diagnosis  of,  809. 
diet  in.  820. 
digitalis  in,  819. 
duration  of,  818. 
effects  of,  786. 
embolism    and    thrombosis 

in,  805. 
endocarditis   in,    786,   797, 

811. 
erythema  in,  802, 
etiology  of,  787. 
examples     illustrative     of, 

806-809. 
family  history  in,  113,  789- 

791. 
fibrous  nodules  in,  785,  801, 

813. 
foetal,  229. 

head-troubles  in,  805. 
heart-disease  in,  786,  794, 

797,  806,  812,  817,  819. 
heredity  of,  113,  789-791. 
hot  springs,  their  waters  in 

chronic  cases,  821. 
iron  in,  820. 
joints  in,  796. 
manifestations  of,  786,  806. 
meningitis  in,  805. 
microbes  of,  793. 
morbid  anatomy  of,  793. 
muscular  exercise  as  a  pre- 
disposing cause  of,  787. 
name  of,  785. 
nervous  symptoms  of,  805. 
nodules  in,  785,  801,  813. 
of  the  foetus,  229. 
opium  in,  819. 
pain  in,  815. 
pathology  of,  792. 
peculiarities    of,    in    early 

life,  785. 
pericarditis    in,    788,    794, 

795,  798,  811. 
perspiration  in,  797. 
pleurisy  in,  799. 
pneumoni.a  in,  799. 
poison  of,  793. 
predisposing  causes  of,  787. 
prevention  of,  821. 
prognosis  of,  812. 


INDEX    TO   VOLUME    I. 


999 


Rheumatism,      purpuric      ery- 
thema in,  803. 
pyajmia  mistaken  for,  810. 
rachitis  mistaken  for,  810. 
salicin  and  the    salicylates 

in,  815,  816. 
scarlatinal,  570, "TSS. 
scrofulous     swellings    mis- 
taken for,  810. 
sex  in,  791. 
stiffness    of   tendons   from, 

705. 
stimulants  in,  819. 
symptoms  of,  786,  794,  806. 
syphilis  of  the  bones  mis- 
taken for,  811. 
temperament  in,  791. 
temperature  in,  796,  820. 
tendinous   nodules  in,  785, 

801,  813. 
thrombosis  in,  793,  805. 
tongue  in,  797,  815. 
tonsillitis  in,  796,  800,  811. 
transmissibility  of,  to   off- 
spring, 113,  789-791. 
treatment  of,  814,  821. 
"Whipham's    table   illustra- 
tive of  treatment,  818. 
Rheumatoid  arthritis,  822. 

anatomical    characters    of, 

822. 
causes  of,  822. 
definition  of,  822. 
diagnosis  of,  S23. 
etiology  of,  822. 
morbid  anatomy  of,  822. 
pathology  of,  822. 
prognosis  of,  823. 
symptoms  of,  822. 
treatment  of,  823. 
Rhythm  of  breathing,   25,    26, 
56,  66,  67,  123. 
{See  also  Cheyne-Stokes.) 
Ribs,  beading  of  the,  86. 
Rickets.     See  Rachitis. 
Ridges,  epiblastic,  948. 
Rita-Christina,  930. 
Rokitansky's  opinion  as  to  the 
effects    of    maternal   impres- 
sions, 193. 
Rosary,    rachitic,     its     signifi- 
cance, 86. 
Roseola   epidemica.      See    Ru- 
bella. 
Rotch,   Dr.   T.  M.,    on    infant- 
feeding  and  weaning,  270. 
Rothein,  684. 
Round  worms,  129,  972. 
Rubei'aciion,  981. 
Rubella,  084. 
age  in,  688. 
albuminuria  in,  696. 
bacteria  of,  688. 
causes  of,  087. 
complications  in,  697,  702. 
contagion  of,  687. 
definition  of,  084. 
desquamation  in,  093. 
diagnosis  of,  098. 
diet  in,  701. 
epidemics  of,  086,  087. 
eru]jtion  of,  090. 
etiology  of,  087. 
glands  in,  69.5,  697. 
history  of,  684. 
incubative  stage,  089,  699. 
infectiousness  of,  687. 


Rubella,  influence  of  sex  in,  688. 
invasion  of,  689. 
measles,      its       differences 

from,  699. 
mortality  from,  698. 
names  of,  684. 
prodromes  of,  089,  699. 
])rognosis  in,  698. 
pulse  in,  696. 
rash  of,  691,  693. 
relapse  in,  698. 
scarlet  fever,  its  differences 

from,  699. 
sex  in,  688. 
sore  throat  in,  095. 
stage     of     eruption,     690, 
694. 
of  incubation,  689. 
of  invasion,  089. 
symptoms  of  eruptive  stage, 

094. 
synonymes  of,  084. 
throat  in,  695. 
tongue  in,  696. 
treatment  of,  700. 
urine  in,  696. 
vomiting  in,  695. 
Rubeola.     See  Measles. 
Rules  for  feeding,  273. 
Rupture    of    the    colon,    intra- 
uterine, 232. 


Saddle-back    curvature    of    the 

spinal  column,  98. 
Saint  Benoit  twins,  930. 
Salaam  convulsions,  121. 
Salicin  and  the  salicylates,  816. 
Salicylic  acid  in  scarlatina,  574. 
Salivary  secretion,  67. 
Sanitaria,  cautions  with  regard 

to  the  choice  of,  407. 
Sarcina  (the  genus),  152. 
Sarcolactic  acid  a  possible  cause 
of    the    sense    of    fatigue    in 
growing  children,  55. 
Sarcoma  of  the  kidney,  130. 
Scalp,  11. 

blood-tumor  of,  97. 
wounds  of,  202. 
Scapula  in  infancy,  46. 
Scarlatina.     See  Scarlet  Fever. 
Scarlatinal  diphtheria,  564,  568, 
569.  574,  607. 
rheumatism,  788. 
Scarlatinous  nephritis,  571,  578. 
pleural     effusions     in, 
122. 
pharyngitis,  607. 
Scarlet  fever,  555. 
age  in,  559. 
albuminuria    in,  -564,   570, 

578. 
alimentary  tract  in,  570. 
anatomical    characters    of, 

563. 
angina  of,  568,  569. 
antipyrin  in,  576. 
belladonna  in,  561. 
brain  in,  564. 
causes  of,  550. 
chlorate  of  ])otash  in,  577. 
cold-water     treatment     of, 

570. 
complications  of,  569,  577. 


Scarlet  fever,  conditions  favor- 
ing. 557-560. 
contagium  of,  556. 
convulsions  in,  570. 
coryza  of,  509. 
definition  of,  555. 
diagnosis  of,  571. 
diet  in,  579. 
diphtheritic   symptoms  in, 

564,  508,  509,  574,  607. 
disinfection  in,  561,  575. 
diuretics  in,  579. 
dropsy  of,  573. 
ear-troubles  after,  570. 
ej)idemics  of,  559,  500. 
eruption  of,  503,  505,  567, 

578. 
etiology  of,  556. 
eye-troubles   in   and  after, 

570. 
febrile  symptoms  of,  575. 
foetal,  228. 
forms  of,  565. 
geography,  etc.,  139. 
heart  in,  569. 
historj',  555. 
immunity  from,  562. 
incubation  of,  561. 
inoculation  with,  557. 
inunctions  in,  561,  578. 
in  utero,  228. 
irregular  types  of,  568. 
isolation  of,  561,  575. 
kidneys  in,  122,  564,  570, 

671,  578. 
malignant  form  of,  569. 
measles,  its  differences  from, 

699. 
mercuric  iodide  in,  574. 
milk  as  a  vehicle  for,  557. 
mortality  from,  574. 

as  influenced  by  2)ov- 
erty,  etc.,  559. 
nephritis  of,  122,  564,  570, 

571,  578. 
nervous  system  in,  570. 
of  the  foetus,  228. 
onset  of,  505. 
pathological    anatomy    of, 

503. 
pathology  of,  562. 
pilocar])ine     in      nephritic 

comjilications  of,  579. 
portability  of,  550. 
l)0tas.-ium  chlorate  in,  577. 
predisposition  to,  558,  559. 
prevention  of,  500. 
prognosis  of,  573. 
prophylaxis  of,  560. 
pulse  in,  507. 
quinine  in,  575. 
regular  type  of,  565. 
relations    to    the    Hendon 

disease,  557. 
rheumatism  after,  570,788. 
rubella,  its  diflerence  from, 

699. 
salicylic  acid  in,  574. 
season  of  the  year  for,  559. 
second  attacks  of,  51)2. 
sequels  of,  569. 
sex  in,  559. 
small-pox,    its    differences 

from,  738. 
sore  throat  in,  556,  564,  508, 

569,  577. 
stimulants  in,  577. 


1000 


INDEX   TO    VOLUME    I. 


Scarlet  fever,  susceptibility  to, 
669,  662. 
symptoms  of,  565. 
synonymes  of,  655. 
temperature  of,  566. 
throat-symptoms    in,    556, 

564,  566,  568,  669,  677. 
treatment  of,  674. 
types  of,  565. 
ursemic  symptoms  in,  579. 
urine  in,  567. 
varieties  of,  566,  568,  569. 
virus  of,  556,  567. 
Schizomycetes,  160. 
Schools,  overpressure  in,  410. 
Sclerema,  109. 

how    distinguishable    from 
erysipelas,  780. 
Scoliosis,  3. 

Scrofula  as  related  to  tubercu- 
losis, 40.'3. 
in  the  wet-nurse,  331. 
its  geographical  range,  etc., 
146. 
Scrotum,  41. 
Sea-bathing,  367. 
Seat-worms,  129,  972. 
Second  summer,  341. 
Section  of  the  body,  20. 
of  the  head,  14,  16, 
of  the  neck,  21. 
Seguin,  Dr.  E.,  his  observations 
on  the  effects  of  maternal  im- 
pressions, 192. 
Seminal  granule,  943. 
Sense-perceptions   in   early   in- 
fancy, 62. 
Septic  vibrion,  164. 
SepticiBmia  of  the  fcetus,  229. 
Sequels  of  enteric  fever,  476. 
Sero-sanguineous      infiltration, 

258. 
Serous  envelope,  952. 
Sewer-gas  as  a  vehicle  of  diph- 
theria, 591. 
Sexual  excitement  as  caused  by 
improper  food,  346. 
precocity,  93,  390,  392,  410. 
Shakespeare,  Dr.  E.  0.,  on  chol- 
era infectiosa,  900. 
on   practical   bacteriolog}', 
147. 
Shedding     of    the     temporary 

teeth,  375. 
Shoes  of  children,  370. 
Siamese  twins,  936. 
Sick  child,  the,  349. 
Sickness,  management  in,  354. 

signs  of,  350. 
Sick-room,  349.  351,  361. 
Sight  in  early  infancy,  62. 
Sigmoid  flexure,  35. 
Significance  of  heightened  tem- 
perature, 425. 
Signs  of  disease  in  a  wet-nurse, 
333. 
of     sickness    in    children, 
350. 
Sinus  terminalis,  953. 
Sinuses  at  birth,  12. 
Skeleton,    development    of,    38, 

46. 
Skin,  71. 

as  influenced  by  maternal 

impressions,  210. 
in  fever,  419,  429. 
in  typhoid,  473. 


Skin-diseases, as  related  to  teeth- 
ing, 385. 
how     discriminated     from 
small-pox,  738. 
Skoda's  tympanitic  percussion- 
sound,  123. 
Skull,  hydrocephalic,  12,  95. 
infantile,  2,  3,  12. 
rachitic,  96. 
Slavering,  380. 
Sleep,  talking  in,  121. 
terrors  in,  121. 
walking  in,  121. 
Sleeplessness  in  relapsing  fever, 
512. 
in  typhoid,  487. 
Sleep-walking,  121. 
Slow  pulse,  the  significance  of, 

104. 
Small  intestine,  35. 
Small-pox.     See  Variola. 
Smell,  the  sense  of,  in  early  in- 
fancy, 63. 
Smith,    Dr.  J.  L.,  on    cerebro- 
spinal fever,  614. 
on  diphtheria,  580. 
Social  condition  as  influencing 

disease,  136,  408,  413. 
Sodium  benzoate  in  diphtheria, 

669. 
Solid  culture-media,  178. 
Solutions   used   in  the  staining 

of  bacteria,  161. 
Solvents  in  dijjhtheria,  670. 
Somatopleure,  948. 
Somnambulism,  121. 
Sordes  in  enteric  fever,  488. 
Sore  throat,  128. 

(<S'ee  also  Diphtheria,  Rubella, 
Scarlet  Fever,  and  Tonsil- 
litis.) 
South      Carolina      twins,     the, 

932. 
Soxhlet's  sterilizing  apparatus, 

298,  371. 
Spasms,  carpo-pedal,  121. 
Specific  treatment  of  typhoid, 

495. 
Spermatozoa,  942. 
Spina  bifida,  98. 
Spinal  column,  43. 

cord  in  diphtheria,  613. 
curvatures,    abnormal,    97, 
98. 
normal,  43,  44. 
Spirilli,  156. 
Spirillum,  155. 
Splanchnic  layer,  948. 
Splanchnopleure,  948. 
Spleen,  36. 

enlarged,  85. 
in  diphtheria,  617. 
in  enteric  fever,  470. 
in  malaria,  840. 
in  yellow  fever,  865. 
Splenic  fever  of  sheep,  bacillus 

of  the,  153. 
Spoiled  children,  348. 
Sponging  in  general,  959. 
in  typhoid,  436,  492. 
Spontaneous  dislocations,  475. 
Spores,  the  staining  of,  for  mi- 
croscopic study,  168. 
Spotted    fever.      See    Cerebro- 
spinal Fever. 
Sputum,  absence  of,  in  diseases 
of  respiration,  122. 


Staining  of  microbes,  160,  162, 

168. 
Standing,  61. 

Star-fish,  fertilization  of  ovum 
in,  944. 
polar  cells  of,  941. 
Steam  ster-ilizer,  174. 
Stenosis  of  the  larynx  after  en- 
teric fever,  466. 
Sterilization  of  food,  294,  298, 

301-305. 
Sterilized  milk,  317,  371, 
Sterilizing  apparatus,  bacterio- 
logical studies,  173,  177, 
for  infants'  food,  299. 
Sterno-cleido-mastoid      muscle, 

injuries  of  the,  265, 
Sternopagus,  937. 
Stiffness  of  tendons  after  rheu- 
matism, 795. 
Still-birth,  apparent,  247. 

from  syphilis,  221,  225. 
Stimulants    in    children's    dis- 
eases, 819,  971. 
in  diphtheria,  658. 
in  fever,  437. 
in  scarlatina,  677, 
Stomach,  34,  68. 

capacity  of  the,  295. 
development  of,  34. 
Frolowski's    investigations 

on,  273,  295. 
in    diphtheria,     611,     616, 

623. 
its  phj'siology,  68. 
Stomatitis,  127. 

in  teething,  383. 
Stone  in  the  bladder,  130. 
Stoves,  363,  364. 
Strabismus  as  a  sign  of  cerebro- 
spinal fever,  63(). 
Streak,  the  primitive,  9-16. 
Streptococcus  (the  genus),  151, 
Stricture  of  the  colon,  its  seat, 

35. 
Strippings,    their    richness    as 
compared  with  that  of  other 
milk,  289,  290. 
Strumous  disorders  of  puberty, 

402. 
Strychnine  in  diphtheritic  pa- 
ralysis, 673. 
Stupor  in  cerebro-sjiinal  fever, 
631. 
in  enteric  fever,  470. 
in  typhus  fever,  499. 
Subzonal  membrane,  954, 
Sucking-cushions,  17, 
Sugar  in  infants'  food,  324, 
of  milk,  325. 

teats  condemned,  383,  387. 
Sulphur  bath,  358. 

for     rheumatoid    arthritis, 
824. 
Sulphurous      mineral      waters, 
their  use  in  chronic  dis- 
orders of  puberty,  406. 
their  use  in  rheumatoid  ar- 
thritis, 824. 
Sunlight,  361. 
Sunstroke,  439. 

Superior  vesical  artery,  its  de- 
velopment, 256,  257, 
Supernumerary  teeth,  377. 
Superstitions    about     teething, 

386. 
Sweating,  its  significance,  106, 


INDEX   TO   VOLUME    I. 


1001 


Symptoms.     See  the  names  of 
the    various   diseases    in 
this  index, 
of  fever,  427. 
Syncephalus,  935. 
Syncope  of  the  newly-born,  250. 
Synophthalmia,  935. 
Synote,  935. 
Synotia,  935. 

Syphilis    as   a    cause    of    still- 
birth?, 221,  225. 
as    an    inherited    disease, 

980. 
bacillus  of,  167. 
foetal,  221. 

diagnosis  of,  222. 
osteochondritis  in,  223, 

224. 

prognosis  of,  225. 

treatment  of,  225. 

from  vaccination,  747. 

geographical  range  of,  144. 

how     distinguished      from 

rheumatism,  811. 
in  the  wet-nurse,  332,  334. 


T. 

Table  for  the  differential  diag- 
nosis    of    relapsing 
fever,  510. 
of  rubella,  measles,  and 
scarlet  fever,  699. 
of  defects  of  the  upper  ex- 
tremities due  to  maternal 
impressions,  205. 
of  first  menstruations,  391. 
of  infantile  weights,  52. 
of  rules  for  feeding,  273. 
showing  relative  size  of  the 

head  and  chest,  94. 
showing      significance      of 
tem])erature,  103. 
Tables  of  defects  supposed  to  be 
due  to  maternal  iuij)res- 
sions,  196-202,  205,  207, 
20S,  209,  210. 
of  temperatures  in  typhus 

fever,  498. 
showing  averages  of  height 
and   weight,   53,  54,   89, 
90,  91. 
showing  results  from  vari- 
ous methods  of  treating 
rheumatism,  818. 
Taches  bleuatres,  474. 
Tact  essential   in  the  diagnosis 
of  children's  diseases,  81,  82. 
Tape-worm,  973. 
Tarsal    bones,   development   of, 

50. 
Taylor,  Dr.  W.  M.,    his    views 

regarding  diphtheria,  590. 
Tears,  absence  of,  108. 
Teeth,  absence  of,  377. 

anomalies  of,  370,  377. 
care  of  the,  367. 
congenital,  376. 
deciduous,  373,  375. 
development    of,    69,    373, 

375. 
eruption  of,  375,  377. 
grinding  of  the,  381. 
Hutchinson,  379. 
in  childhood,  17. 
malformation  of,  378. 


Teeth,  malposition  of,  378. 
permanent,  375. 
shedding  of  first,  375. 
supernumerary,  377. 
(i^ee  also  Dentition.) 
Teething  as  the  cause  of   dis- 
ease, 75. 
delayed,  92,  378. 
diarrhoea  in,  383. 
disorders  of,  350,  379. 
its  effect  on  the  foetus,  219. 
management  of,  386. 
multiple,  377. 
precocious,  376. 
retarded,  92,  376. 
superstitions  about,  386. 
symptomatology  of,  379. 
treatment  of,  386. 
Temperature,  charts  of,  in   en- 
teric fever,  458,  460, 
462,  476. 
in  relapsing  fever,  508. 
in  typhus,  498. 
in  yellow  fever,  864. 
daily  curve  of,  102. 
in  disease,  98,  425-427. 
in  typhoid,  462. 
(See  also  under  the  names  of 
the  various  diseases.) 
instability  of,  a  feature  in 
the    diseases    of    young 
children,  425. 
normal,  71. 
of  the  nursery,  364. 
Temporal  bone,  15. 
Tenderness    of    the    abdomen, 

86. 
Tendon  reflexes  in  diphtheritic 
paralysis,  633,  672. 
in  enteric  fever,  472. 
Tendon-stiflfness  in  rheumatism, 

795. 
Terata  anadidyma,  925,  926. 
anakatiididyma,  926. 
katadidyma,  925,  926. 
{See  also  Joined  Twins  ) 
Teratology,  922. 

literature  of,  938. 
Terminal  sinus,  953. 
Terrors,  nocturnal,  121. 
Testicle,  descent  of  the,  31,  32. 
Testicles,  42. 

Tetanus  of  the  newly-born,  138. 
Tetany,  121. 
Tetrapous  monsters,  932. 
Theea  folliculi,  940. 
Therapeutics  of  infancy,  8,  956. 
Thermic  fever,  439. 

how     discriminated     from 
yellow  fever,  871. 
Thcrmogencsis,  418. 
Thermolysis,  419. 
Thermometry,  98. 
Thoma,  R.,  his  observations  on 
the  growth  of  the  blood-ves- 
sels, 6,  255. 
Tlioracic  complications   in    ty- 
phoid, 491. 
Thoracopagus,  937. 
Thorax,  the,  24. 

size  of,  at  birth,  55. 

in    relation    to    hcad- 
diiuncter,  55,  94. 
Throat,  examination  of,  128. 
Thrombosis    due    to    injections 
for  naivus,  17. 
in  rheumatism,  793,  805. 


Thrombus  of  the  ductus  arteri- 
osus, 254. 
neonatorum,  261. 
blood  in,  4. 
causes  of,  262. 
treatment  of,  263. 
Thrush,  128. 
Thjmus  gland,  25. 
Tibia,  development  of,  49. 
Tied  tongue,  19,  121. 
Tobacco,  its  use  in  early  life,  411. 
Toilet,  306. 
Toilet-powders,  366. 
Tongue,  defects  of  the,  19. 

in  fever,  429. 
Tongue-tie,  19,  121. 
Tonic  remedies,  969. 
Tonsillitis,  128. 

in  rheumatism,  800. 
Tonsils,  anatomy  of,  20. 
Tooth-rash,  77. 

Topography  of  the  body,  23,  24, 
26,  28,  30,  32,  36. 
of  the  neck,  23. 
Torticollis,  22,  97. 

traumatic,  265. 
Touch,  the  sense  of,  in  early  in- 
fancy, 63. 
ToxaEsmia.     See  Blood-poison. 
Trace,  the  primitive,  946. 
Tracheo-bronchial     glands     in 

whooping-cough,  710. 
Tracheotomy,  22. 
Training,    mental,    moral,    and 
physical,  4  09,  413. 
of  girls  of  the  upper  classes, 
413. 
Trance,  hysterical,  397. 
Transfusion  of  blood,  966. 
Transmission     of     disease     by 
heredity,  110. 
by  milk  as  a  vehicle, 
557,  594,  901. 
Traumatism  of  the  foetus,  232. 
Treatment    of    disease    by    the 
skin,  956. 
of  nervous  disorders  of  fe- 
male puberty,  415. 
specific,  of  ty|ihoid,  495. 
(See  also  under  the  names  of 
diseases  in  this  index.) 
Tremor  in  enteric  fever,  488. 
Triangle,  Ilcsselbach's,  33. 
Trichinosis,    how   distinguished 

from  typhoid,  481. 
Trismus    neonatorum,    its    geo- 
graphical range,  138. 
Trunk,  etc.,  as  nflrecte<l  l>j'  ma- 
ternal im])rcssions,  209. 
Trypsin  in  diphtheria,  072. 
Tube-cultures,  183,  184. 
Tubercle,  miliary,  404. 
Tubercular  meningitis,  convul- 
sions in,  428. 
its  diagnosis  from  enteric 
fever,  119. 
Tuberculosis,  acute,  simulating 
ty])hoid,  480. 
as  related  to  scrofula,  403. 
bacillus  of,  152,  165. 
causes  of,  403. 
contagious  quality  of,  403, 

404. 
curability  of,  403. 
foetus  usually  exempt  from, 

229. 
inoculations  with.  403. 


1002 


INDEX    TO    VOLUME    I. 


Tuberculosis  of  puberty,  402. 

of  the  breast  in  the  wet- 
nurse,  331,  335. 

scrofula  as  a  cause  of,  403. 

tendencies  to,  111. 

treatment  of,  404. 
Tubes,  Esmarch's,  183. 

feeding-,  298. 
Tumors,  internal,  diagnosis  of, 

85. 
Turkeys,  diphtheria  in,  593. 
Turpentine  in  diphtlieria,  617. 
Twins,  joined,  922. 
{See  Joined  Twins.) 

Siamese,  936. 
Two-headed  Nightingale,  930. 
Tympany  in  enteric  fever,  489. 
Typhoid    fever.      See    Enteric 

Fever. 
Typho-malaria,  842. 
Typhus  fever,  497. 

anatomical  characters  of, 
498. 

causes  of,  497. 

contagion  of,  498. 

definition  of,  497. 

diagnosis  of,  499. 

etiology  of,  497. 

history  of,  497. 

hospital  treatment  of,  498. 

how  distinguished  from 
hemorrhagic  small-pox, 
500. 

maeulEB  of,  498,  499. 

pathology  of,  498. 

prognosis  of,  501. 

recurrent.  See  Relapsing 
Fever. 

sanitation  of,  497. 

symptoms  of,  498. 

synonymes  of,  497. 

temperature  in,  498. 

treatment  of,  502. 

in  hospitals,  498. 
Tyrotoxicon,  371,  970. 


U. 

Ulceration  of  Ihe  bowels  in  en- 
teric fever,  454. 
Ulcero-membranous        pharyn- 
gitis, 60S. 
Ulna,  its  development,  48. 
Umbilical     artery,    closure    of, 
252. 
cord,  237,  955. 

in  monstrosities,  937. 
vein,  255,  256. 
vessels,  6,  255. 
Umbilicus,  30. 
Understanding,     the     develojj- 

ment  of  the,  64. 
Unilateral     deformity     of    the 

head,  97. 
Unsanitary  surroundings    as    a 

cause  of  tuberculosis,  403. 
Upper  exticmity,  46. 

as  affected  by  maternal  im- 
pressions, 205. 
Urethra,  40. 
Urinary  calculus,  130. 
fistulas,  30. 
sediments,  130. 
Urine,  70. 

examination    of,   for    signs 
of  disease,  75. 


Urine  in  fever,  432. 
in  sickness,  363. 
in  typhoid,  473. 
Urticaria,  how    distinguishable 

from  erysipelas,  780. 
Uterine    disease,    its    effect   on 

the  foetus,  219. 
Uterus,  42. 

and  bladder,  their  relative 
position    in    the    infant. 
18,  42. 
Uvula  in  diphtheria,  613,  614. 


V. 

Vaccination,  743,  749. 

age  best  suited  for,  752. 

best  season  for,  752. 

conveyance  of    other    dis- 
eases in,  747. 

dangers  of,  747,  751. 

definition  of,  743. 

degeneration  of  the  lymph 
of,  748. 

erysipelas  from,  751,  774. 

etymology  of,  747. 

forms  of  the  lymph  of,  749. 

history  of,  743. 

in  early  infancy,  752. 

irregular  effects  of,  751. 

lymph  used  in,  747,  749. 

methods  of,  749. 

nature  of  its  effects,  746. 

operation  of,  749. 

phenomena  of,  750. 

preservation  of  the  lymph 
of,  749. 

protection  afforded  by,  751. 

repetition  of,  753. 

season  of  the  year  for,  752. 

selection  of  Ij'mph  for,  749. 

susceptibility  to  its  effects, 
752. 

syphilis  from,  747. 

virus  of.  747,  748. 
Vaccinia.     See  Vaccination. 
Vaccine  lymph,  747,  748. 

degeneration  of,  747. 

forms  of,  749. 

preservation  of,  749. 

selection  of,  749. 
Vapors,  medication  by,  978. 
Varicella,  754. 

age  of  patients,  756. 

ana;mia  following,  766. 

causes  of,  766. 

complications  of,  763. 

constitutional     effects      of, 
761,  765. 

contagion  of,  757. 

cutaneous  lesion  of,  764. 

defined,  764. 

diagnosis  in,  763. 

distinctness    from    variola, 
766,  758,  763. 

eruption  of,  760. 

etiology  of,  756. 

gangrenous,  762. 

history  of,  754. 

incubation  of,  754. 

inoculability  of,  757. 

invasion  of,  764. 

literature  of,  756. 

macules  of,  760. 

mucous  membranes  in,  761. 

names  of,  754. 


Varicella,    nephritis  following, 

763. 
pathological    anatomy    of, 

759. 
prognosis  in,  766. 
propagation  of,  757. 
rash  of.  760,  761. 
scars  from,  761. 
sequels  of,  763. 
symptoms  of,  759. 
syphilis  simulating,  765. 
treatment  of,  766. 
Variola,  722. 

age  of  patients,  723. 
anatomical    characters    of, 

724. 
bacteria  of,  724. 
causes  of,  723. 
complications  of,  725p  733, 

736. 
confluent,  729,  731. 
contagion  of,  723. 
corymbose,  729. 
death  from,  7S8. 
decline,  stage  of,  731. 
definition  of,  722. 
desiccation  of,  731. 
diagnosis  of,  737. 
digestive  tract  in,  734. 
discrete,  729. 
ear-troubles  in,  735. 
eruptive  stage  of,  72S. 
etiology  of,  723. 
eye-troubles  in,  726,  734. 
foetal,  228,  723. 
geographic  range  of,  144. 
heart  in,  734. 
hemorrhagic,  729,  732. 
history  of,  722. 
how  distinguished  from  en- 
teric fever,  479. 
incubation  of,  726. 
initial  rash  of,  727,  728. 
inoculation  of,  743,  744. 
in  utero,  228. 
invasive  stage  of,  727. 
iron  in,  741. 
keratitis  in,  734. 
lesions  in,  725. 
maturation,  stage  of,  730, 
modified  or  varioloid,  727, 

729,  732. 
names  of,  722. 
pathology  of.  724. 
pitting  in,  74  0. 
prognosis  in,  736. 
prophylaxis  against,  742. 

[See  Vaccination.) 
range,     geographical     and 

racial,  144,  723. 
rash,  preliiiiinavy,  727,  728. 
second  attacks  of,  724. 
secondary  fever  of,  730. 
semi-confluent,  729. 
sequelie  of,  733. 
sex  of  patients.  723. 
stages  of,  726-731. 
symptoms  of,  726. 
synonymes  of,  722. 
throat-troubles  in,  735. 
treatment  of,  739. 
types  of,  729. 
varieties  of,  729. 
Varioloid,  727,  729,  732. 
Vasculous  area,  953. 
Vaui;lian    and    Novy's    discov- 
eries, 450,  46i,  y70. 


INDEX    TO    VOLUME    1. 


1003 


Vaughan  and  Novy,  their  pro- 
posed definition  for  infectious 
disease,  45. 
Veins,  omphalo-mesenterie,  05.'). 
Ventilation,  354,  362,  3t53. 
Vermiform  appendix,  970. 

its  position,  35. 
Vernix  caseosa,  71,  239. 
Vertebral  column  in  infancy,  3, 

43. 
Vesical  artery,  its  development, 

256. 
Vesication  in  therapeutics,  981. 
Vesicle,  germinal,  940. 
Vesicular  emphysema  in  diph- 
theria, 615. 
Vessels,  lymphatic,  22,  40. 
\'ibrio  (the  genus),  154. 
Vibrion  seplique,  154. 
Viscera,  position  of,  24. 

(iS'ee  also  Topography.) 
Vitelline  membrane,  952. 
Vitello-intestinal  duct,  952. 
Vitellus,  940. 
Voice  in  hysteria,  396. 
Volitional  movements,  56. 
Vomiting  from  overfeeding,  or 
from  improper  food,  341. 
in  enteric  fever,  466. 
in  meningitis,  428. 
its  significance,  126. 
of  yellow  fever,  866,  867. 
Vulvitis,  130. 

diphtheritic,  625. 


W. 

Walking,  61, 

delay  in,  92. 

loss  of  the  power  of,   as  a 
sign  of  rachitis,  92. 
Wanning  the  nursery,  362. 
Warren,  Dr.  J.  C,  on  the  clos- 
ure of  the  ductus  arteriosus 
and  of  the  umbilical  and  hy- 
pogastric arteries,  252. 
Washing  the  newly-born  child, 

240. 
Wasting,  91. 

as  a  diagnostic  sign,  88. 
Water-closet,  365. 
Water  for  drinking,  372. 
Watery  solutions  of  dyeing-ma- 
terial in  bacteriological  stud- 
ies, 161. 
Waxliam,  Dr.  F.  E.,  on  measles, 

675. 
Wealth  and  poverty  as  factors 

in  disease,  135. 
Weaning,  270,  287,  387. 

diet  after,  337. 
Weekly  gain  in  weight,  271-273. 
Weight  and  height  i\s  influenced 
by  food,  90,  92. 
as  a  diagnostic  index,  87. 
as  a  guide  in  prognosis,  91. 
its  relations  to  height,  90, 

92. 
normal  gain  or  growth  in, 

5,  52,  273. 
of  the   blood   as    compared 
with  that  of  the  bixly,  65. 


Weight  of   the    heart   as    com- 
pared  with   that  of  the 
lungs,  5. 
ratios  of  height  to,  53,  88, 

89,  90. 
weekly  gain  in,  271-273. 
Westmanna     Islands,     trismus 

neonatorum  in.  139. 
Wet-nurse,  286,  330. 
diet  of,  336. 

examination  of,  333-336. 
moral  qualities  of,  330. 
physical  condition  of.  331. 
signs  of  disease  in,  333. 
syphilis  in,  332,  333,  334. 
Wetting  the  bed,  130. 
Wharton,  the  jelly  of,  955. 
Whey,  wine,  342. 
Whipham's    table  showing   the 
results    of    various    plans   of 
treatment     for     rheumatism, 
818. 
Whooping-cough.       See      Per- 
tussis. 
Will,  development  of  the,  56. 
Willingham  prodigy,  the,  393. 
Wilson,    Dr.   J.   C,  on    enteric 

fever,  441. 
Windows,  363,  365. 
Wine  whey,  342. 
Winter    residence    for   tubercu- 
lous children,  407. 
Woman's    milk,   275,   279,  280, 
282,  283,  284,  289,  290,  303, 
306,  308,  310. 
Wood,   Miss    Catherine,  on   the 
nursing     of     sick     children, 
347. 
Wormian  bones,  12. 
Worms,  129,  343,  972. 
Wounds  of  the  foetus,  232. 

of  the  scalp  and  face,  262. 
Wry-neck,  22,  97. 
traumatic,  265. 


Xiphopagus,  936. 


Yale,   Dr.    L.    M.,   on    nursery 

hygiene,  360. 
Yellow  fever,  853. 

accidental      epidemics     of, 

858. 
anatomical    characters    of, 

864. 
as  a  children's  disease,  853. 
black  vomit  in,  867. 
blood  in,  865. 
cadaver  after,  864. 
causation  of,  857. 
charts  illustrating,  855,  865. 
conii)are(l  with  dengue,  893. 
complications  of,  870. 
contagiousness  of,  856,  860, 

803'. 
deaths  from,  tabulated,  856. 
definition  of,  853. 
diagnosis  of,  870. 


Yellow  fever,  differential  com- 
parison of,  with  dengue. 
893-895.- 

effect  on  the  foetus,  230. 

epidemic    quality    of,    858- 
861. 

etiology  of,  857. 

facies  in,  866. 

fever  of,  865. 

focal  zone  of,  858. 

foetal,  230. 

fomites  in,  860. 

food  in,  875. 

geography  of,  858. 

hemorrhages  in,  869. 

history  of,  853. 

in  children,  853. 

incubation  of,  863,  865. 

jaundice  of,  866. 

kidneys  in,  864. 

liver  in,  864. 

morbid  anatomy  of,  864. 

mortality  from,  856,  859. 

mutclcs  in,  864. 

names  of,  853. 

nervous  symptoms  in,  869. 

odor  in,  867. 

pathology  of,  864. 

perifocal  zone  of,  858. 

perspiration  in,  867. 

prognosis  in,  .*^72. 

prophylaxis  of,  875. 

])ulse  in,  865. 

quarantine  in,  875. 

race  in,  875. 

second  attacks  rare,  870. 

sex  in,  863. 

skin  in,  866,  875. 

spleen  in,  865. 

stages  of,  863. 

stimulants  in,  875. 

stomach  in,  864. 

symptoms  of,  865. 

synonymes  of,  853. 

tables  of  dealh-rato,  851. 

temperature  in,  865,  866. 

thermic  fever  distinguished 
from,  871. 

tongue  in,  867. 

transmission   of,   856,   860, 
863. 

treatment  of,  872. 

typhoid  condition   in,  869, 
874. 

urine  in,  867,  874. 

vomiting  of,  866,  867. 

zones  of,  858. 
Yellow  milk,  bacterium  of,  152. 
Yolk-sac,  952. 

Youth,    dangers    which    bc.=ct, 
408,  409. 

Z. 

Zeiss's    oil-iiumersion   apochro- 
matic  lens,  1  58. 

Zenker's  degeneration,  613. 

Zona  pcllucida,  940. 
radiata,  941. 

Zones  of  yellow  fever,  858. 

Zoogla>a,  156. 

Zopf 's  classification  of  the  bac- 
teria, 150. 


END    OF    VOLU.ME    1. 


Printeo  by  J.    B.    LiPPiNCOTT  Company,    Philadelphia. 


■^^mm 


